2016 asmph strabismus & amblyopia
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Transcript of 2016 asmph strabismus & amblyopia
Strabismus & Amblyopia
Alvina Pauline D. Santiago, MDNovember 2, 2016ASMPH
© AP Santiago 2016
Outline: Strabismus
❖ Definition
❖ Muscle Origin & Insertion, Function, Innervation
❖ EOM Concepts and Muscle Movements
❖ Laws of Ocular Motility
❖ Adjacent Anatomical Structures with Functional Correlations
© AP Santiago 2016
Strabismus: Definition
Any misalignment of the eyes
❖ Manifest vs latent:
-tropia vs –phoria
❖ Direction
❖ Eso-
❖ Exo-
❖ Hyper-
❖ Hypo-
© AP Santiago 2016 © AP Santiago 2016
Strabismus
© AP Santiago 2016
Extraocular Muscles 1. Medial Rectus2. Lateral Rectus3. Superior Rectus4. Inferior Rectus5. Levator Palpebrae
Superioris6. Muller’s Muscle
http://www.images.missionforvisionusa.org/anatomy/uploaded_images/eomMR-783818.jpg
© AP Santiago 2016
http://www.cambridgequestions.co.uk
Annulus of Zinn
© AP Santiago 2016
Spiral of Tillaux
www.cybersight.org
© AP Santiago 2016
Horizontal rectus muscles
Medial rectus Lateral rectus
© AP Santiago 2016
Vertical rectus muscles
Inferior rectus Superior rectus
© AP Santiago 2016
Oblique muscles
Superior obliqueInferior oblique
© AP Santiago 2016
EOM Muscle: MR & LR
Muscle Origin Insertion Innervation Action
Medial Rectus
Annulus of Zinn
5.5 mm from limbus
CN 3, inferior
Adduction
Lateral Rectus
Annulus of Zinn
6.9 mm from limbus
CN 6 Abduction
© AP Santiago 2016
EOM Muscle: Vertical SR & IR
Muscle Origin Insertion Innervation Action
Inferior Rectus
Annulus of Zinn
(inferior tendon of
Zinn)
6.5 mm from limbus
CN 3 inferior
DepressionExtorts
Adducts
Superior Rectus
Annulus of Zinn
(superior tendon of
Lockwood)
7.7 from limbus
CN 3 superior
ElevatesIntorts
Adducts
© AP Santiago 2016
Inferior Oblique
❖ Origin: Shallow depression on orbital plate of maxilla
❖ Insertion: inferotemporal quadrant of sclera near the macula Rangeen Shandran R.
http://www.slideshare.net/RangeenChandran
© AP Santiago 2016
Superior Oblique
❖ Origin: Lesser wing of sphenoid
❖ Functional origin: Trochlea
❖ Insertion: curved
❖ anterior: 12-14 mm behind limbus
❖ posterior 17-19 mm behind limbus OM Patel, http://www.slideshare.net/ompatel9889
© AP Santiago 2016
EOM Muscle: Oblique IO & SO Muscle Origin Insertion Innervation ActionInferior Oblique
Shallow depression on orbital plate of maxilla
Infero-temporal
quadrant of sclera near the macula
CN 3 inferior
ExtortsElevatesAbducts
Superior Oblique
Lesser wing of
sphenoid but
Functional origin:
Trochlea
anterior: 12-14 mm
behind limbusposterior
17-19 mm behind limbus
CN 4 IntortsDepressesAbducts
© AP Santiago 2016
Blood Supply
❖ ciliary arteries also arise from these muscular arteries
❖ 7 branches
❖ 2 per rectus muscle except LR which receives only 1
OM Patel, http://www.slideshare.net/ompatel9889
© AP Santiago 2016
EOM Muscle: Levator & Muller Muscle Origin Insertion Innervation Action
Levator Palpebrae Superioris
Under surface of
Lesser wing of Sphenoid
Levator Apo-
neurosis
CN 3 Superior
Lid elevation; Deepens palpebral
foldMuller’s Muscle
(superior palpebral muscle)
Inferior and bulbar
aspect of Levator
palpebrae behind the
fornix
Upper edge of tarsal
plate
Sympathe-tic fibers
Elevates Lids
http://www.images.missionforvisionusa.org/anatomy/2006/03/extraocular-muscles.html © AP Santiago 2016
Orbital Apex
Anatomy and Function Correlation
http://lms.ecco-org.eu
© AP Santiago 2016
http://image.slidesharecdn.com/theorbit-140707121113-phpapp02/95/the-imaging-of-the-orbit-13-638.jpg?cb=1404735201
© AP Santiago 2016
Ophthalmic nerve (V1) branches and distribution
http://emedicine.medscape.com/article/1873373-overview#a2 © AP Santiago 2016
http://image.slidesharecdn.com/theorbit-140707121113-phpapp02/95/the-imaging-of-the-orbit-15-638.jpg?cb=1404735201
© AP Santiago 2016
Maxillary Nerve Branches (V2)
http://emedicine.medscape.com/article/1873373-overview#a2 © AP Santiago 2016
Maxillary Nerve Branches (V2)
http://emedicine.medscape.com/article/1873373-overview#a2 © AP Santiago 2016
