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CONGENITAL / ESSENTIAL INFANTILE
ESOTROPIA
V.Chandrasekhar Reddy
Hyderabad.India
drvcreddy@gmail.com
Esotropia(Convergent Squint)..Cornea deviated nasally
 4-5% of squint in gen population.
 0.1% of population have CET
...
Pseudo strabismusPseudo strabismus
 Epicanthal fold
 Wide nasal bridge
 Ectopia of macula
 Narrow IPD
Heredity:  multifactorial genetic basis for
congenital esotropia.
 suggested loci on regions 3p26.3-26.2 and
6q24.2-25.1...
pathogenesispathogenesis
Worths sensory concept. Inborn and
irreversible defect of fusion.
Chavasse mechanical concept. ...
Certain risk factors .
 prematurity, family history, perinatal or
gestational complications, systemic
disorders, use of s...
CETCET
Alignment is achieved by 4mths in the
normal infant and stereopsis can be
measured in the laboratory.
Early misal...
What to be seen in a patient with
congenital esotropia? (Diagnostic
criteria)
 * Neurologically normal 70% (except for
E...
A special characteristic of congenital
esotropia - OKN asymmetry
Temporal to Nasal (T/N).Smooth
following, rapid and accu...
Congenital ETCongenital ET
ET by 6 mths
> 30 D ET & Stable
Assymetry of OKN
Cross fixation
Abd restriction
No clinic...
Associated featuresAssociated features
IO overaction 60%,
nystagmus,DVD 50% > 1yr
Amblypoia (35%)
AHP
 It can be asso...
Alternating
Cross fixation
Monocular
IO OA DVDIO OA DVD
Differential DiagnosisDifferential Diagnosis
Congenital VIth Nervepalsy
Duane Syndrome Type I
Mobius Syndrome
Nystagmu...
CongenitalCongenital VIVIthth
nerve palsynerve palsy
Esotropia.
Management goalManagement goal
To make the eyes as close to orthotropia
with normal vision,develop some fusion
to keep al...
ManagementManagement
Ruleout accomadation element with
atropine.
Treat refractive error
Botax to keep fusion potential ...
Non surgical interventionNon surgical intervention
Botulinum toxin
To postpone surgery
Not as effective as surgery
Spect...
SurgerySurgery
 40d ET at 4 mths will not resolve
spontaneously
Must be as done early as possible to get
binocular funct...
timing of surgerytiming of surgery
Early surgery decreases the severity of DVD and
lowers the need for additional operatio...
Surgical alignment before 18 mos. better
binocularity
will even better binocularity be achieved with
alignment before 12...
Surgical options
Recession of both MR
Symmetrical or asymmetrical
No of muscles depends upon
amount of deviation
Weake...
Results to be expected fromResults to be expected from
surgery for CETsurgery for CET
Single muscle..Sparingly MR Recessio...
RESULT TO BE EXPECTED FROM
SURGERY FOR CET
 Cong ET 50pd
 Adult ET 40pd
 Equal vision
 ET .>N more AC/A
+Oblique muscl...
3 muscle surgery….50-70pd
5mmBMR+9mm LR…<1yr
7mm BMR+10mmLR..>3yr
4 muscle surgery
>75 pd. Not a routine
7mm BMR +10mm LR
Why does early alignmentWhy does early alignment
improve stereoacuityimprove stereoacuity
outcomes in CET?outcomes in CET?...
40pd
BMR Recession
6mm
60 pd.Restriction of abd LE BMR Recession 6mm
+LLR Resection 8mm
Management of CETManagement of CET
Confirm diagnosis
Fixation
fusion
Amblyopia
Accomadation,Refraction
Associated fe...
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Congenital et

