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Phospholine Iodide in the management of esotropia

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

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Phospholine Iodide in the management of esotropia

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  1. Phospholine Iodide in the management of esotropia Lionel Kowal Claudia Yahalom RVEEH / CERA Melbourne SQUINT CLUB DUNEDIN 2005

  2. 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

  3. CURRENT STATUS: • Difficult to obtain : application to TGA for each patient • Expensive [$A130 a bottle]

  4. PARKS 1958 ABNORMAL ACCOMMODATIVE CONVERGENCE IN SQUINT n=1249 • Old / difficult: Why bother? • because it sometimes works very well!

  5. PARKS 1958 ABNORMAL ACCOMMODATIVE CONVERGENCE IN SQUINT n=1249 • No Rx: n=73 • Isoflurophate n=47 .. after Rx is stopped • BMR n=104 18: no better • One MR n=74 26: no better

  6. PARKS 1958number where A:AC improved [ result perfect]

  7. 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

  8. 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+%]

  9. 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

  10. Definition of Outcomes • Success (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

  11. Table 1: Results of patients receiving PI according to indication for treatment

  12. 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

  13. 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.

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. ISOFLUROPHATE FOR RECURRENT ETMims & 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

  25. 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.

  26. Aphorism of Hippocrates 300BC Life is short The art long Opportunity fleeting Experiment treacherous Judgement difficult

  27. Conclusion PI has a useful role in the treatment of recurrent ET, if glasses will not be worn.

  28. Postoperative Miotics for patients with infantile esotropiaSpierer 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

  29. 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.

  30. References • Parks M. • ABNORMAL ACCOMMODATIVE CONVERGENCE IN SQUINT • AMA Archives of Ophthalmology • 1958: ;364-380

  31. Treatment groups

  32. Kids with ET and low plus (<4), who didn’t accept glasses: group A 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.

  33. B: ET and >+4 #1:↓ POTS for 4/12. Later ET 60∆→BMR A.ET = accommodative ET. PA = partially accommodative

  34. C: near only ET

  35. 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.

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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

  41. 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

  42. 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

  43. D: PI “rescue ” for recurrent / residual ET following surgery

  44. 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)

  45. 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

  46. 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

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