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Strabismus Surgery and the Late Elderly

Strabismus Surgery and the Late Elderly. Logan Mitchell Lionel Kowal RVEEH, Melbourne Private Eye Clinic, Melbourne. “Elderly” - who?. Older than me? Older than my parents? WHO: No definition Geriatric literature Early elderly = 65 – 75 years old Late elderly = ≥75 years old.

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Strabismus Surgery and the Late Elderly

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  1. Strabismus Surgery and the Late Elderly Logan Mitchell Lionel Kowal RVEEH, Melbourne Private Eye Clinic, Melbourne

  2. “Elderly” - who? • Older than me? • Older than my parents? • WHO: No definition • Geriatric literature • Early elderly = 65 – 75 years old • Late elderly = ≥75 years old

  3. Australian population data 22.5 million (2010 est.) Life expectancy at birth: 82 yrs Ageing population 65 yrs and older 13.5% (2009 est.) = 3 million 25% (2042 est.) = 6.2 million “Elderly” - how many?

  4. “Elderly” and Strabismus • Prevalence ~ 4% (adult strabismus) • No population-based data on “elderly” population • 6600 Medicare-billed strabismus operations • 27 million eligible patients • 2.4%

  5. “Elderly” and Strabismus • Prevalence of strabismus in >65 year olds (assumptive) • 4% prevalence adult strabismus • 120,000 in 2009 • 250,000 in 2042

  6. Elderly Strabismus – the literature • 4 papers • Paper #1 • Repka JAAPOS 2007 as described • 70% horizontal surgery • 14% reported as re-operations (?low)

  7. Elderly Strabismus – the literature • Paper #2: Magramm & Schlossman JPOS 1991 • Retrospective • 104 pts • mean 69 yrs old (60-89) • ¼ cosmetic indication, ¾ diplopic • 1/3 childhood onset • Adult onset • Mean delay to surgery 8 yrs Aetiologies

  8. Elderly Strabismus – the literature • Paper #3: Dawson et al Strabismus 2001 • Retrospective • 111 patients • mean 67 yrs old (60-90) • ½ cosmetic, ½ diplopic • 1/3 childhood onset • Adult onset – similar aetiologies • Outcomes • ~60% orthotropic +/- 10∆ • 21% re-operation rate

  9. Elderly Strabismus – the literature • Paper #4: Rutar & Demer JAAPOS 2009 • “Heavy eye syndrome” in elderly • A la, but different from, ‘myopic strabismus fixus’ • Degeneration of SR-LR aponeurotic band

  10. Adult Strabismus (as substitute) • Adults delay seeking surgical correction • Mean delay 19 years • diplopic 15 yrs vs 28 yrs non-diplopic • Reasons

  11. Strabismus Surgery in the 'Late Elderly' • Aim • To Identify the characteristics and outcomes of patients undergoing strabismus surgery aged 75 years or older between October 2005 – October 2010 • Methods • Retrospective chart review • Locations • Private Eye Clinic (Dr Lionel Kowal) • RVEEH

  12. 35 patients Age: mean 79 years (75-95) Male:Female 16:19 Indications Cosmesis – 6 (17%) Diplopia – 29 (83%) Duration of symptoms: mean 12 years (0-69) 19 done with adjustable sutures 3 surgeries performed under regional anaesthetic Results

  13. Results • Previous surgeries • (plus 2 with previous botox)

  14. Aetiology of Strabismus

  15. 14 patients CNVI in 9 patients 5 compressive 2 ICA aneurysm (1 previous surgery) 2 meningioma 1 ependymoma 3 ischaemic / uncertain cause 1 traumatic (CHI) (1 previous surgery) CNIV in 6 patients 3 congenital 1 with 2 previous surgeries Remaining 2: average duration of diplopia = 6 years 3 uncertain aetiology CNIII in 1 patient Combined with CNVI in ICA aneurysm patient Neuroparalytic Strabismus

  16. Restrictive Strabismus • 8 patients • 3 thyroid eye disease • Mean duration on symptoms: 1.3 years • 4 traumatic / iatrogenic • 2 previous retinal detachment surgery • 1 previous sinus surgery • 1 previous orbital trauma • 1 Brown’s syndrome • Symptoms for >50 years

  17. Decompensated Phoria • 7 patients • 5 with decompensated intermittent exotropia • 2 decompensated divergence insufficiency • Mean duration of symptoms: 37 years

  18. Consecutive Exotropia • Only 2 patients • Childhood esotropia • Previous surgery x 1, and x 3 • Mean duration of misalignment: >40 years

  19. Outcomes • Mean follow-up 8 months • “Overall”

  20. Outcomes • Diplopia

  21. Outcomes in Neuroparalytic Cases • “Overall” result • Diplopia

  22. Outcomes in Other Cases • “Significant improvement” or better • Restrictive strabismus 88% • Decompensated phoria 86% • Consecutive exotropia 100%

  23. Complications • Couldn’t find a muscle (2) • Post-childhood trauma, consecutive XT • Re-operations (3 = 8.6%) • 2 on one patient (SOP), 1 on 95 year old lady (XT) • Recurrences (6) • Dealt with prisms in 4 cases • No known systemic complications

  24. Conclusions (I) • Strabismus in the very elderly • Exists • Is not extremely rare • Will increase • Is under-represented in the literature • Diplopia is a frequent indication for surgery • Patients delay surgery • Often at our (medical) behest • Varied aetiologies • Neuroparalytic causes common (note compressive causes)

  25. Conclusions (II) • Surgical considerations • Systemic risk of general anaesthetic • ?risk of regional anaesthetic • Thinner conjunctiva • Risk of anterior segment ischaemia • Probably 2 muscles maximum • Diplopic indication common • More accurate surgery, adjustable sutures

  26. Conclusions (III) • Surgery is reasonably successful • Very low risk of making things worse (1/35) • 68% achieved at least significant improvement • ?More guarded success in neuroparalytic patients • 83% free of diplopia (with/without prisms/AHP)

  27. Thank You

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