1

Clinical Testing and Clinical Testing and Treatment of Infantile StrabismusTreatment of Infantile Strabismus

Curtis R. Curtis R. Baxstrom,MA,OD,FCOVD,FNORABaxstrom,MA,OD,FCOVD,FNORA

55thth International Congress of Behavioral OptometryInternational Congress of Behavioral OptometrySydney, AustraliaSydney, Australia

April 22, 2006April 22, 2006

IntroductionIntroduction

Infant BinocularityInfant Binocularity

Is an infant binocular at birth ?Is an infant binocular at birth ?ExotropiaExotropia vs. vs. EsotropiaEsotropiaCongenital vs. Infantile Congenital vs. Infantile EsotropiaEsotropiaSingle vs. Multiple Causal FactorsSingle vs. Multiple Causal FactorsEsotropiaEsotropia -- Time of OnsetTime of Onset

Single vs. Multiple Factors Single vs. Multiple Factors Leading to StrabismusLeading to Strabismus

2

Possible Factors of StrabismusPossible Factors of Strabismus

GeneticsGeneticsOrientation and LocalizationOrientation and LocalizationReciprocal InterweavingReciprocal Interweaving((bilateralitybilaterality, reflexes, etc.), reflexes, etc.)AccommodationAccommodationAbduction DeficitsAbduction DeficitsMotion ProcessingMotion ProcessingVestibular influencesVestibular influencesCross fixationCross fixationEffects of treatment (lenses, Effects of treatment (lenses, etc)etc)

InterocularInterocular DifferencesDifferencesand and EmmetropizationEmmetropizationMotor to Sensory Motor to Sensory DevelopmentDevelopmentVisual Field developmentVisual Field developmentand similarities within the and similarities within the visual fieldsvisual fieldsPrinciples of developmentPrinciples of developmentAttentionalAttentional DistributionDistributionSystemic Disease / TraumaSystemic Disease / TraumaMonodeprivationMonodeprivation (cornea, (cornea, lens)lens)

Time of Onset for StrabismusTime of Onset for Strabismus

4 Months 4 Months -- supinesupine9 Months 9 Months –– sitting / standingsitting / standing18 Months 18 Months -- locomotionlocomotion3 Years 3 Years -- preschool, moving in spacepreschool, moving in space

Differential DiagnosisDifferential DiagnosisAccommodative Accommodative esotropiaesotropiaPseudoesotropiaPseudoesotropiaDuaneDuane’’s Type Is Type INystagmusNystagmus Blockage SyndromeBlockage Syndrome66thth Nerve ParesisNerve ParesisOthersOthers

3

uncommonuncommonuncommon

commoncommoncommon

IOOAMotion AsymmetryVOR

uncommoncommonDVDuncommoncommonL or ML nystagmuscommonuncommonAmblyopia> + 3.00 sphere< + 3.00 sphereRefraction10 to 40 PD25 to 60 PDAngle>6 months to 7 yearsBirth to 6 monthsOnset

AccommodativeInfantile

Infantile vs. Accommodative Infantile vs. Accommodative EsotropiaEsotropia

Developmental ConsiderationsDevelopmental Considerationsand Unique Characteristics to and Unique Characteristics to

Consider When Evaluating Consider When Evaluating InfantsInfants

Developmental Considerations Developmental Considerations and Modelsand Models

KraskinKraskin –– ““Three Fundamental AbilitiesThree Fundamental Abilities””RethyRethy––““Vision moves from motor to sensoryVision moves from motor to sensory””Sutton Sutton –– ““Movement is learningMovement is learning””StreffStreff –– ““Vision is MotorVision is Motor””Pepper Pepper –– ““Principles of MovementPrinciples of Movement””

Three Fundamental Abilities Dealing with the Space Construct

Information Processing

Movement Patterns Three Fundamental Abilities

Balance with Gravity Where am I?

Orientation Freedom to compute

Balance with Task Where is it?

Localization Range to compute

Manipulate Task What is it?

Centering/Identification Facility to compute

4

RethyRethy –– Motor to SensoryMotor to Sensory Quantitative vs. Qualitative Quantitative vs. Qualitative Information Information -- RGMRRGMR

Skeletal Component Skeletal Component -- seek and hold imageseek and hold imageVisceral Component Visceral Component -- discriminates and discriminates and defines the imagedefines the imageCortical Component Cortical Component -- unifies and interprets unifies and interprets the imagethe image

Visual Models and RGMRVisual Models and RGMR

Optical Model Optical Model -- primarily skeletalprimarily skeletal•• Reach Reach -- vergencevergence•• Grasp Grasp -- accommodationaccommodation•• Release Release -- change fixation or attentionchange fixation or attentionDevelopmental Model Developmental Model -- adds visceral and adds visceral and corticalcortical•• ManipulateManipulate

Projection Projection -- as if it were as if it were ……PrehensionPrehension -- localize with hands, confirmationlocalize with hands, confirmationLocomotion Locomotion -- time and space beyond reachtime and space beyond reach

Projection and ManipulationProjection and Manipulation

5

Principles of Movement (RGMR)Principles of Movement (RGMR)

Can I do it ?Can I do it ?How well can I do it ?How well can I do it ?How long can I do it ?How long can I do it ?Can I accept change ? Can I accept change ? Can I problem solve ?Can I problem solve ?

