what is strabismus? “diplopia” - welch medical...
TRANSCRIPT
Double Double Trouble::PostPost‐‐surgical Strabismussurgical Strabismus
Anya Trumler, MD
Wilmer Pediatric Ophthalmology
I have no financial interests to disclose.
What is strabismus?What is strabismus?
• Misalignment of theMisalignment of the eyes
• Strabismus ≠Double– Can have double vision out of one eye
– Some patients only use t tione eye at a time.
“DIPLOPIA”DIPLOPIA
Causes of Binocular Double Vision
• Infantile / Childhood onset/• Need for glasses• Cranial nerve palsyp y• Tendency for eye misalignment that decompensated• Trauma• Thyroid eye disease• Loss or poor vision in one eye • Post‐surgical
Post‐Surgical StrabismusPost Surgical Strabismus• Anesthesia
• Cataract surgery
• Refractive surgery
• Retina
• Glaucoma
AnesthesiaAnesthesia
– Reported incidence of new onset diplopia after cataract surgery:
• Retrobulbar anesthesia: 1% • Topical anesthesia: 0% – 0.2%
Yangüela J, Gómez‐Arnau JI, Martín‐Rodrigo JC, Andueza A, Gili P, Paredes B, Porras MC, González del Valle F, Arias A. Diplopia after cataract surgery: comparative results after topical or regional injection anesthesia. Ophthalmology. 2004 Apr;111(4):686‐92.
Retrobulbar BlockRetrobulbar Block
What is it about the block?What is it about the block?
• Needle injury to muscle?• Ischemia?
– Injection in perimusclar space causing compression• Neurogenic injury?• Neurogenic injury?• Toxic effect of the meds?
– Lidocaine– Marcaine– Hyaluronidase– Epinephrine– Epinephrine
i h b lb dl f h• A 1.5 inch retrobulbar needle from the inferiortemporal approach can reach any extraocular muscle.muscle.
• Incidence:– Inferior rectus > Superior rectus > all others
Capo H, Roth E, Johnson T, Munoz M, Siatokowski RM. Vertical strabismus after cataract surgery. Ophthalmology. 1996; 103:918‐21.Guyton DL. Strabismus compliations of local anesthetics. Seminars in Ophthalmology. 2008; 23:298‐301.
Anesthetic AgentAnesthetic Agent
• All anesthetic agents directly injected into muscle areAll anesthetic agents directly injected into muscle are myotoxic– Bupivicaine (Marcaine) is most and Procaine least
– Hyaluronidase protective• Dispersive
• Initial paresis in in some followed by progressive segmental fibrosissegmental fibrosis.– Reversal of direction of diplopia.
HyaluronidaseHyaluronidase
• Medication added to help spread the anesthetic
• In 2002 there was a shortage of Hyaluronidase throughout worldworld
• In a single French hospital, 7205 cataract surgeries were performed under RB anesthesia between 2001 2003:performed under RB anesthesia between 2001‐2003:– 2001‐2002 – Wydase available
• 3582 patients – no diplopia– 2002 2003 – No Wydase available– 2002‐2003 – No Wydase available
• 3623 patients – 27 with diplopia (0.75%)
Hamada S, Devys JM, Xuan TH, Ganem S, Sahel JA, Héran F, Plaud B. Role of hyaluronidase in diplopia after peribulbar anesthesia for cataract surgery. Ophthalmology. 2005 May;112(5):879‐82.Jehan FS, Hagan JC 3rd, Whittaker TJ, Subramanian M. Diplopia and ptosis following injection of local anesthesia without hyaluronidase. J Cataract Refract Surg. 2001 Nov;27(11):1876‐9.
Bupivicaine to treat esotropiaBupivicaine to treat esotropia
Pre‐injection 5 months post‐injection 1 1 year post‐injection 2Pre injection 5 months post injection 1 1 year post injection 2ET 25 ET 15 ET 11
Images pre (A) and post (B) injection of BupivicaineImages pre (A) and post (B) injection of Bupivicaine
Scott AB, Alexander DE, Miller JE. Bupivacaine injection of eye muscles to treat strabismus. Br J Ophthalmol 2007 91:146‐148.
