Eso deviation

ESO DEVIATION

Prepared by:

Anis Suzanna Binti Mohamad

Optometrist

B.Sc (Hons) UKM

Different type of deviations

Convergent Squint

Divergent Squint

Vertical Squint

ESOTROPIA

Eso Deviation

Eso

Tropia Phoria

1° 2 ° Consec. i. Conv. ExcessConstant ii. Div. Weaknessi. withAccom. Elem. iii. Non-specificii. without Accom. Elem. Intermittenti.Accom.

ii. Distance - near eso

- distance esoiii. Time - cyclic/alternate day squintiv. Non-specific

Fully Accom. Esotropia

Normal BSV for all distances when hypermetropia is corrected.

Manifest convergent dev. – without hypermetropic correction.

Fully Accom. Esotropia

Aetiology :Low uncorrected hypermetropia (<3DS)

- squint not develop if patient has sufficient base in fusional vergences.

Moderate degrees hypermetropia (3-5DS) – amount of NFR not enough to overcome conv. esotropia.

High degree hypermetropia (>5DS) – insuperable hypermetropia – patient remain straight or occasionally diverge.

Fully Accom. Esotropia

Investigation :Age of onset – 2-3 years old – starts to be

interested in close work.FH Refraction VA – may be reduced in deviating eye.HirschbergCT – with and without glasses.OM Convergence – with glasses – binoc. to 6cm.

Fully Accom. Esotropia

- Strength of BSV – BVA, PFR, synopthophore.- PCT – with and without glasses.

Management

-Prescribe fully hypermetropic lenses-Gls. worn full time-Occlusion – if amblyopia present-Orthoptic exercises – to strengthen BSV

Fully Accom. Esotropia

Convergence Excess Esotropia

Normal BSV at distance and esotropia on accommodation for near fixation.

Aetiology :- *High AC/A ratio (5/6 times normal

amount)- Remote near point of accom.- Onset – 3-5 years of age

Convergence Excess Esotropia

Investigation :- Fundi and Media check- Refraction- VA – likely to be equal- CT - - OM- Convergence- Assessment of strength of BSV- PCT- AC/A ratio

Convergence Excess Esotropia

Management :

-Prescribe hypermetropic correction if required

-Treat any amblyopia

-Surgery

-Other methods :

- Bifocals – combine with orthoptic exercise

- Contact lens

Near Esotropia

- also known as non-accom. conv. excess eso

- Manifest deviation at near (irrespective of accom.) and BSV at distance.

- Aetiology : excess tonic convergence

Near Esotropia

Investigation :- Fundi and Media check- Refraction- VA- CT- OM- Convergence- Assessment of BSV- PCT

Near Esotropia

Management :

- Surgery

Distance Esotropia

- Manifest convergent deviation at distance

- BSV at near

- Has to be differentiated from mild 6th nerve palsy, Accom./convergence spasm and divergence paralysis.

Distance Esotropia

Investigation :- Fundi and Media check- Refraction- VA- CT- OM- Convergence- Assessment of BSV- PCT

Distance Esotropia

Management :

- rare type of deviation

- Important to differentiate from mild 6th nerve palsy.

- Surgery done generally : Bilateral LR resection.

Primary Cyclic Esotropia

Esotropia occurs at regular intervals (48hrs)Onset : 4-5 years oldEmmetropic and equal VA

Management :- deviation generally becomes more constant.- Surgery : MR recess + LR resect- Prognosis : good, even when surgery done on

straight day.

Primary Constant Esotropia

Esotropia with accom. Element

- eso increase on accom.

- eso may be reduced with any necessary

hypermetropic correction.

- also known as partial accom. esotropia.

Primary Constant Esotropia

Esotropia without accom. Element

- deviation unaffected by accom.

- significant ref. error unlikely to be

present

- Types : infantile esotropia, acquired

non-accom. esotropia, nysragmus

blockage syndrome, normo-sensorial late

onset esotropia.

Primary Constant Esotropia

Normosensorial late onset esotropia

- onset – 2-4 years of age

- NRC

- normal sensory and motor fusion

Management :

- Surgery – when dev. Stable (if indicated).

Primary Constant Esotropia

Nystagmus Blockage syndrome- use conv. to block manifest nystagmus- Nystagmus – congenital, horizontal,

manifest.- Nystagmus – increase in intensity on

abduction and blocked on adduction.- Esotropia – non-accom., variable.- Face turn towards fixing eye

Primary Constant Esotropia

- BE appears conv. Though esotropia is unilat.- DVD rare- Commonly associated with neurological disorders.- Results of strabismus – unpredictable

Management:- full correction- Treat amblyopia- Surgery

Primary Constant Esotropia

General Investigation :

Aim : - to make diagnosis

- assess whether potential for BSV present.

