Transcript The use of Phosfoline Iodine as therapeutic option for

Phospholine Iodide in the
management of esotropia
Lionel Kowal
Claudia Yahalom
RVEEH / CERA Melbourne
SQUINT CLUB DUNEDIN 2005
HISTORY France 120y, US 55y
 Javal
‘Manuel theorique et practique du
strabisme’: bifocals & miotics for ET 1886
 Samuel Abraham:
Pilo / eserine for ET
 46 cases Amer J Ophth 1949: 16/46
‘helpful’ AJO 1952,1961; JPO 1964,1966
CURRENT STATUS:
 Difficult
to obtain : application to TGA for
each patient
 Expensive
[$A130 a bottle]
PARKS 1958
ABNORMAL ACCOMMODATIVE
CONVERGENCE IN SQUINT n=1249
Old
/ difficult: Why
bother?
 because it sometimes
works very well!
PARKS 1958
ABNORMAL ACCOMMODATIVE
CONVERGENCE IN SQUINT n=1249
 No
Rx: n=73
 Isoflurophate
 BMR
 One
n=47 .. after Rx is stopped
n=104
MR
n=74
18: no better
26: no better
PARKS 1958
number where A:AC improved
No Rx
Miotic
< 7y
9/31
29%
4/15
27%
7 -12y
20/40
28/32
87%
All
[ result perfect]
BMR
One MR
69 / 104 27 /74
66%
36%
[40;38%] [7;9.5%]
PARKS 1958
ABNORMAL ACCOMMODATIVE
CONVERGENCE IN SQUINT
The
lasting improvement of the
abnormal A:AC produced by
miotic is similar to the
permanent result attained by
surgery
Patients studied
 Retrospective
chart review of patients from
a private strabismus practice.
 20 consecutive children with ET reluctant
to wear glasses
 PI “second choice” for mgmt of ET
 Ages 0.5 to 6 y [Parks : low expectations
of success - 25+%]
Four groups of children with ET
A. Hyperopes <+4 who refuse glasses: n=5.
B. Hyperopes >+4 who refuse glasses: n=7
C. Uncosmetic near- only ET: n=1
D. Recurrent ET after initially successful outcome from
recent ET surgery.
Glasses not tolerated / refused
n=9
2/9 had an unsuccessful trial of PI prior to surgery
Definition of Outcomes
(S). Esophoria / tropia ≤10∆
whilst using +/- after stopping PI
 Relative success (RS). One of:
*decreased angle of ET (either D or N = 0)
*% of time strabismic reduced to < 25%
 No success (NS): little / no improvement in
angle or POTS
 Success
Table 1: Results of patients receiving PI according to indication for treatment
#
A: Hyperopia <4
1
2
B: Hyperopia > +4
C: Near only ET
D: ‘Rescue’ recurrent ET
RS 4/12
RS: decreased angle
3
S (with later relapse)
4
RS
5
S
6
NS
7
NS
8
NS
9
10
S
S
NS
11
S
12
NS
13
RS
14
Lost f/u
15
16
Lost f/u
NS
S
17
NS
18
S
19
RS
20
NS (not tolerated)
HOW GOOD WAS IT?

A / B / C : 2 successes / 13 pts

D [recurrent ET]: 5-8 success / 9 pts

13 + 9 = 22; 2 pts had PI @ 2 different stages of
their course
 A/B/C: 2 lost to followup
PI RESCUE FOR RECURRENT ET
#19 RS





