The use of botulinum toxin in the management of convergence insufficiency exotropia
1
Mean preoperative central gaze esotropia measured 15.0 D 7.7 D at distance and 4.1 D 3.4 D at near in Group A, and 10.4 D 6.8 D at dis- tance and 0.6 D 1.7 D at near in group B (P 5 0.148, distance; P 5 0.003, near). Postoperatively, no patient in either group had symptom- atic diplopia or convergence insufficiency in follow-up from 8.5 months to 3.3 years. Discussion: Most cases of DPE are caused by LR sag due to age-re- lated connective tissue degeneration. Nevertheless, recession of the MR, physiological antagonist of the sagging LR, provides binocular single vision without convergence insufficiency at near, and is more convenient for intraoperative adjustment under topical anes- thesia than LR resection. Conclusions: MR recession is a technically convenient and effective alternative to LR resection in DPE. 047 The Change in Patients' Quality of Life Following Strabismus Surgery. Robert C. Cheeseman, Vicki Wong, Jane Young, Ian B. Marsh, Jon M. Durnian Purpose: To investigate the change in patients' quality of life (QoL) scores using the strabismus-specific QoL AS-20 questionnaire. Methods: A prospective study of adult patients undergoing strabis- mus surgery for either functional or restorative reasons was per- formed. The questionnaire was completed at the time of diagnosis and at every post-operative visit. Patient demographics, pre- and postoperative orthoptic measurements and AS-20 scores were re- corded. The individual patient variables were correlated to change in AS-20 scores to assess whether certain patients have a greater effect from surgery. Results: Of 63 patients who were identified: median age 35 years; 52% female. Preoperatively the median magnitude of deviation was 30 D and the median AS-20 score was 40. The mean follow up was 63 days. Postoperatively: the median magnitude of deviation was 9 D and the median AS-20 score was 70. There was a significant im- provement in total AS-20 scores (Z 5 6.16, P \0.0001). Gender, age and preoperative deviation showed no significant relationship to the improvement in AS-20 score, however change in deviation change showed a significant correlation (P 5 0.022). Discussion: Strabismus surgery significantly improves patients' QoL scores. All patients have similar improvements with gender, age and preoperative strabismus size having no significant relationship to the change in AS-20 score. The amount of deviation change correlates well to the improvement in QoL scores. Conclusions: Strabismus surgery has a highly positive effect on pa- tients' quality of life. It is not possible to predict preoperatively which patients will benefit the most from strabismus surgery. 048 Inferior oblique advancement surgery for thyroid eye disease and orbital blowout fracture patients with symptomatic incyclotorsion. Christopher S. Child, Kelly A. MacKenzie, Gillian G. W. Adams Background/Purpose: Incyclotorsion and excyclotorsion may inhibit motor fusion in strabismus patients with resultant intractable diplo- pia. Inferior oblique (IO) advancement surgery has previously been described in the management of incyclotorsion following macular translocation surgery for macular degeneration but has not been previously described in the management of non-translocation patients. Methods: Case notes review of 3 patients (1 orbital blowout fracture (OBF), 2 post-orbital decompression thyroid eye disease (TED) pa- tients) who underwent IO advancement surgery (under the lateral rectus muscle and sutured to sclera between the superior and lateral recti) at our institution to treat incyclotorsional diplopia. All 3 patients had undergone multiple previous strabismus surgeries including su- perior oblique tenotomies. Results: Mean age at surgery was 51.7 years (range, 29-62). Preoperative incyclotorsion in primary position measured 5 , 13 , and 20 in our patients. Torsion at first postoperative visit measured 1 degree excyclotorsion, 0 and 3 incyclotorsion respectively. All patients reported symptomatic improvement following surgery. No surgical complications were encountered. Discussion: Torsional diplopia is debilitating for the patient and a sur- gical challenge for the strabismologist. We report favourable out- comes following graded IO advancement in 3 complex patients with intractable torsional diplopia following multiple previous strabismus surgeries. Conclusions: We propose IO advancement surgery as an effective procedure in the management of intractable torsional diplopia in OBF and TED patients. Although previously described in the manage- ment of macular translocation surgery, this surgical procedure has not been previously reported for this group of patients. 049 The use of botulinum toxin in the management of convergence insufficiency exotropia. Emma Dawson, Chris Child, John P. Lee, Gill G. Adams Background/Purpose: Convergence insufficiency is a common con- dition in which there is a failure to converge for close work, with exo- tropia at near. Various surgical and nonsurgical treatments have been described, but some patients remain symptomatic despite treatment. The role of botulinum toxin in strabismus management is well established, but its use in the treatment of convergence insuf- ficiency has not been previously reported. Our aim is to describe the results of lateral rectus injection in the management of convergence insufficiency. Methods: A retrospective review of the toxin clinic database of all convergence insufficiency patients treated with botulinum toxin between 1982 and 2010. Results: Ten patients were identified, 8 female and 2 male. The mean age at treatment was 32 years with a range of 9 to 62 years. Conver- gence ranged from 18cm to complete paralysis in 3 patients. Previous management included convergence exercises in all patients, prisms in 7 (70%) and surgery in 4 (40%). Eight (80%) patients had improve- ment in symptoms 2 to 3 weeks post botulinum toxin injection into a single lateral rectus muscle. One patient declined further treat- ment. Of the remaining 9 patients their symptoms returned after 3 months to 6 years of follow-up. Seven patients were managed with maintenance toxin treatment, with a mean of 4 injections (range 2 to 11). Two patients proceeded to surgery. The mean follow-up was 3.8 years. Discussion: Botulinum toxin, though not always successful, can be useful in the treatment of convergence insufficiency patients who have failed other management. Conclusions: To our knowledge, this is the first time botulinum toxin has been used in the role of these patients. 