Cataract SurgeryCataract Surgery
• 1,600,000 cataract surgeries performed in US each year. • Incidence of complications: 0.1% to 6.8%
• Risks:• Risks:– Endophthalmitis– Retinal Detachment
Cystoid Macular Edema– Cystoid Macular Edema– Posteriorly dislocated lens material– Suprachoroidal hemorrhage
I d i t l– Increased intraocular pressure– Loss of eye– Diplopia
H, Kersey JP, Oystreck DT, Cline RA, Lyons J. Diplopia following cataract surgery: a review of 150 patients. Eye2008 22: 1057‐1064.
Cataract Surgery 1950’s ‐ 1970’s
– Patients left aphakic (no lens p (implant)
– High power glasses magnifyg p g g y• Create difference in image size
1980’s to present1980 s to present
– IOL’s and Phaco
– Increased patient expectationsexpectations
Diplopia is discussed– Diplopia is discussed more often in literature
Why would patients in today’s age get double vision?
• Retrobulbar anesthesia
• Patients with previous eye misalignment
• Monovision
MonovisionMonovision
Correct one eye to make distance sharp and the other y peye to make near vision sharp.– Contact lenses, cataract surgery, refractive surgery
f l d d– Benefit: No glasses needed– Drawback: Double vision, decreased depth perception
• 70% of patients developed diplopia two years after monovision
• 50% recovered 4 months after discontinuing monovision.
Pollard ZF, Greenberg MF, Bordenca M, Elliott J, Hsu V. Strabimus precipitated by monovision. Am J Ophthalmol. 2011 Sept;152(3):479‐82.
Refractive SurgeryRefractive Surgery
• What should be included in the pre‐operativeWhat should be included in the pre operative evaluation?
• Does strabismus preclude a patient from• Does strabismus preclude a patient from refractive surgery?
C f f bi b d i h• Can some forms of strabismus be treated with refractive surgery?
Pre‐operative EvaluationPre operative Evaluation
• History of strabismus / diplopiay / p p• BCVA• Manifest Refraction• If hyperopic check cycloplegic refraction• Use a lensometer ‐make sure no prism• Cross Cover• Trial of contact lenses if not aiming for emmetropiaemmetropia
Kushner BJ, Kowal L. Diplopia after refractive surgery: occurrence and prevention. Arch Ophthalmol. 2003 Mar;121(3):315‐21.
Can refractive surgery correct an eye lmisalignment?
• In a study of 16 hyperopic esotropes and 12In a study of 16 hyperopic esotropes and 12 myopic exotropes.– Improved ocular alignment in all.p g– No patient experienced decompensation of strabismus or diplopia.
• Why? – The patients need for glasses is contributing to the eye misalignment.
Kirwan C, O'Keefe M, O'Mullane G, Sheehan C. Refractive surgery in patients with accommodative and non‐accommodative strabismus ‐ one year prospective follow up. Br J Ophthalmol. 2009 Nov 30
TreatmentTreatment
• If strabismus ‐ have them evaluated by aIf strabismus have them evaluated by a strabismus specialist
• Under promise and over deliver ethos• Under‐promise and over‐deliver ethos
• Clear documentation of discussion and f ll l i i i iawareness of all relevant issues is imperative
Retinal DetachmentRetinal Detachment
• Diplopia is a well‐known complication of scleral p p pbuckling for retinal detachment. – 3‐20% for retrospective73% with transient diplopia in prospective– 73% with transient diplopia in prospective.
• Why?– Scarring of eye musclesScarring of eye muscles– Decreased vision post‐operatively– Macular not in same position– Large change in glasses prescription – buckle and/or oil
Sauer A, Bouyon M, Bourcier T, Speeg‐Schatz C. Diplopia complicating scleral buckling surgery for retinal detachment J Fr Ophtalmol 2007 Oct;30(8):785‐9retinal detachment. J Fr Ophtalmol. 2007 Oct;30(8):785 9.Kasbekar SA, Wong V, Young J, Stappler T, Durnian JM. Strabismus following retinal detachment repair: a comparison between scleral buckling and vitrectomy procedures. Eye. 2011: 25:1202‐06.