Cong ET. BMR 5.5 /LR Rs OU/ slipped LLR /
LLR advanced - all between 7 and 15 mo. CR
+2.
Straight.
24 mo: recurrent ET. CR +4.25, +4.5.
Gls refused - PI.
Usually straight.
PI RESCUE FOR RECURRENT ET
#4 RS
 BMR
4.5 @ 14 mo for ET onset 10 mo
 Initially perfect
 Later ET 0-15
ET’ 0-25
 PI ET 0
ET’ 0-20
PI RESCUE FOR RECURRENT ET
#17 NS
BMR 6.5mm for ET 35-40 / 40-57
CR + 1.5
 W1 Orthotropia
 W8 ET 25 / 30
 PI : No effect
 M6 : LR Rs OU
PI RESCUE FOR RECURRENT ET
#13 RS
 3yo
ET 25/35.
 CR +2.25, +1.5 BUT +1 blurs OU.
 ET 0-40/ 30-60. BMR 6.5.
 W1 Orthotropic D&N.
 M3 ET 14 / 18.
 M7 ET 20 / 35
 PI ET 0 / 25 - 30
 + 0.5 DS blurs OU
PI RESCUE FOR RECURRENT ET
#5 S
8
mo ET 50. CR +2. BMR 6
 3w: [ET’]
 POTS bad day >50%
 6w: PI POTS 0%
 Taper over 9 mo stays good
PI RESCUE FOR RECURRENT ET
#18 S
 ET
45/60.
 CR +1.25. BMR 6.5
 D6 Orthotropic D&N
 W4 ET 25-30
 PI Orthotropic
4mo f/up
PI RESCUE FOR RECURRENT ET
#7 NS then S









i/mitt ET from 3mo
+4.5 DS OU
9mo ET<30, ET’ 30
Refused gls. Screamed with PI
15 mo: ET’ 35 BMR 5
D1 slight XT.
M2 ET 20. CR +3.75, +3
Gls refused. PI.
3.5 y: gls. Orthotropic D & N
PI RESCUE FOR RECURRENT ET
#16
NS then S









2 mo: [ET]. CR +3 DSOU
6 mo: ET 30∆, CR +1.5, +1.
9 -23 mo: I/mitt ET’
23 mo: ET’ 25∆.
32 mo: PI. Deteriorated to ET/ET’ 30-35/30-45∆  BMR
5.5.
D6: XT8∆, small X’
D15: ET’6∆.
W5: ET 10/16∆
CR/MR +0.75.
PI E/E’<10∆, FR D<6∆, N>6∆
8 mo postop: uses PI on bad days
PI RESCUE FOR RECURRENT ET
#3 S








54 mo: ET 30/ 50 [X2] & 25 / 30. CR +0.5
BMR 5.5. [XT]. D3: Lang 3/3
D 19: ET’ 30. Gls tried / refused. Rx: PI
Next 5 mo: reduced to 2ce weekly.
5mo: orthophoric, BIFR > 12
Stop PI @ 6 mo
10 mo: ET’ 35; EX=0, FR>6.
MR= CR= +0.75 DS OU
Rx: bifocals with +3 add: STRAIGHT
Results: success





PI clearly successful in 2 pts [of 7] in group B
with >+4. PI treatment continues.
5 pts [of 9] in group D had clear success,
allowing these pts to avoid or delay repeat
surgery.
2/5 still need daily PI.
1/5 uses PI if ET is seen (‘bad days’)
2/9 patients in “successful” for 2-4 months, and
then  to bifocals / SV glasses
PROBLEMS WITH MIOTICS

Mims:
 279 of his pts + 323 pediatric ophthalmologists
surveyed:
 Iris cysts 1
 Intolerance to hyperopic correction 1

LK:
 Screaming after instillation n=1
 15+ yrs ago: Iris cysts
ISOFLUROPHATE FOR
RECURRENT ET
Mims & Wood BVQ 1993;8:11-20
n
=117
 57/117: ET < 8∆, ET’ < 20∆
 38/57 [67%]: initial response
 16/57 [28%]: no other Rx
Summary
 PI
is a useful adjunct in treatment of
recurrent ET.
 In
patients for whom surgery was followed
by an early recurrence of ET with + : PI
might help to avoid/delay further surgery
even if unsuccessful preop.
Aphorism of Hippocrates 300BC
Life is short
The art long
Opportunity fleeting
Experiment treacherous
Judgement difficult
Conclusion
PI has a useful role in the treatment of
recurrent ET, if glasses will not be worn.
Postoperative Miotics for patients with infantile esotropia
Spierer A, Zeeli T. Ophthalmic surgery and lasers. Dec 1997(28) 1002-5

Retrospective study including 42 children who
underwent BMR recession for cong. ET.
 2 groups: the treatment group (20 children) who
got PI 1 drop/day for 4/12 1 week after the
surgical procedure, and the control group (21
children)
 Twelve months postoperatively, the
residual/recurrent ET increased an average of
1.4 and 2.8 D in the treatment and control
groups respectively (not statistically significant)
•Amblyopia was more prevalent in the treatment group (20% and 5% respectively)
•Surgeons decided arbitrarily whom to treat with PI
References






