2016 asmph strabismus & amblyopia
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#ASMPH lecture to Year Level 7, November 2, 2016 on #strabismus and #amblyopia, including #PEDIG studies
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2016 asmph strabismus & amblyopia
- 1. Strabismus & Amblyopia Alvina Pauline D. Santiago, MD November 2, 2016 ASMPH © AP Santiago 2016
- 2. Outline: Strabismus ❖ Definition ❖ Muscle Origin & Insertion, Function, Innervation ❖ EOM Concepts and Muscle Movements ❖ Laws of Ocular Motility ❖ Adjacent Anatomical Structures with Functional Correlations © AP Santiago 2016
- 3. Strabismus: Definition Any misalignment of the eyes ❖ Manifest vs latent: -tropia vs –phoria ❖ Direction ❖ Eso- ❖ Exo- ❖ Hyper- ❖ Hypo- © AP Santiago 2016 © AP Santiago 2016
- 4. Strabismus © AP Santiago 2016
- 5. Extraocular Muscles 1. Medial Rectus 2. Lateral Rectus 3. Superior Rectus 4. Inferior Rectus 5. Levator Palpebrae Superioris 6. Muller’s Muscle http://www.images.missionforvisionusa.org/anatomy/ uploaded_images/eomMR-783818.jpg © AP Santiago 2016
- 6. http://www.cambridgequestions.co.uk Annulus of Zinn © AP Santiago 2016
- 7. Spiral of Tillaux www.cybersight.org © AP Santiago 2016
- 8. Horizontal rectus muscles Medial rectus Lateral rectus © AP Santiago 2016
- 9. Vertical rectus muscles Inferior rectus Superior rectus © AP Santiago 2016
- 10. Oblique muscles Superior oblique Inferior oblique © AP Santiago 2016
- 11. EOM Muscle: MR & LR Muscle Origin Insertion Innervation Action Medial Rectus Annulus of Zinn 5.5 mm from limbus CN 3, inferior Adduction Lateral Rectus Annulus of Zinn 6.9 mm from limbus CN 6 Abduction © AP Santiago 2016
- 12. EOM Muscle: Vertical SR & IR Muscle Origin Insertion Innervation Action Inferior Rectus Annulus of Zinn (inferior tendon of Zinn) 6.5 mm from limbus CN 3 inferior Depression Extorts Adducts Superior Rectus Annulus of Zinn (superior tendon of Lockwood) 7.7 from limbus CN 3 superior Elevates Intorts Adducts © AP Santiago 2016
- 13. Inferior Oblique ❖ Origin: Shallow depression on orbital plate of maxilla ❖ Insertion: inferotemporal quadrant of sclera near the macula Rangeen Shandran R. http://www.slideshare.net/RangeenChandran © AP Santiago 2016
- 14. Superior Oblique ❖ Origin: Lesser wing of sphenoid ❖ Functional origin: Trochlea ❖ Insertion: curved ❖ anterior: 12-14 mm behind limbus ❖ posterior 17-19 mm behind limbus OM Patel, http://www.slideshare.net/ompatel9889 © AP Santiago 2016
- 15. EOM Muscle: Oblique IO & SO Muscle Origin Insertion Innervation Action Inferior Oblique Shallow depression on orbital plate of maxilla Infero- temporal quadrant of sclera near the macula CN 3 inferior Extorts Elevates Abducts Superior Oblique Lesser wing of sphenoid but Functional origin: Trochlea anterior: 12-14 mm behind limbus posterior 17-19 mm behind limbus CN 4 Intorts Depresses Abducts © AP Santiago 2016
- 16. Blood Supply ❖ ciliary arteries also arise from these muscular arteries ❖ 7 branches ❖ 2 per rectus muscle except LR which receives only 1 OM Patel, http://www.slideshare.net/ompatel9889 © AP Santiago 2016
- 17. EOM Muscle: Levator & Muller Muscle Origin Insertion Innervation Action Levator Palpebrae Superioris Under surface of Lesser wing of Sphenoid Levator Apo- neurosis CN 3 Superior Lid elevation; Deepens palpebral fold Muller’s Muscle (superior palpebral muscle) Inferior and bulbar aspect of Levator palpebrae behind the fornix Upper edge of tarsal plate Sympathe- tic fibers Elevates Lids http://www.images.missionforvisionusa.org/anatomy/2006/03/extraocular-muscles.html © AP Santiago 2016
- 18. Orbital Apex Anatomy and Function Correlation http://lms.ecco-org.eu © AP Santiago 2016
- 20. Ophthalmic nerve (V1) branches and distribution http://emedicine.medscape.com/article/1873373-overview#a2 © AP Santiago 2016
- 22. Maxillary Nerve Branches (V2) http://emedicine.medscape.com/article/1873373-overview#a2 © AP Santiago 2016