Evaluation of InfantsEvaluation of Infants

6

What is the most importantWhat is the most importantcomponent of an infant exam?component of an infant exam?

Does the Case History tell us Does the Case History tell us everything?everything?

How about motor development as an How about motor development as an indicator of visual development?indicator of visual development?

PrematurityPrematurityTodayToday

30 weeks >80% live30 weeks >80% live26 weeks 50% live26 weeks 50% live24 weeks >25% live24 weeks >25% live

10 Years Ago10 Years Ago28 weeks 50% lived28 weeks 50% lived26 weeks none lived26 weeks none lived

Evidence for Developmental HxEvidence for Developmental HxMajor A, Maples WC, Toomey S, DeRosier W, Gahn D. RetrospectiveMajor A, Maples WC, Toomey S, DeRosier W, Gahn D. Retrospective

study of factors associated with infantile esotropia. Submittedstudy of factors associated with infantile esotropia. Submitted for for publication Optom Vis Sci. 2005.publication Optom Vis Sci. 2005.

Pulled Hastings Records and Looked for Pulled Hastings Records and Looked for Infantile Esotropia Dx that had not been Infantile Esotropia Dx that had not been previously treatedpreviously treatedCompared to matched to non esotropes by Compared to matched to non esotropes by age and genderage and gender•• Twenty Six Factors EvaluatedTwenty Six Factors Evaluated•• Twelve were significant at .05 or betterTwelve were significant at .05 or better

7

Evidence for Developmental HxEvidence for Developmental HxMajor A, Maples WC, Toomey S, DeRosier W, Gahn D. RetrospectiveMajor A, Maples WC, Toomey S, DeRosier W, Gahn D. Retrospective

study of factors associated with infantile esotropia. Submittedstudy of factors associated with infantile esotropia. Submitted for for publication Optom Vis Sci. 2005.publication Optom Vis Sci. 2005.

0

2

4

6

8

10

12

Odds Ratio

PrematFam O HxCardio DisSyst DisHBP Preg< Birth WtOxygenGI DisMaleOtit MedC SectAugm LabResp Dis

Behavioral Observations Behavioral Observations --Manipulation and ProjectionManipulation and Projection

Fundamental abilities to learn the Fundamental abilities to learn the construct of space and timeconstruct of space and timeProjection Projection -- static or dynamic?static or dynamic?PrehensionPrehensionDevelopment of Postural ControlDevelopment of Postural ControlLocomotionLocomotionDonDon’’t forget the factor of timet forget the factor of time

Visual AcuityVisual Acuity

Changing optical properties, focusingChanging optical properties, focusingDifferentiation of fovea, changes in Differentiation of fovea, changes in photoreceptors and dendritesphotoreceptors and dendritesMyelinationMyelination of visual pathwayof visual pathwayIncreased synaptic connectivity and Increased synaptic connectivity and pruningpruning* Changes in arousal, sleep cycles* Changes in arousal, sleep cycles

8

Methods and ProbesMethods and Probes

Fix and follow, resistance to occlusionFix and follow, resistance to occlusionOKNOKNTeller cardsTeller cardsFace Dot paddleFace Dot paddleOther FPL cards / paddlesOther FPL cards / paddlesElectrodiagnosticElectrodiagnostic –– VEP / VERVEP / VER

9

RetinoscopyRetinoscopy and and Refractive StatusRefractive Status

Special ConsiderationsSpecial Considerations

Qualitative factors Qualitative factors -- brightness, pattern, brightness, pattern, color, equalitycolor, equalitySingle vs. multiple distancesSingle vs. multiple distancesAutorefractorsAutorefractorsFour steps to binocularityFour steps to binocularity--GetmanGetmanX 180X 180--horizontal scan, X 90horizontal scan, X 90--vertical scanvertical scanX 45/135 (looking at two places at once?)X 45/135 (looking at two places at once?)CycloplegiaCycloplegia (dilation enough)(dilation enough)

Color of Color of RetinoscopyRetinoscopy (OEP 1958)(OEP 1958)