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Congenital et

  1. 1. CONGENITAL / ESSENTIAL INFANTILE ESOTROPIA V.Chandrasekhar Reddy Hyderabad.India drvcreddy@gmail.com
  2. 2. Esotropia(Convergent Squint)..Cornea deviated nasally  4-5% of squint in gen population.  0.1% of population have CET  50% ocular deviations in paed age group are Esotropias  40% cong ET of all ET
  3. 3. Pseudo strabismusPseudo strabismus  Epicanthal fold  Wide nasal bridge  Ectopia of macula  Narrow IPD
  4. 4. Heredity:  multifactorial genetic basis for congenital esotropia.  suggested loci on regions 3p26.3-26.2 and 6q24.2-25.1 and may share alleles that underlie Duane retraction syndrome Unaffected parents are more likely to have slightly deficient stereopsis, but do not have OKN asymmetry.
  5. 5. pathogenesispathogenesis Worths sensory concept. Inborn and irreversible defect of fusion. Chavasse mechanical concept.  Neural components necessary for normal binocular vision are present in strabismic individuals at birth, but the development of fusion is eventually impeded by abnormalities of optical input (eg, monocular cataracts) or muscular output (eg, cranial nerve palsies) 
  6. 6. Certain risk factors .  prematurity, family history, perinatal or gestational complications, systemic disorders, use of supplemental oxygen as a neonate, use of systemic medications.   Awareness of these risk factors can lead to early detection and management of esotropia
  7. 7. CETCET Alignment is achieved by 4mths in the normal infant and stereopsis can be measured in the laboratory. Early misalignment constant or intermittent beyond 2-4 months is required to be sure of the diagnosis of congenital ET.  OKN asymmetry present in all infants becomes symmetrical by 6 months in the normal. Patients with congenital ET retain OKN asymmetry
  8. 8. What to be seen in a patient with congenital esotropia? (Diagnostic criteria)  * Neurologically normal 70% (except for ET) * Hyperopia less than +3.50 (A greater hyperopia does not rule out congenital ET) * Esotropia (30-70PD ± nystagmus)
  9. 9. A special characteristic of congenital esotropia - OKN asymmetry Temporal to Nasal (T/N).Smooth following, rapid and accurate Refixation  Nasal to Temporal (N/T).Jerky, inaccurate movement with halting refixation 
  10. 10. Congenital ETCongenital ET ET by 6 mths > 30 D ET & Stable Assymetry of OKN Cross fixation Abd restriction No clinical CNS involement Deviation same for D & N Consistant features
  11. 11. Associated featuresAssociated features IO overaction 60%, nystagmus,DVD 50% > 1yr Amblypoia (35%) AHP  It can be associated with a systemic disease such as Down’s syndrome, albinism, cerebral palsy, or hydrocephaly.1-4
  12. 12. Alternating Cross fixation Monocular
  13. 13. IO OA DVDIO OA DVD
  14. 14. Differential DiagnosisDifferential Diagnosis Congenital VIth Nervepalsy Duane Syndrome Type I Mobius Syndrome Nystagmus (blockage ) Syndrome Down Sydrome Albinism Cerebral Palsy etc.. Maybe associated with CNS and other systemic abnormalities.
  15. 15. CongenitalCongenital VIVIthth nerve palsynerve palsy Esotropia.
  16. 16. Management goalManagement goal To make the eyes as close to orthotropia with normal vision,develop some fusion to keep alignment May require multiple surgeries Alignment with 8-10d results in monofixation syndrome …comfortable surgical result
  17. 17. ManagementManagement Ruleout accomadation element with atropine. Treat refractive error Botax to keep fusion potential live Treat amblyopia surgery
  18. 18. Non surgical interventionNon surgical intervention Botulinum toxin To postpone surgery Not as effective as surgery Spects Acc ET Prisms Temp measure Small angle
  19. 19. SurgerySurgery  40d ET at 4 mths will not resolve spontaneously Must be as done early as possible to get binocular function. Large deviation…..correction is more ET + amb…more correction Fusion potential must be undercorrected
  20. 20. timing of surgerytiming of surgery Early surgery decreases the severity of DVD and lowers the need for additional operation for DVD oblique overaction. Yagasaki et al, Zak and Morin Early vs. Late Infantile Strabismus Surgery Study (ELISS), children operated at age 6-24 months had better gross stereopsis at age 6 years compared with those operated on later
  21. 21. Surgical alignment before 18 mos. better binocularity will even better binocularity be achieved with alignment before 12 mo.  The Pediatric Eye Disease Investigator Group (PEDIG) in the Congenital Esotropia Observation Study (CEOS) determined that ET of 40 diopters or more present at 2 months persists until 7 months - diagnosis of congenital ET can be made  ET of less than 40 prism diopters or intermittent ET at 2 mos. has a 50% chance of persisting at 7 mos.
  22. 22. Surgical options Recession of both MR Symmetrical or asymmetrical No of muscles depends upon amount of deviation Weakening of IO rece.wmv
  23. 23. Results to be expected fromResults to be expected from surgery for CETsurgery for CET Single muscle..Sparingly MR Recession Small angle (10-15pd),fusion potential,diplopia DRS Possible OVER CORRECTION
  24. 24. RESULT TO BE EXPECTED FROM SURGERY FOR CET  Cong ET 50pd  Adult ET 40pd  Equal vision  ET .>N more AC/A +Oblique muscle for AV,&IOOA BMR Recession  Minimal 2.5mm MR for 15- 20pd  Maxim.7mm for 40pd BLR Resection  Div insufficiency. 20pd .5mm  Res ET 40pd 9mm R&R  CET ..poor vision one eye  2.5MR-5LR..20-25pd  5MR+9LR <1yr….50pd  7MR+10LR..>3yrs 50pd+ Two muscle surgery Measurement from insertion
  25. 25. 3 muscle surgery….50-70pd 5mmBMR+9mm LR…<1yr 7mm BMR+10mmLR..>3yr
  26. 26. 4 muscle surgery >75 pd. Not a routine 7mm BMR +10mm LR
  27. 27. Why does early alignmentWhy does early alignment improve stereoacuityimprove stereoacuity outcomes in CET?outcomes in CET? patients with stereo less likely to need a 2nd surgery [p=0.05] and less likely to have DVD (P <.001). CONGENITAL ESOTROPIA 27
  28. 28. 40pd BMR Recession 6mm
  29. 29. 60 pd.Restriction of abd LE BMR Recession 6mm +LLR Resection 8mm
  30. 30. Management of CETManagement of CET Confirm diagnosis Fixation fusion Amblyopia Accomadation,Refraction Associated features Surgery as early as possible depending on anesthetist readiness
  31. 31. Thank u

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