Spierer A. Postoperative miotics for patients with infantile
esotropia. Ophth surg and lasers. 1997;28:1002-5.
Parks M. Management of acquired esotropia. Brit J
Ophthal. 1974;58:240-6.
Hiatt R. Miotics vs glasses in esodeviation. J Ped
Ophthal and strabismus. 1979;16:213-7.
Hiatt. Medical management of accommodative esotropia.
J Ped Ophthal and strabismus. 1983;199-201.
Goldstein JH. The role of miotics in strabismus.Surv
Ophthalmol. 1968;13:31-46.
Abraham SV. The use of miotics in the treatment of
nonparalytic convergent strabismus. A progress report .
Am J ophthalmol. 1952;35:1191-5.
References


Parks M.
ABNORMAL ACCOMMODATIVE
CONVERGENCE IN SQUINT
 AMA Archives of Ophthalmology
 1958: ;364-380
Treatment groups
Child with Esotropia
D- Residual / Recurrent
ET s/p Sx
A- Low Hypermetropia
B- High hypermetropia
C- Near only ET
Kids with ET and low plus (<4), who didn’t accept glasses: group A
Age
yrs
CR
ET type
PI tx
Results
F/U (m)
2
4
+3.75 ou
Cong. 65^
2/12
RS
8
7
0.5
+2.75 ou
Cong. Int.
40^
Pre-op
Post op
→NS
→S
36
8
0.5
+1.50 ou
R s/p IO –
For SO palsy.
ET 20^
3/12
NS
10
10
2
R + 1.50
L + 3.00
ET 20^
M/p no
amblyopia
2/12
NS
9
16
6
+1.00 ou
Alt ET 20^→
2 yrs later 35^
Pre-op
Post op
→NS
→S
38
Patient #2: ↓ angle of ET to 50 ^. Then BMR was done.
Patients #7 and #16 had a residual ET 15-20^ shortly s/p Sx.
B: ET and >+4
#
Age
yrs
CR
ET type & size
PI tx
Results
F/U
(m)
1
0.8
+4.50
Cong ET 25∆
4/12
RS
14
6
1.4
R+ 6.75
L + 5.25
A. ET 30∆
2/12
NS
12
9
1
+6 OU
A. ET 25 ∆
Ongoing for
4/12
S
6
11
4
+5 OU
PA/A ET 20∆
Ongoing for
6/12
S
6
12
0.8
+4 OU
PA/A ET
30∆
1/12
NS
8
15
4
+4 OU
Cong. ET
45∆
1/12
NS
Lost
f/u
20
1.5
+4 OU
PA/A ET
40∆
Not tolerated
NS
6
#1:↓ POTS for 4/12. Later ET 60∆→BMR
A.ET = accommodative ET.
PA = partially accommodative
C: near only ET
#
14
Age yrs
1.9
CR
ET type
+1.50 OU
Int. ET
for near
PI tx
1/12
Results
?
F/U (m)
6
(lost)
PI RESCUE FOR RECURRENT ET
#19







‘Large’ cong ET. BMR 5.5 @ 7mo, residual ET,
LR Rs OU @ 15 mo. CR +2.
D1: ET 50. slipped LLR.
OR: RLR advanced, RMR 9 from limbus - Botox,
LMR 11 from limbus.
Postop: XT, face turn. Straight.
24 mo: recurrent ET. CR +4.25, +4.5.
Gls refused - PI.
Usually straight.
PI RESCUE FOR RECURRENT ET
#4
 10
mo [ET]
 13 mo 25
14 mo 30
 BMR 4.5
 ET 0-15
ET’ 0-25
 PI ET 0
ET’ 0-20
PI RESCUE FOR RECURRENT ET
#13
 3yo
ET for 6mo. ET 25/35.
 CR +2.25, +1.5 BUT +1 blurs OU.
 ET 0/30, 25, 40/60. BMR 6.5.
 W1 early XT by history. Orthotropic D&N.
 M3 ET 14 / 18.
 M7 ET 20 / 35
 PI ET 0 / 25 - 30
 + 0.5 DS blurs OU
PI RESCUE FOR RECURRENT ET
#5
8
mo ET 50. CR +2. BMR 6
 3w: [ET’]
 POTS bad day >50%
 6w: PI POTS 0%
 Taper over 9 mo stays good
PI RESCUE FOR RECURRENT ET
#17
 ET
since 12 mo
 35-40 / 40-57 CR + 1.5
 BMR 6.5
 W1 Orthotropia
 W8 ET 25 / 30 CR + 1.25
 PI : No effect
 M6 : LR Rs OU
PI RESCUE FOR RECURRENT ET
#7