Dull RedDull Red--low recognition or awarenesslow recognition or awarenessBright PinkBright Pink--better recognition, not on spatiallybetter recognition, not on spatiallyDull PinkDull Pink--first indication of quality reflexfirst indication of quality reflexWhite PinkWhite Pink--better quality, some refractory statesbetter quality, some refractory statesWhiteWhite--now now ““setset”” with quality and consistencywith quality and consistency

10

Development of Development of RetinoscopicRetinoscopic Reflex in InfantsReflex in Infants

Findings of Findings of GetmanGetman, up to 8 months, up to 8 monthsRandom StageRandom StageRight or Left StageRight or Left StageRight and Left StageRight and Left StageBilateral StageBilateral Stage

AccommodationAccommodationGross vs. FineGross vs. FineStriated vs. Smooth tissueStriated vs. Smooth tissueCenter of rotation, projection ( as if )Center of rotation, projection ( as if )

Fixation and Abduction DeficitsFixation and Abduction DeficitsFixation is a volitional limitation of movementFixation is a volitional limitation of movementHirschberg differencesHirschberg differencesNasal retina more dominantNasal retina more dominantVolitional abduction deficit with corresponding Volitional abduction deficit with corresponding cross fixation patterncross fixation patternRelative abduction deficit not present or less Relative abduction deficit not present or less with dollwith doll’’s eye test (s eye test (vestibularlyvestibularly driven)driven)Gaze palsyGaze palsy

Pursuit and OKN Pursuit and OKN AsymmetriesAsymmetries

11

Asymmetry in PursuitsAsymmetry in Pursuits

Asymmetry in Motion ProcessingAsymmetry in Motion Processing

12

Vestibular Ocular EvaluationVestibular Ocular Evaluation

IOOA IOOA –– Inferior Oblique Inferior Oblique OveractionOveraction

DVD DVD –– Dissociated Vertical Dissociated Vertical DeviationDeviation

and the Dorsal Light Reflexand the Dorsal Light Reflex

13

StereopsisStereopsis

Visual Fields Visual Fields -- binocular binocular hemifieldhemifield

BirthBirth 1717--34 degrees34 degrees3 Months3 Months 4040--50 degrees50 degrees6 Months6 Months 7070--84 degrees84 degrees

14

Treatment of Treatment of Infantile Infantile EsotropiaEsotropia

Traditional Medical ApproachesTraditional Medical Approaches

Do Nothing, Deny EverythingDo Nothing, Deny EverythingLenses to Lenses to ““correctcorrect”” refractive errorrefractive errorUnilateral patchingUnilateral patchingMuscle SurgeryMuscle SurgeryBotoxBotox injectionsinjections

Traditional Optometric ApproachTraditional Optometric Approach

Do NothingDo NothingVisual GuidanceVisual GuidanceLenses, PrismsLenses, PrismsSelective OcclusionSelective OcclusionVision TherapyVision Therapy•• DirectDirect•• Delayed or PassiveDelayed or Passive

15

Procedures Should PossessProcedures Should PossessFour CharacteristicsFour Characteristics

Must be of value in itselfMust be of value in itselfAll techniques should be related in some fashionAll techniques should be related in some fashionAll techniques should set the stage for what All techniques should set the stage for what follows, or establish a better foundationfollows, or establish a better foundationEach technique should serve as a measuring Each technique should serve as a measuring device (patient and therapist)device (patient and therapist)

Traditional Visual GuidanceTraditional Visual Guidance

Refractive StatusRefractive Status

Smith and Atkinson support less than full Smith and Atkinson support less than full manifest refractionmanifest refractionQuality and range of visual contactQuality and range of visual contactSymmetrySymmetryWatch facial changesWatch facial changes

Selective OcclusionSelective OcclusionCompleteCompleteFull vs. Part TimeFull vs. Part TimeSelectiveSelective•• Area Area –– sector, sector, binasalbinasal, dot, dot•• Graded to OpaqueGraded to Opaque•• Set vs. alternating patternSet vs. alternating pattern

16

Why might sector occlusion help?Why might sector occlusion help?

Eliminates cross fixation patternEliminates cross fixation patternPrevent Prevent amblyopiaamblyopiaPrevent anomalous correspondencePrevent anomalous correspondencePromote alternation of eyesPromote alternation of eyesDecrease confusion / strabismusDecrease confusion / strabismusModify visual field relationshipsModify visual field relationshipsModify amount and quality of light between eyes Modify amount and quality of light between eyes (suppression)(suppression)Easier adaptation versus full occlusionEasier adaptation versus full occlusion

Treatment of InfantsTreatment of InfantsBeyond the Optical ModelBeyond the Optical Model

Extended Visual GuidanceExtended Visual GuidanceCranial Osteopathy / CranialCranial Osteopathy / Cranial--SacralSacralAbduction Deficit / Cross FixationAbduction Deficit / Cross FixationMotion AsymmetriesMotion AsymmetriesVestibular ConsiderationsVestibular ConsiderationsLater influences of accommodationLater influences of accommodationDo developmental delays and conditions Do developmental delays and conditions affect our outcomes ?affect our outcomes ?

