Transcript Consecutive exotropia

Consecutive Exotropia
Lionel Kowal
Elaine Wong
CONSECUTIVE XT
Any XT happening after previous ET
[usually after ET surgery]
 Rare: spontaneous consecutive XT
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CONSECUTIVE XT - WHY?
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1. The ET correction doesn’t ‘grow’ with
the pt
 Ciancia:
perfect early alignment after Cong ET
surgery  30% consec XT after 25y
 Recession MR : mechanical disadvantage
CONSECUTIVE XT - WHY?
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2. Early consec XT:
 Wrong
surgical dose
 Poor surgical technique
 Poor early healing
CONSECUTIVE XT - WHY?
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3. Later consec XT:
 ‘Stretched
scar’ - look for stretchmarks,
healing of other surgical scars, ….
 Irene Ludwig : Scar remodelling & Scar
migration
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Scar remodeling after strabismus surgery very under recognised
 Ludwig
IH, Chow AY., J AAPOS. 2000
 Ludwig IH Trans Am Ophthalmol Soc. 1999
 Need to use non- absorbable sutures if
recognised
Consecutive XT
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Results of consecutive XT in LK’s practice over
last 2 years
91 cases of consecutive XT
Average time to XT ~ 8 years
58 had XT surgery by LK
32 with follow up >1 yr
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Number of surgeries: 1-4
Median: 1
Avg. no. of surgeries: 1.3
No. of Botox for ET : 4 (10%)
No. of Adjustables: 19 (45%)
Pre and post op results
Exotropia ---->
80
70
60
50
<--- Esotropia
(Δ)
40
30
Pre op
Post op
20
10
0
0
5
10
15
20
25
30
-10
-20
-30
Patient number
Pre-op: Range 6 – 66 XT; Avg 31XT
Post-op: Range 18ET – 45XT; Avg 0
35
Post- op results
12
11
11
No. of patients
10
8
7
6
4
3
2
0
Excellent (0-5 ET/
XT)
Good (6-10 ET/ XT)
Imperfect (11-20
ET/ XT)
Poor (>20 ET/ XT)
Amblyopia and XT surgical results
60.00%
% of patients
50.00%
40.00%
No amblyopia
6/12 - 6/36
<6/48
30.00%
20.00%
10.00%
0.00%
No amblyopia
6/12 - 6/36
<6/48
Excellet
good
Imperfect
Poor
26.67%
36.36%
50.00%
40.00%
45.45%
0.00%
26.67%
9.09%
33.33%
6.67%
9.09%
16.67%
Hypermetropia and XT surgery results
70.00%
60.00%
% of patients
50.00%
40.00%
<+2.00
+2.00 - +4.00
> +4.00
30.00%
20.00%
10.00%
0.00%
<+2.00
+2.00 - +4.00
> +4.00
Excellent
Good
Imperfect
Poor
37.50%
20.00%
50.00%
25.00%
60.00%
33.33%
18.75%
20.00%
16.67%
18.75%
0.00%
0.00%
Age and XT surgery results
50.00%
45.00%
% of patients
40.00%
35.00%
<20
20-40
>40
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
Excellent
Good
Imperfect
Poor
<20
44.44%
33.33%
22.22%
0.00%
20-40
33.33%
33.33%
20.00%
13.33%
>40
25.00%
37.50%
25.00%
12.50%
Spontaneous consec XT
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2 cases of spontaneous consec XT
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accounts for 2% of all consecutive XT
Case 1
 10
yo girl with infantile ET
 Noted XT at ~ 2 yo
 Now XT 10Δ with V pattern
 Hypermetropia R +8.75 L +7.00
 R amblyopia 6/12
 No surgical Rx
Spontaneous XT
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Case 2
 30
yo female
 Infantile ET ? When noted XT
 RXT of 35Δ
 No obliques OA
 Hypermetropia R +7.50, L +4.50
 R Amblyopia 6/45
 RMMRs 5.5mm, RLMRc 7.5mm
 Post op – RET 7Δ
Conclusions
Spontaneous consecutive XT – rare!
 Consecutive XT a difficult surgical problem
 69% with good surgical results
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