i/mitt ET from 3mo;1st seen 6 mo
+4.5 DS OU EX=0
9mo ET<30, ET’ 30
Refused gls. Screamed with PI
15 mo: ET’ 35 BMR 5
D1 slight XT.
M2 ET 20. CR +3.75, +3
Gls refused. PI. Variable compliance.
3.5 y: gls. Orthotropic D & N
PI RESCUE FOR RECURRENT ET
#16









2 mo: [ET]. CR +3 DSOU
6 mo: ET 30∆, CR +1.5, +1.
9 -23 mo: varying POTS. [ET’].
23 mo: ET’ 25∆.
32 mo: PI. Good response then deteriorated to
ET/ET’ 30-35/30-45∆  BMR 5.5.
D6: XT8∆, small X’
D15: ET’6∆.
W5: ET 10/16∆
CR/MR +0.75.
PI E/E’<10∆, FR D<6∆, N>6∆
8 mo: uses PI on bad days
PI RESCUE FOR RECURRENT ET
#3









[ET’] onset 4. CR +0.50.
54 mo: ET 30, ET’ 50 [X2]; 25 / 30
BMR 5.5. [XT]. D3: Lang 3/3
D 19: ET’ 30. Gls tried / refused. Rx: PI
Next 5 mo: reduced to 2ce weekly.
5mo: orthophoric, BIFR > 12
Stop PI @ 6 mo
10 mo: ET’ 35; EX=0, FR>6.
MR= CR= +0.75 DS OU
Rx: bifocals with +3 add
D: PI “rescue ” for recurrent / residual ET following surgery
Age
yrs
CR
ET type & size
in ∆
PI tx
Results
Time off PI
F/u months
3
4
Plano
N 50
D 30
Res. N ET.
Tx for 4/12
S→
Later relapse
4/12→Rec N
ET→Bif.
18
4
0.8
Plano
Cong. ET 20
Rec.ET20∆
Tx for 3/12
S
Ongoing
16
5
0.8
+2.00 ou
Cong.ET50^
Res N ET
Tx for 6/12
S
Ongoing
PI on bad
days only
12
7
0.5
+2.75 ou
Cong. Int.40
Res.ET20^.
Tx for?
S
15/12
36
13
3
R +2.50
L +1.50
R ET Int.30
Res.ET25^.
Tx for ?
S→
Later relapse
2/12 → Rec
N ET→Bif.
20
16
6
+0,75 ou
Alt ET 35
Pre BMR : NS
S
Ongoing for
post op
recurrence
38
17
1.8
+2.00 ou
N 50
D 35
Res.ET25^.
Tx for 2/12
NS
18
5
+1.00 ou
ET 45
Res.ET25^.
Tx for 1/12
S
19
1
+4.50 ou
Cong ET s/p 2
sx. 50^
Res.ET25^.
Tx for 3/12
RS for 3/12
14
ongoing
3
24
Results: (RS) Relative success
RS was seen in:
 1 patient in group A (↓strabismic angle)
 1 patient in group B (↓POTS)
 1 in group C (ortho for 3 months)
PI RESCUE FOR RECURRENT ET
#18
 ET
onset 3. 1st seen age 5. ET 45/60.
 CR +1.25. BMR 6.5
 D6 Orthotropic D&N
 W4 ET 25-30
 PI Orthotropic
4mo f/up
PROBLEMS WITH MIOTICS







1. Cataract - only in the elderly glaucoma
population
2. Cholinergic crisis in unrecognised myesthenic
n=1
3. Iris cysts
4. Reduced plasma cholinesterase
5. Transient myopia
6. Retinal detachment
7. SLUD salivation / lacrimation / urination/
defecation