Cavernous Sinus Syndrome
❖ CN 3, 4, 6 palsy
❖ Optic neuropathy
❖ Oculo-sympathetic paresis
❖ Impairment of ophthalmic and maxillary branch of CN5
http://skullanatomy.info/individ%20spaces/orbit/04_brain_pan.jpg
© AP Santiago 2016
Cavernous Sinus Syndrome ❖ CN 3, 4, 6 palsy =
ophtalmoplegia❖ Optic neuropathy❖ Oculo-sympathetic
paresis: Horner Syndrome
❖ Impairment of ophthalmic and maxillary branch of CN5: sensory loss
❖ Proptosis
http://emedicine.medscape.com/article/1161710-overview
© AP Santiago 2016
EOM Concepts & Movements
❖ agonist muscles
❖ antagonist muscles
❖ yoke muscles
❖ synergistic muscles
❖ Ductions & Versions
❖ dextroversion
❖ levoversion
❖ dextroelevation
❖ levoelevation
❖ Dextrodepression
❖ Levodepression
❖ Vergence Eye Movements
❖ Convergence
❖ Divergence
© AP Santiago 2016
Ocular Motility: EOM Movement
© AP Santiago 2016
Laws of Ocular Motility: Hering’s Law
© AP Santiago 2016
Laws of Ocular Motility: Sherrington’s Law
© AP Santiago 2016
Strabismus Evaluation
❖ Complete 5 point examination
❖ Gross
❖ Pupils
❖ EOM
❖ Intraocular Pressure
❖ Fundus evaluation
❖ Perform refraction
❖ Stereoacuity testing
❖ Strabismus Evaluation:
❖ Gold Standard: Alternate Prism Cover Test
© AP Santiago 2016
Strabismus Evaluation: Hirschberg’s Corneal Light Reflex
© AP Santiago 2016
Strabismus Evaluation: Bruckner Test
© AP Santiago 2016
Strabismus Evaluation
❖ Cover Uncover Test
https://www.youtube.com/watch?v=f5HbIZi4u70
© AP Santiago 2016
Strabismus Evaluation
❖ Alternate Cover Test
https://www.youtube.com/watch?v=U59OEkjoIGg © AP Santiago 2016
ALTERNATE PRISM COVER TEST
Gold standard for measuring deviation
Courtesy of R. Pena 2015
© AP Santiago 2016
Strabismus Evaluation
From Rosenbaum & Santiago, Clinical Strabismus Managemenment 1999
© AP Santiago 2016
© AP Santiago 2016
Strabismus Evaluation: Torsion
From Rosenbaum & Santiago, Clinical Strabismus Managemenment 1999 © AP Santiago 2016
From Rosenbaum & Santiago, Clinical Strabismus Managemenment 1999
© AP Santiago 2016
Outline: Amblyopia
❖ Definition
❖ Diagnosis
❖ Treatment
❖ Lessons learned from PEDIG
❖ The Futurehttp://www.eyestudioinc.com/wp-content/uploads/2016/01/Amblyopia3.jpg
© AP Santiago 2016
Amblyopia: Definition
❖ Etymology: dullness of vision
❖ Greek:
❖ amblus = dull
❖ Stem: ops = eye or vision
❖ Observer (MD) sees nothing, and the patient sees very little
❖ von Graefe
❖ lazy eye
© AP Santiago 2016
Amblyopia: Definition
❖ Unilateral or bilateral decrease in vision caused by pattern vision deprivation or abnormal binocular interaction for which no cause can be detected by physical examination, and which in appropriate cases, reversible by therapeutic measures
❖ von Noordenhttp://www.ascrs.org/sites/default/files/styles/hall_of_fame/public/external-profile/
Von%20Noorden%20Formal%20Portrait%20001.jpg?itok=XvJmWnEs
© AP Santiago 2016
Amblyopia
❖ One eye sees better than the other
❖ Developing visual system / brain will ignore (suppress) one eye
https://www.aapos.org/terms/conditions/21
© AP Santiago 2016
Amblyopia Diagnosis
❖ Fixation Preference
vonNoorden, Ocular Motility
© AP Santiago 2016
Fixation Preference
© AP Santiago 2016
Fixation Preference & Visual Acuity
© AP Santiago 2016
Vision Assessment
© AP Santiago 2016
Pre verbal Vision Test
❖ Allen cards
❖ Cultural bias
❖ “dated”
❖ Based on experience
❖ Lea symbols
❖ more universal
❖ Same in every culture
❖ Equal blurr
© AP Santiago 2016
Visual Acuity Testing
© AP Santiago 2016
Letter Charts
http://cdn.ilovetypography.com/img/2015/07/Frear_figure8.png
http://precision-vision.com/wp-content/uploads/2015/05/3d3b7d5d68132cc424920deb43e754bb_XL.jpg
© AP Santiago 2016
http://pedig.jaeb.org/Studies.aspx
http://www.abcd-vision.org/amblyopia/ats-pedig.html
Amblyopia PEDIG Studies
https://www.slideshare.net/secret/gbB88iM5gZwHVh
Definitions: PEDIG
❖ Mild Amblyopia: less than 20/40
❖ Moderate Amblyopia:
❖ 20/40 to 20/100 (ATS1)
❖ 20/40 to 20/80 (ATS2)
❖ Severe Amblyopia: 20/100 to 20/400
© AP Santiago 2016
Lessons learned from PEDIG 1. Atropine = patching2. 10 = 15 3. 6 hours = full time
