This patient presented with binocular horizontal diplopia that occurs frequently, especially when tired. She has a history of intermittent exotropia and underwent bilateral lateral rectus recession surgery at age 11. On examination, she displayed small esophoria and 10 prism diopters of base-out exotropia. She was diagnosed with postoperative intermittent exotropic consecutive esotropia. Her management plan includes undercorrection of her glasses prescription, use of Fresnel prisms to relieve diplopia, and titrated prism addition to monitor deviation and diplopia. Consecutive strabismus occurs when a patient develops a deviation in the opposite direction of their original pre-operative alignment.

1. CASE PRESENTATION
A story after another
story…..
Prepared by
Anis Suzanna binti Mohamad
Pegawai Optometri U41
Jabatan Oftalmologi, Hospital Sultanah Bahiyah

2. Outline
History taking
Assessment
Diagnosis
Prognosis
Management
Conclusions
References

3. History taking
• Miss NL, D.O.B: 18.04.1999
• 16/F/M
• Chief complaint
– Pt c/o binocular horizontal diplopia at distance occurs
frequently
– Onset are varies: morning/afternoon/evening
– Frequency: most of the time especially when tired
– Degree: almost the same all the time
– She now in Form 5, will take SPM examination by the end of
this year
– She worried due to she cannot focus in the class
– When diplopia occurred, she unable to see writing on the
whitebord and troublesome for her in order to study

4. • Signs & symptoms
– AHP: Slight face turn to the right
• Previous treatment
– H/o underwent squint surgery (bilateral LR recession) @
11 years old
– Previously she is intermittent exotrope
– She has anisometropia, compliance to glasses
– Start with visual therapy: 2 circles exercise 5 minutes
daily, not comply

5. Assessment
Right eye Left eye
Distance VA
(aided)
6/6 6/6
Near VA (aided) N5@33cm N5@33cm
Current spectacles
Rx
-2.00/-1.50x175 -4.75/-1.75x167
K-reading 45.00 @ 92
47.37 @ 2
44.75 @ 170
47.12 @ 80
Refraction & VA -2.00/-1.50x175
(VA: 6/6)
-4.75/-1.75x170
(VA: 6/6)
1) VA and refraction

6. Binocular vision assessment
Hirschberg Central and symmetry
Cover test (Distant) Small esophoria with LE hypophoria
(Near) Small esophoria with LE hypophoria
Prism cover test (∞) 10 pd BO, 2 pd BU over LE
(Near) 10 pd BO, 2 pd BU over LE
PFV (+ve) (∞) x/12/10 (Near) x/14/12
NFV (-ve) (∞) x/4/11 (Near) x/6/2
NPC See single until 8cm
AC/A ratio 6.8 pd/D
2) Vergence component

7. Binocular vision assessment
Right eye Left eye
AA
Pt’s expected AA:
±13.5 D
9.5 D, 10 D, 10 D 13D, 14D, 14D
PRA (-ve) +2.00DS
NRA (+ve) -3.50DS
Facility 9.0 cpm 9.0 cpm
BE: 5.0 cpm
3) Accommodation component

8. Binocular vision assessment
Krimsky 14 BO
EOM
RMR o/a +1 RIO o/a +2
Worth-4-Dot test Identify 5 shapes, uncrossed diplopia
Stereopsis
50 secs of arc using Random Dot
Stereofly @ 33cm
4) Strabismus

9. Binocular vision assessment
5) Additional test (Hess screen test)

10. Diagnosis
 Post-operative Intermittent
Exotropic Consecutive Esotropia

11. Prognosis
• Good
• Patient & parents cooperative and
committed towards treatment
• Goal:-
– Obtain single vision

12. Management & Follow-up care
Under correction of her gls Rx
• (give minimum myopia on non-dominant
eye with compromise vision)
Fresnel prism
• (to relieve diplopia in patient)
TCA
• (To check angle of deviation and
diplopia after give fresnel prism)

13. Disscussion
• Consecutive strabismus A deviation of the eye in the op
posite direction to what it was previously.
• This condition
may follow surgery although it may occur spontaneously.
• There are two types:
– consecutive exotropia in a patientwho previously had esotropia
or esophoria
– consecutive esotropia in a patient who previously had exotropia
or exophoria.
Definition

14. Disscussion
Eso
Tropia
Phoria
1° 2 ° Consec. i. Conv. Excess
Constant ii. Div.
Weakness
i. withAccom. Elem. iii. Non-specific
ii. without Accom. Elem.
Intermittent
i.Accom.
ii. Distance - near eso
- distance eso
iii. Time - cyclic/alternate day squint
iv. Non-specific
Eso deviation

15. Guideline for consecutive esotropia management

16. Continue
•An esotropia occurs commonly after surgery for intermittent
exotropia.
• If this consecutive deviation is relatively small (less than 10
diopters) and if abduction is full or nearly full, it should not be
treated.
• A slight overcorrection has been correlated with the most
stable long term postoperative alignment of intermittent
exotropia.
•An overcorrection larger than 10 diopters should be monitored
and if treated it should be done so at first conservatively
including some or all of the following: full plus correction,
alternate patching, and fully correcting base out prism.
•Only if all conservative approaches have been exhausted is
additional surgery indicated.

18. Conclusions
• Good history taking
– Esotropia in a patient who previously had an
exotropia/exophoria.
– Generally occur as a result of surgery- immediate or long
term.
• Post-Operative Consecutive Esotropia
- may be deliberate
- may be due to over-liberal surgery e.g
LR recession or MR resection.
• Management depend on whether the case is
functional or cosmetic.

19. References
• Books
 Essentials of Clinical Binocular Vision by
Erik M. Weissberg; Butterworth
Heinemann 2004
• Website
 http://www.cybersight.org/bins/volume
_page.asp?cid=1-351-355-448
 J Korean Ophthalmol Soc. 2006
Oct;47(10):1623-1629. Korean.