- gain further information to base

management upon.

Primary Constant Esotropia

- Fundi and Media check- Refraction- Case history- VA- CT- OM- Conv.- Suppression- Fixation

Primary Constant Esotropia

Management :- Order any glasses necessary- Treat amblyopia- Determine if pot. BSV present :If present :- Prismotherapy

- advocated if deviation <25PD. - Strength of prism – latent dev. on CT and demonstrable BSV.

Primary Constant Esotropia

- aim : to reduce - may be combine with surgery- Orthoptic treatment to strengthen BSV.

If absent :

- surgery – to obtain cosmetically acceptable dev.- preferably small undercorrection.

Essential Infantile Esotropia

Primary Constant Esotropia

Essential Infantile Esotropia

- onset : first 6 month of life- Esotropia of unknown origin- Stable large angle eso > 30PD- Alternating with crossed fixation- Poor prognosis of BSV

Primary Constant Esotropia

- Commonly associated with DVD, o/action oblique muscles, AHP

- Amblyopia if not alternating

Management :- Full correction- Treat amblyopia- Surgery Primary Constant Esotropia

Primary Constant Esotropia

General Investigation :

Aim : - to make diagnosis

- assess whether potential for BSV present.

- gain further information to base

management upon.

Primary Constant Esotropia

- Fundi and Media check- Refraction- Case history- VA- CT- OM- Conv.- Suppression- Fixation

Primary Constant Esotropia

Management :- Order any glasses necessary- Treat amblyopia- Determine if pot. BSV present :If present :- Prismotherapy

- advocated if deviation <25PD. - Strength of prism – latent dev. on CT and demonstrable BSV.

Primary Constant Esotropia

- aim : to reduce - may be combine with surgery- Orthoptic treatment to strengthen BSV.

If absent :

- surgery – to obtain cosmetically acceptable dev.- preferably small undercorrection.

Secondary Esotropia

Esotropia following loss/impairment of vision

Blind at birth convergent/divergent deviation

Childhood blindness convergent

Secondary Esotropia

Possible cause :- Injuries- Corneal opacities- Congenital/Traumatic unilateral cataract- Optic Atrophy- Untreated anisometropia/amblyopia- Retinal detachment

Secondary Esotropia

Aims of investigation :- Assess VA of each eye – dictates test can

be carried out- Assess whether case is functional or

cosmetic (2º dev. rarely functional)- Assess angle of deviation

Secondary Esotropia

Investigation :- Refraction- History- VA- CT- OM- Measurement of the angle- State of BV (functional/cosmetic)- Post-op diplopia testManagement : surgery

Consecutive Esotropia

Esotropia in a patient who previously had an exotropia/exophoria.

Generally occur as a result of surgery- immediate or long term.

Consecutive Esotropia

Post-Operative Consecutive Esotropia

- may be deliberate

- may be due to over-liberal surgery e.g

LR recession or MR resection.

Management depend on whether the case is

functional or cosmetic.

Consecutive Esotropia

Aim :

Functional cases :- To assess presence of diplopia- To assess angle of deviation- To assess any amblyopia present- To assess BF/pot. for BSV- To assess suppression

Consecutive Esotropia

Cosmetic case :

Ultimate aim – cosmeticaaly good angle without diplopia.

- to assess angle of deviation- to assess any diplopia present- to assess suppression

Consecutive Esotropia

Investigation :- Fundus and Media check- History – patient may return many

years after original surgery. Historyrelating previous treatment important. Read operation notes if available. Ask if patient has symptoms – diplopia.

- VA – relate to vision pre-op.

Consecutive Esotropia

- CT – assess with care. If control present at any distance-do BSV test at that distance. Note if diplopia appreciated – note the type.

- OM – restriction, scars. Note if diplopia can be joined with AHP.

- Convergence

Consecutive Esotropia

- Suppression – density and area of suppression in functional case. Cosmetic case – if angle is small and suppressing – nothing to be done. If angle large and need resurgery – assess post-op diplopia test.

- Measurement of angle – near and distance. If diplopia present – see if it can be joined with prism.

Consecutive Esotropia

- AC/A ratio – in functional case –may influence type of treatment.