- 23. Maxillary Nerve Branches (V2) http://emedicine.medscape.com/article/1873373-overview#a2 © AP Santiago 2016
- 24. Cavernous Sinus Syndrome ❖ CN 3, 4, 6 palsy ❖ Optic neuropathy ❖ Oculo-sympathetic paresis ❖ Impairment of ophthalmic and maxillary branch of CN5 http://skullanatomy.info/individ%20spaces/orbit/04_brain_pan.jpg © AP Santiago 2016
- 25. Cavernous Sinus Syndrome ❖ CN 3, 4, 6 palsy = ophtalmoplegia ❖ Optic neuropathy ❖ Oculo-sympathetic paresis: Horner Syndrome ❖ Impairment of ophthalmic and maxillary branch of CN5: sensory loss ❖ Proptosis http://emedicine.medscape.com/article/1161710-overview © AP Santiago 2016
- 26. EOM Concepts & Movements ❖ agonist muscles ❖ antagonist muscles ❖ yoke muscles ❖ synergistic muscles ❖ Ductions & Versions ❖ dextroversion ❖ levoversion ❖ dextroelevation ❖ levoelevation ❖ Dextrodepression ❖ Levodepression ❖ Vergence Eye Movements ❖ Convergence ❖ Divergence © AP Santiago 2016
- 27. Ocular Motility: EOM Movement © AP Santiago 2016
- 28. Laws of Ocular Motility: Hering’s Law © AP Santiago 2016
- 29. Laws of Ocular Motility: Sherrington’s Law © AP Santiago 2016
- 30. Strabismus Evaluation ❖ Complete 5 point examination ❖ Gross ❖ Pupils ❖ EOM ❖ Intraocular Pressure ❖ Fundus evaluation ❖ Perform refraction ❖ Stereoacuity testing ❖ Strabismus Evaluation: ❖ Gold Standard: Alternate Prism Cover Test © AP Santiago 2016
- 31. Strabismus Evaluation: Hirschberg’s Corneal Light Reflex © AP Santiago 2016
- 32. Strabismus Evaluation: Bruckner Test © AP Santiago 2016
- 33. Strabismus Evaluation ❖ Cover Uncover Test https://www.youtube.com/watch?v=f5HbIZi4u70 © AP Santiago 2016
- 34. Strabismus Evaluation ❖ Alternate Cover Test https://www.youtube.com/watch?v=U59OEkjoIGg © AP Santiago 2016
- 35. ALTERNATE PRISM COVER TEST Gold standard for measuring deviation Courtesy of R. Pena 2015 © AP Santiago 2016
- 36. Strabismus Evaluation From Rosenbaum & Santiago, Clinical Strabismus Managemenment 1999 © AP Santiago 2016
- 37. © AP Santiago 2016
- 38. Strabismus Evaluation: Torsion From Rosenbaum & Santiago, Clinical Strabismus Managemenment 1999 © AP Santiago 2016
- 39. From Rosenbaum & Santiago, Clinical Strabismus Managemenment 1999 © AP Santiago 2016
- 40. Outline: Amblyopia ❖ Definition ❖ Diagnosis ❖ Treatment ❖ Lessons learned from PEDIG ❖ The Future http://www.eyestudioinc.com/wp-content/uploads/2016/01/Amblyopia3.jpg © AP Santiago 2016
- 41. Amblyopia: Definition ❖ Etymology: dullness of vision ❖ Greek: ❖ amblus = dull ❖ Stem: ops = eye or vision ❖ Observer (MD) sees nothing, and the patient sees very little ❖ von Graefe ❖ lazy eye © AP Santiago 2016
- 42. Amblyopia: Definition ❖ Unilateral or bilateral decrease in vision caused by pattern vision deprivation or abnormal binocular interaction for which no cause can be detected by physical examination, and which in appropriate cases, reversible by therapeutic measures ❖ von Noorden http://www.ascrs.org/sites/default/files/styles/hall_of_fame/public/external-profile/ Von%20Noorden%20Formal%20Portrait%20001.jpg?itok=XvJmWnEs © AP Santiago 2016
- 43. Amblyopia ❖ One eye sees better than the other ❖ Developing visual system / brain will ignore (suppress) one eye https://www.aapos.org/terms/conditions/21 © AP Santiago 2016
- 44. Amblyopia Diagnosis ❖ Fixation Preference vonNoorden, Ocular Motility © AP Santiago 2016
- 45. Fixation Preference © AP Santiago 2016
- 46. Fixation Preference & Visual Acuity © AP Santiago 2016
- 47. Vision Assessment © AP Santiago 2016
- 48. Pre verbal Vision Test ❖ Allen cards ❖ Cultural bias ❖ “dated” ❖ Based on experience ❖ Lea symbols ❖ more universal ❖ Same in every culture ❖ Equal blurr © AP Santiago 2016
- 49. Visual Acuity Testing © AP Santiago 2016
- 52. Definitions: PEDIG ❖ Mild Amblyopia: less than 20/40 ❖ Moderate Amblyopia: ❖ 20/40 to 20/100 (ATS1) ❖ 20/40 to 20/80 (ATS2) ❖ Severe Amblyopia: 20/100 to 20/400 © AP Santiago 2016
