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Consecutive Exotropia 1. General comments 2. Surgical audit

Consecutive Exotropia 1. General comments 2. Surgical audit. Lionel Kowal, Director Elaine Wong, 2005 Registrar & 2006 Fellow OCULAR MOTILITY CLINIC & CERA, RVEEH, MELBOURNE. CONSECUTIVE XT. Any XT happening after previous ET [usually after ET surgery] Rare: spontaneous consecutive XT.

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Consecutive Exotropia 1. General comments 2. Surgical audit

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  1. Consecutive Exotropia 1. General comments2. Surgical audit Lionel Kowal, Director Elaine Wong, 2005 Registrar & 2006 Fellow OCULAR MOTILITY CLINIC & CERA, RVEEH, MELBOURNE

  2. CONSECUTIVE XT • Any XT happening after previous ET [usually after ET surgery] • Rare: spontaneous consecutive XT Old medial rectus Surgery

  3. CONSECUTIVE XT - WHY? • Ciancia: CET. n=390. perfect early alignment after Cong ET surgery  30% consec XT over next 25y • Reason #1: If repositioned MR successfully aligns the eyes, subsequent growth of globe, muscle, orbit may alter this mechanical ‘balance’  mechanical disadvantage of repositioned MR * The ET correction doesn’t ‘grow’ with the pt * *Speculative - no evidence

  4. The ET correction doesn’t ‘grow’ with the pt • Globe growth: ? Rc changes the way the sclera anterior to the new insertion subsequently grows : a 5mm Rc becomes a 7mm Rc * *Speculative - no evidence

  5. Core defect in consec XT • Usually medial rectus underaction • Rx: Have to make MR function normal [or near- normal] for satisfactory long term result

  6. #1 : L XT ‘A’ pattern L>R MR UASO OA OU Sup obl OA OU L XT XT greater on downgaze ‘A’ pattern MR UA L > R

  7. #2, RMR UA R XT RMR UA Right Gaze LMR normal

  8. #3, RMR UA RMR UA R XT

  9. #4, LMR UA LMR UA L XT

  10. Early consec XT - WHY?More reasons • #2: Wrong surgical dose Surgical tables assume normal globe size, average muscle stiffness [L-T curve], average scleral rigidity, average mechanical response of antagonist, …. • #3: Poor surgical technique • #4: Knots come undone • #5: Poor / aberrant early healing Vicryl hydrolysis not uniform

  11. Delayed consec XT - WHY? Reason #6 • ‘Stretched scar’ - look for stretchmarks, healing of other surgical scars, …. • Scar remodelling is an ongoing lifelong process • Scar is metabolically more active than tendon • Ludwig IH J AAPOS. 2000 & Trans Am Ophthalmol Soc. 1999 • Use non- absorbable sutures -  recurrence of stretched scar Reason #7: Scar migration* [Ludwig] *Speculative - no evidence

  12. Audit of Consecutive XT • LK private pts, 2y to Oct 2005: • 91 cases of consec XT • Av time to XT ~ 8 y • 58/91 : XT surgery by LK • 32 : follow up ≥1 y • Number of surgeries: 1- 4 • Median: 1 • Average:1.3 • Botox for consec ET : 4 (10%) • Adjustables: 19 (57 %)

  13. These are difficult cases • Need to make MR function normal or XT will recur • Difficult to dissect out tendons • Muscle ‘meat’ can be 20+ mm from limbus • Adjustables often necessary [57%] • Fat may be present • NO surgical tables • Guide: Early ET ≥ 10 ∆

  14. Pre-op: Range 6 – 66 XT; Av 31XTPost-op: Range 18ET – 45XT; Av 02/32: ended up worse! - work in progress

  15. 22/32 ≤ ± 10 ∆ 3/32 10% poor result

  16. Amblyopia no guide to surgical outcome

  17. Hyperopia no guide to surgical outcome

  18. Younger pts less likely to get bad results

  19. RESULTS 1 • Gomez De Liano Sanchez et al • Consecutive exotropia surgery Arch Soc Esp Oftalmol. 2001 • Retrospective n= 30 • Before surgery, 53% amblyopia, 67% rotation limitation. • LR Rc OU for < 35 ∆ • Advance 1-2 MR if > 35 ∆ • 70%: ≤± 10∆ > 50% one surgery.

  20. RESULTS 2 • Donaldson MJ, Forrest MP, Gole GA Surgical management of consec XT J AAPOS. 2004 • n=59. F/up ≥ 6w [mean 16 mo] • Sx : LR Rc, MR adv to original insertion • Time to XT Sx mean 14y (4mo-47 y) LK 8y • Mean preop XT 32 ∆ LK 31∆ • Result ≤±10∆ : 71% @ final follow-up LK 71% • 66% : exodrift after surgery - mean 8 ∆

  21. Spontaneous consecutive XT • 2 cases of spontaneous consecutive XT • 2% of all consecutive XT • High +, amblyopia, cong ET • # 1 : 10 yo F, infantile ET • XT first noted ~ 2 yo • Now XT 10Δ with V • R +8.75, L +7.00 • R amblyopia 6/12 • No surgery

  22. Spontaneous consec XT • # 2 • 30 yo F • Infantile ET ? Age onset XT • RXT 35Δ • R +7.50, L +4.50 • R 6/45 • R Rc/ Rs : RET 7Δ

  23. Spontaneous consec XT • Alan Scott : unpublished series n= 19 • ET ≤ 20 ∆ Onset ≤ 2y • ≥ + 4 DS Amblyopia ≥ 1 line • 12/19 : spontaneous consec XT • Only 4/19 stayed ET • ET usually declined ≥ age 5 • “This set you don’t want to touch surgically at an early age” • LK: 70 pts with ET > +6 2003-5 • 2/70 spontaneous consec XT

  24. SUMMARY - CONSEC XT • Difficult • Common in a dedicated strabismus practice • Common in a cong ET population • Expect 70% to do very well • Expect 10% not to do very well

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