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