4. 2 = 65. 6 > 2
6. Glasses alone works.7. If not, then glasses+patching.
8. Teenagers benefit from patching.
© AP Santiago 2016
❖ Amblyopia PEDIG Studies
© AP Santiago 2016
Lessons learned from PEDIG
1. Atropine = patching
❖ Moderate amblyopia
❖ 3-7 years; younger than 8
❖ Strabismic = anisometropic amblyopia
❖ Atropine better tolerated
❖ Same rate of deterioration or improvement
❖ Same rate of recurrence
© AP Santiago 2016
Amblyopia PEDIG Studies
=© AP Santiago 2016
Amblyopia PEDIG Studies (ATS 2)
For age 3-7 with severe amblyopia, 6 h = 10 h patching
© AP Santiago 2016
Amblyopia PEDIG Studies (ATS 2B)
For 3-7 y with moderate amblyopia, same results with 2 or 6h of patching© AP Santiago 2016
Amblyopia PEDIG Studies
© AP Santiago 2016
Amblyopia PEDIG Studies
❖ 7 to < 18 y ❖ 20/40 to 20/400 ❖ 27% Improves with glasses
alone ❖ 7-12 improved even if treated
previously ❖ 13-17 improved if not treated
previously ❖ Will it stay?
© AP Santiago 2016
Amblyopia Treatment Study-5 (ATS-5) spectacles alone, then patch 2 hrs vs spectacles
❖ Ophthalmology 2006: 113 (6) 904-912.
❖ 5 wks: 1.1 lines treated; 0.5 lines specs
❖ Any visit average: 2.2 lines treated; 1.1 lines specs
❖ After glasses, 2 hrs patching (with 1 hr near activity) improves moderate to severe amblyopia
https://t2.ftcdn.net
✚
http://cdn4.teen.com
© AP Santiago 2016
Amblyopia PEDIG Studies
Daily = weekly atropine ❖ 20/40 to 20/80 ❖ 3-7 years
© AP Santiago 2016
❖ Amblyopia PEDIG Studies
© AP Santiago 2016
Lessons learned from PEDIG
❖ 2 hours works even for severe amblyopia
❖ When 2 hrs doesn’t work, additional push to 6h improves 3 to <8 years with VA 20/50 to 20/400
❖ Bangerter filter = patching
❖ Levodopa-carbidopa promising
© AP Santiago 2016
What more PEDIG?
http://www.imore.com
http://www.geek.com
http://www.cclonline.com/
http://icons.iconarchive.com © AP Santiago 2016
Amblyopia Treatment Study-18 (ATS-18) Binocular Computer Activities for Treatment of Amblyopia
Ended May 2, 2016
❖ To compare the effectiveness of 1 hour/day of binocular game play 7 days per week (minimum of 4 days per week) with 2 hours/day of patching 7 days per week, in children 5 to <13 years of age (younger cohort), as a non-inferiority study.
❖ To compare the effectiveness of 1 hour/day of binocular game play 7 days per week (minimum of 4 days per week) with 2 hours/day of patching 7 days per week, in children 13 to <17 years of age (older cohort), as a superiority study.
© AP Santiago 2016
Amblyopia Treatment: The Future
❖ Advanced algorithms, electronics, materials
❖ Intermittent automatic electronic occlusion
http://www.treatlazyeye.in
VIDI Smart Glasses
© AP Santiago 2016
• Dichoptic Treatment (Hess)• Virtual Reality Games• Repetitive Transcranial Magnetic
Stimulation (rTMS) [Thompson]
Amblyopia Treatment: The Future Treatment for amblyopic adults
© AP Santiago 2016
Amblyopia Treatment: The Future
❖ Suppression caused amblyopia (reverse paradigm)
❖ Dr. Robert Hess
Mc Gill University, CA
❖ Dichoptic Treatment: Tetris
❖ Improvement in 3D vision
❖ 1 hr/day for 2 weeks
http://www.treatlazyeye.in
VIDI Smart Glasses
© AP Santiago 2016
© A
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Dichoptic Tetris
© AP Santiago 2016
Virtual Reality Games for Amblyopia
❖ 0:33 The Oculus Rift
❖ 0.38 – 1:29 How it Workshttps://www.youtube.com/watch?
v=KumScsJ0xNQ
© AP Santiago 2016
Repetitive Transcranial Magnetic Stimulation (rTMS)
❖ Rapidly changing magnetic fields applied to head with a hand-held coil
❖ Weak electric currents induced in the brain which excite neurons in target areas
❖ Tx for migraine, Parkinson, stroke, depression
❖ Visual loss in amblyopia not due to loss of brain cells but ongoing suppression
http://www.drchugh.com/images/rtms.png