Type of DiplopiaType of Diplopia
• Diplopia 0.5% ‐ 20% after retinal detachmentp op a 0.5% 0% a te et a detac e t– Hypertropia – 58%– Horizontal deviation – 17%– Torsional – 46%
• More common in those with a scleral buckle.
Cooper LL, Harrison S, Rosenbaum AL. Ocular torsion as a complication of scleral buckle procedures for retinal detachments. J AAPOS. 1998 Oct;2(5):279‐84.
Scleral BuckleScleral Buckle
www.avclinic.com/ScleralBuckle.jpg
TreatmentTreatment
• Time
• Prisms
• Blurring of second image
• Scleral buckle removal???
• Strabismus surgery
Santiago AP, Rosenbaum AL. Strabismus following scleral buckle. In: Rosenbaum AL, Santiago AP. (eds). Clinical Strabismus Management - Principles and Surgical Techniques, Chap. 28. WB Saunders Company: Philadelphia, 1999.
TreatmentTreatment
• Removal of buckle has minimal improvementRemoval of buckle has minimal improvement on strabismus.
• Re detachment rate of 4 33% for scleral• Re‐detachment rate of 4 – 33% for scleral buckle removal for various reasons.
R d i i i i i i l i• Recommend minimizing tissue manipulation to perform strabismus surgery.
Wong V, Kasbekar S, Young J, Stappler T, Marsh I, Durnian JM. The effect of scleral exoplant removalon strabismus following retinal detachment repair. J of APPOS. 2011;14:331‐333.
Goezinne F, Berendschot TJM, Van Daal EWM, Janssen LCH, Liem ATA, Lundqvist IJ, Hendriskse F, Heij EC.Diplopia was not predictable and not associated with buckle position after scleral buckling surgery for retinal detachment. Retina. 2012;32 (8); 1514‐24.
GlaucomaGlaucoma
• DiplopiaDiplopia – Trabeculectomy
Glaucoma drainage device– Glaucoma drainage device
Glaucoma Drainage Devices
Molteno and Double Plate Molteno
BaerveldtMolteno 3
Krupin
Ahmed
Molteno 3
Type of ImplantType of Implant
• Highest incidence with Baerveldt and Krupin g est c de ce t ae e dt a d upglaucoma implant.– Largest plates.– Plates are tucked under rectus muscles
Frank JW, Perkins TW, Kushner BJ. Ocular motility defects in patients with the Krupin valve implant. Ophthalmic Surg. 1995 May‐Jun;26(3):228‐32.westcoastglaucoma.com
EtiologyEtiology• Space occupying effect from the plate.
I h i N i M l t• Ischemia, Necrosis or Muscle trauma.
• Poor vision causing sensory exotropia
• Scarring • Limits movement in the direction
f f h lof action of the muscle.
Santiago AP, Rosenbaum AL. Strabismus following glaucoma drainage device. In: Rosenbaum AL, Santiago AP. (eds). Clinical Strabismus Management ‐ Principles and Surgical Techniques, Chap. 28. WB Saunders Company: Philadelphia, 1999.
Surgical TreatmentSurgical Treatment
• Discussion between glaucoma and strabismusDiscussion between glaucoma and strabismus specialist.
• Treatment:• Treatment: – Complete removal scarring around implant.
Si d i f h i l l i h l f l– Size reduction of the implant plate is helpful.• In one study of 7 patients, it did not interfere with IOP controlcontrol.
– Strabismus surgery on the contralateral eye if mild restriction.restriction.
Diplopia after Eye SurgeryDiplopia after Eye Surgery
• Not as uncommon as we would likeNot as uncommon as we would like
• Try and identify those patients at risk
dif i l h i li i i k• Modify surgical techniques to limit risk.
Thanks and have a great evening!Thanks and have a great evening!