What is the single greatest What is the single greatest factor impeding our success factor impeding our success

with infantile with infantile esotropiaesotropia ??

Extended Visual GuidanceExtended Visual GuidanceBasicsBasics-- change crib, viewing positions, inform regarding change crib, viewing positions, inform regarding johnnyjohnny jump ups, walkers, etc.jump ups, walkers, etc.BilateralityBilaterality, Reciprocal Interweaving (Rowley), Reciprocal Interweaving (Rowley)Arousal state should be consideredArousal state should be consideredAttentionalAttentional DistributionDistributionBreaking of Breaking of esotropiaesotropia patternpattern•• McCarthy(4mo) and McCarthy(4mo) and NasopalpebralNasopalpebral Reflex, blinkReflex, blink

Watch for occlusion factorsWatch for occlusion factorsIncrease lateral viewing and vestibular rotational Increase lateral viewing and vestibular rotational activities activities Biochemical and nutritional considerationsBiochemical and nutritional considerationsOthersOthers

17

Cross Fixation and Abduction Cross Fixation and Abduction DeficitsDeficits

Cross FixationCross Fixation-- binasalsbinasals, sector, sectorAbduction DeficitAbduction Deficit•• Cranial Osteopathy/Cranial SacralCranial Osteopathy/Cranial Sacral•• Pursuits/Saccades Pursuits/Saccades -- LudlamLudlam•• OKNOKN•• DollDoll’’s Eye s Eye -- vary speed and rangevary speed and range•• Vestibular Vestibular -- Rotational TherapyRotational Therapy

Cranial Osteopathy / Cranial Osteopathy / Cranial Sacral TherapyCranial Sacral Therapy

Cranial pulse or rhythmCranial pulse or rhythmCranial molding and movementCranial molding and movementPetrosphenoidalPetrosphenoidal Ligament / Ligament Ligament / Ligament of Gruberof Gruber

See See www.cranialacademy.comwww.cranialacademy.com

18

Motion Processing AsymmetryMotion Processing Asymmetry

Pursuits Pursuits -- slow to faster (N to T)slow to faster (N to T)OKN OKN -- slow to faster (N to T)slow to faster (N to T)Watch for changes in Watch for changes in stereopsisstereopsis

19

Vestibular Ocular ConsiderationsVestibular Ocular Considerations

What keeps an infants eyes straight at What keeps an infants eyes straight at birth ?birth ?Vertical strabismus prior to age one?Vertical strabismus prior to age one?Self stimulation for improving Self stimulation for improving bilateralitybilateralityArousalArousal

Vestibular ProtocolVestibular Protocol

Reason for vestibular stimulationReason for vestibular stimulationChild likes itChild likes itArousalArousalSymmetrical ocular motor toneSymmetrical ocular motor toneIncrease ROM, change pattern of gaze palsyIncrease ROM, change pattern of gaze palsyCombined with prism compensation, for angle Combined with prism compensation, for angle reductionreduction

Vestibular ProtocolVestibular ProtocolEyes closed or in dark roomEyes closed or in dark roomIn lap, chair or heldIn lap, chair or heldHead position for lateral SC canalsHead position for lateral SC canalsRotationsRotations-- minimum 1, maximum 10minimum 1, maximum 10Fixation activity post rotation, also can use Fixation activity post rotation, also can use mirror if single caregivermirror if single caregiverUncover or lights on for fixationUncover or lights on for fixationSpeed Speed –– just under 1 cycle per secondjust under 1 cycle per secondPREVENTION/GUIDANCEPREVENTION/GUIDANCE--lateral swingslateral swings

20

Infantile Infantile EsotropiaEsotropia CasesCases

Treatment SummaryTreatment Summary

Case History and EvaluationCase History and EvaluationVisual HygieneVisual HygieneAppropriate LensesAppropriate LensesSelective Occlusion for Cross Fixation Selective Occlusion for Cross Fixation Range of Movement for Abduction Deficit and/or Range of Movement for Abduction Deficit and/or Cranial OsteopathyCranial OsteopathyOnce binocularity established, consider Once binocularity established, consider removing toolsremoving toolsAppropriate followAppropriate follow--up careup care

Thank you for your Thank you for your interest in this special interest in this special

population !population !