Transcript “Elderly” - who? - The Private Eye Clinic

Strabismus Surgery
and
the Late Elderly
Logan Mitchell
Lionel Kowal
RVEEH, Melbourne
Private Eye Clinic, Melbourne
“Elderly” - who?
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Older than me?
Older than my parents?
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WHO: No definition
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Geriatric literature
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Early elderly = 65 – 75 years old
Late elderly = ≥75 years old
“Elderly” - how many?
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Australian population
data
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22.5 million (2010 est.)
Life expectancy at birth:
82 yrs
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Ageing population
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65 yrs and older
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13.5% (2009 est.) =
3 million
25% (2042 est.) =
6.2 million
“Elderly” and Strabismus
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Prevalence ~ 4% (adult strabismus)
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No population-based data on “elderly” population
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6600 Medicare-billed strabismus operations
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27 million eligible patients
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2.4%
“Elderly” and Strabismus
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Prevalence of strabismus in >65 year olds
(assumptive)
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4% prevalence adult strabismus
120,000 in 2009
250,000 in 2042
Elderly Strabismus – the literature
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4 papers
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Paper #1
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Repka JAAPOS 2007 as described
70% horizontal surgery
14% reported as re-operations (?low)
Elderly Strabismus – the literature
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Paper #2: Magramm & Schlossman JPOS 1991
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Retrospective
104 pts
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mean 69 yrs old (60-89)
¼ cosmetic indication, ¾ diplopic
1/3 childhood onset
Adult onset

Mean delay to
surgery 8 yrs
Aetiologies
Elderly Strabismus – the literature
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Paper #3: Dawson et al Strabismus 2001
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Retrospective
111 patients
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mean 67 yrs old (60-90)
½ cosmetic, ½ diplopic
1/3 childhood onset
Adult onset – similar aetiologies
Outcomes
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~60% orthotropic +/- 10∆
21% re-operation rate
Elderly Strabismus – the literature
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Paper #4: Rutar & Demer JAAPOS 2009
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“Heavy eye syndrome” in elderly
A la, but different from, ‘myopic strabismus fixus’
Degeneration of SR-LR aponeurotic band
Adult Strabismus (as substitute)
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Adults delay seeking surgical correction
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Mean delay 19 years
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diplopic 15 yrs vs 28 yrs non-diplopic
Reasons
Strabismus Surgery
in the 'Late Elderly'
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Aim
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To Identify the characteristics and outcomes of patients
undergoing strabismus surgery aged 75 years or older
between October 2005 – October 2010
Methods
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Retrospective chart review
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Locations

Private Eye Clinic (Dr Lionel Kowal)
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RVEEH
Results
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35 patients
Age: mean 79 years
(75-95)
Male:Female 16:19
Indications
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Cosmesis – 6 (17%)
Diplopia – 29 (83%)
Duration of symptoms:
mean 12 years (0-69)
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19 done with
adjustable sutures
3 surgeries performed
under regional
anaesthetic
Results
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Previous surgeries
35
30
29
25
20
15
10
4
5
1
1
2
3
0
0

1
(plus 2 with previous botox)
Aetiology of Strabismus
6%
3%
9%
20%
39%
23%
neuroparalytic
restrictive
decompensated phoria
consecutive
sensory
unknown
Neuroparalytic Strabismus
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14 patients
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CNVI in 9 patients
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5 compressive
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3 ischaemic / uncertain
cause
1 traumatic (CHI)
 (1 previous surgery)
3 congenital
 1 with 2 previous
surgeries
 Remaining 2:
average duration of
diplopia = 6 years
 2 ICA aneurysm
 (1 previous
surgery)
 2 meningioma
 1 ependymoma
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CNIV in 6 patients
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3 uncertain aetiology
CNIII in 1 patient
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Combined with CNVI in
ICA aneurysm patient
Restrictive Strabismus
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8 patients
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3 thyroid eye disease
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4 traumatic / iatrogenic
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Mean duration on symptoms: 1.3 years
2 previous retinal detachment surgery
1 previous sinus surgery
1 previous orbital trauma
1 Brown’s syndrome
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Symptoms for >50 years
Decompensated Phoria
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7 patients
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5 with decompensated intermittent exotropia
2 decompensated divergence insufficiency
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Mean duration of symptoms: 37 years
Consecutive Exotropia
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Only 2 patients
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Childhood esotropia
Previous surgery x 1, and x 3
Mean duration of misalignment: >40 years
Outcomes
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Mean follow-up 8 months
“Overall”
3%
29%
31%
Perfect
Significant improvement
Little/no improvement
Worse
37%
Outcomes
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Diplopia
17%
35%
3%
Free of diplopia
(with AHP)
(with prism)
(with AHP and prism)
DIPLOPIC
3%
42%
Outcomes in Neuroparalytic Cases
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“Overall” result
Perfect
3 (21%)
Significant improvement
2 (14%)
Little/no improvement
8 (57%)
Worse
1 (7%)
Diplopia
Free of diplopia
11 (79%)
(with AHP)
2 (14%)
(with prism)
6 (43%)
(with AHP and prism)
1 (7%)
Diplopic
3 (21%)
Outcomes in Other Cases
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“Significant improvement” or better
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Restrictive strabismus 88%
Decompensated phoria 86%
Consecutive exotropia 100%
Complications
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Couldn’t find a muscle (2)
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Re-operations (3 = 8.6%)
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2 on one patient (SOP), 1 on 95 year old lady
(XT)
Recurrences (6)
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Post-childhood trauma, consecutive XT
Dealt with prisms in 4 cases
No known systemic complications
Conclusions (I)
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Strabismus in the very elderly
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Exists
Is not extremely rare
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Is under-represented in the literature
Diplopia is a frequent indication for surgery
Patients delay surgery
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Will increase
Often at our (medical) behest
Varied aetiologies
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Neuroparalytic causes common (note compressive
causes)
Conclusions (II)
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Surgical considerations
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Systemic risk of general anaesthetic
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Thinner conjunctiva
Risk of anterior segment ischaemia
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?risk of regional anaesthetic
Probably 2 muscles maximum
Diplopic indication common
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More accurate surgery, adjustable sutures
Conclusions (III)
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Surgery is reasonably successful
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Very low risk of making things worse (1/35)
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68% achieved at least significant improvement
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?More guarded success in neuroparalytic patients
83% free of diplopia (with/without prisms/AHP)
Thank You