- 53. Lessons learned from PEDIG 1. Atropine = patching 2. 10 = 15 3. 6 hours = full time 4. 2 = 6 5. 6 > 2 6. Glasses alone works. 7. If not, then glasses+patching. 8. Teenagers benefit from patching. © AP Santiago 2016
- 54. ❖ Amblyopia PEDIG Studies © AP Santiago 2016
- 55. Lessons learned from PEDIG 1. Atropine = patching ❖ Moderate amblyopia ❖ 3-7 years; younger than 8 ❖ Strabismic = anisometropic amblyopia ❖ Atropine better tolerated ❖ Same rate of deterioration or improvement ❖ Same rate of recurrence © AP Santiago 2016
- 56. Amblyopia PEDIG Studies = © AP Santiago 2016
- 57. Amblyopia PEDIG Studies (ATS 2) For age 3-7 with severe amblyopia, 6 h = 10 h patching © AP Santiago 2016
- 58. Amblyopia PEDIG Studies (ATS 2B) For 3-7 y with moderate amblyopia, same results with 2 or 6h of patching © AP Santiago 2016
- 59. Amblyopia PEDIG Studies © AP Santiago 2016
- 60. Amblyopia PEDIG Studies ❖ 7 to < 18 y ❖ 20/40 to 20/400 ❖ 27% Improves with glasses alone ❖ 7-12 improved even if treated previously ❖ 13-17 improved if not treated previously ❖ Will it stay? © AP Santiago 2016
- 61. Amblyopia Treatment Study-5 (ATS-5) spectacles alone, then patch 2 hrs vs spectacles ❖ Ophthalmology 2006: 113 (6) 904-912. ❖ 5 wks: 1.1 lines treated; 0.5 lines specs ❖ Any visit average: 2.2 lines treated; 1.1 lines specs ❖ After glasses, 2 hrs patching (with 1 hr near activity) improves moderate to severe amblyopia https://t2.ftcdn.net ✚http://cdn4.teen.com © AP Santiago 2016
- 62. Amblyopia PEDIG Studies Daily = weekly atropine ❖ 20/40 to 20/80 ❖ 3-7 years © AP Santiago 2016
- 63. ❖ Amblyopia PEDIG Studies © AP Santiago 2016
- 64. Lessons learned from PEDIG ❖ 2 hours works even for severe amblyopia ❖ When 2 hrs doesn’t work, additional push to 6h improves 3 to <8 years with VA 20/50 to 20/400 ❖ Bangerter filter = patching ❖ Levodopa-carbidopa promising © AP Santiago 2016
- 65. What more PEDIG? http://www.imore.com http://www.geek.com http://www.cclonline.com/ http://icons.iconarchive.com © AP Santiago 2016
- 66. Amblyopia Treatment Study-18 (ATS-18) Binocular Computer Activities for Treatment of Amblyopia Ended May 2, 2016 ❖ To compare the effectiveness of 1 hour/day of binocular game play 7 days per week (minimum of 4 days per week) with 2 hours/day of patching 7 days per week, in children 5 to <13 years of age (younger cohort), as a non-inferiority study. ❖ To compare the effectiveness of 1 hour/day of binocular game play 7 days per week (minimum of 4 days per week) with 2 hours/day of patching 7 days per week, in children 13 to <17 years of age (older cohort), as a superiority study. © AP Santiago 2016
- 67. Amblyopia Treatment: The Future ❖ Advanced algorithms, electronics, materials ❖ Intermittent automatic electronic occlusion http://www.treatlazyeye.in VIDI Smart Glasses © AP Santiago 2016
- 68. • Dichoptic Treatment (Hess) • Virtual Reality Games • Repetitive Transcranial Magnetic Stimulation (rTMS) [Thompson] Amblyopia Treatment: The Future Treatment for amblyopic adults © AP Santiago 2016
- 69. Amblyopia Treatment: The Future ❖ Suppression caused amblyopia (reverse paradigm) ❖ Dr. Robert Hess Mc Gill University, CA ❖ Dichoptic Treatment: Tetris ❖ Improvement in 3D vision ❖ 1 hr/day for 2 weeks http://www.treatlazyeye.in VIDI Smart Glasses © AP Santiago 2016
- 70. ©APSantiago2016
- 71. Dichoptic Tetris © AP Santiago 2016
- 72. Virtual Reality Games for Amblyopia ❖ 0:33 The Oculus Rift ❖ 0.38 – 1:29 How it Works https://www.youtube.com/watch? v=KumScsJ0xNQ © AP Santiago 2016
- 73. Repetitive Transcranial Magnetic Stimulation (rTMS) ❖ Rapidly changing magnetic fields applied to head with a hand-held coil ❖ Weak electric currents induced in the brain which excite neurons in target areas ❖ Tx for migraine, Parkinson, stroke, depression ❖ Visual loss in amblyopia not due to loss of brain cells but ongoing suppression http://www.drchugh.com/images/rtms.png