050 Analysis of visual acuity and foveal abnormalities in albinism using digital fundus images. Alejandra Decanini Mancera, Patti S. Harvey, Ann Holleschau, C. Gail Summers Background/Purpose: Albinism is an inherited disorder of melanin biosynthesis. Patients with albinism have foveal maldevelopment and decreased visual function. The purpose of this study was to use retinal images to describe foveal abnormalities in albinism and to correlate the results with visual acuity. Journal of AAPOS Volume 16 Number 1 / February 2012 e13
-
Upload
emma-dawson -
Category
Documents
-
view
215 -
download
1
Transcript of The use of botulinum toxin in the management of convergence insufficiency exotropia
Volume 16 Number 1 / February 2012 e13
Mean preoperative central gaze esotropia measured 15.0D� 7.7 D atdistance and 4.1D � 3.4D at near in Group A, and 10.4D � 6.8D at dis-tance and 0.6D � 1.7D at near in group B (P 5 0.148, distance; P 50.003, near). Postoperatively, no patient in either group had symptom-atic diplopia or convergence insufficiency in follow-up from 8.5months to 3.3 years.Discussion:Most cases of DPE are caused by LR sag due to age-re-lated connective tissue degeneration. Nevertheless, recession of theMR, physiological antagonist of the sagging LR, provides binocularsingle vision without convergence insufficiency at near, and ismore convenient for intraoperative adjustment under topical anes-thesia than LR resection.Conclusions:MR recession is a technically convenient and effectivealternative to LR resection in DPE.
047 The Change in Patients' Quality of Life Following StrabismusSurgery. Robert C. Cheeseman, Vicki Wong, Jane Young, Ian B.Marsh, Jon M. DurnianPurpose: To investigate the change in patients' quality of life (QoL)scores using the strabismus-specific QoL AS-20 questionnaire.Methods: A prospective study of adult patients undergoing strabis-mus surgery for either functional or restorative reasons was per-formed. The questionnaire was completed at the time of diagnosisand at every post-operative visit. Patient demographics, pre- andpostoperative orthoptic measurements and AS-20 scores were re-corded. The individual patient variables were correlated to changein AS-20 scores to assess whether certain patients have a greatereffect from surgery.Results: Of 63 patients who were identified: median age 35 years;52% female. Preoperatively the median magnitude of deviation was30D and the median AS-20 score was 40. The mean follow up was63 days. Postoperatively: the median magnitude of deviation was9D and the median AS-20 score was 70. There was a significant im-provement in total AS-20 scores (Z5�6.16, P\0.0001). Gender, ageand preoperative deviation showed no significant relationship to theimprovement in AS-20 score, however change in deviation changeshowed a significant correlation (P 5 0.022).Discussion: Strabismus surgery significantly improves patients' QoLscores. All patients have similar improvements with gender, age andpreoperative strabismus size having no significant relationship to thechange in AS-20 score. The amount of deviation change correlateswell to the improvement in QoL scores.Conclusions: Strabismus surgery has a highly positive effect on pa-tients' quality of life. It is not possible to predict preoperatively whichpatients will benefit the most from strabismus surgery.
048 Inferior oblique advancement surgery for thyroid eye diseaseand orbital blowout fracture patients with symptomaticincyclotorsion. Christopher S. Child, Kelly A. MacKenzie,Gillian G. W. AdamsBackground/Purpose: Incyclotorsion and excyclotorsion may inhibitmotor fusion in strabismus patients with resultant intractable diplo-pia. Inferior oblique (IO) advancement surgery has previously beendescribed in the management of incyclotorsion following maculartranslocation surgery for macular degeneration but has not beenpreviously described in the management of non-translocationpatients.Methods: Case notes review of 3 patients (1 orbital blowout fracture(OBF), 2 post-orbital decompression thyroid eye disease (TED) pa-tients) who underwent IO advancement surgery (under the lateralrectus muscle and sutured to sclera between the superior and lateral
Journal of AAPOS
recti) at our institution to treat incyclotorsional diplopia. All 3 patientshad undergone multiple previous strabismus surgeries including su-perior oblique tenotomies.Results: Mean age at surgery was 51.7 years (range, 29-62).Preoperative incyclotorsion in primary position measured 5�, 13�,and 20� in our patients. Torsion at first postoperative visit measured1 degree excyclotorsion, 0� and 3� incyclotorsion respectively. Allpatients reported symptomatic improvement following surgery. Nosurgical complications were encountered.Discussion: Torsional diplopia is debilitating for the patient and a sur-gical challenge for the strabismologist. We report favourable out-comes following graded IO advancement in 3 complex patientswith intractable torsional diplopia following multiple previousstrabismus surgeries.Conclusions: We propose IO advancement surgery as an effectiveprocedure in the management of intractable torsional diplopia inOBF and TED patients. Although previously described in the manage-ment of macular translocation surgery, this surgical procedure hasnot been previously reported for this group of patients.
049 The use of botulinum toxin in the management of convergenceinsufficiency exotropia. Emma Dawson, Chris Child, John P. Lee,Gill G. AdamsBackground/Purpose: Convergence insufficiency is a common con-dition in which there is a failure to converge for close work, with exo-tropia at near. Various surgical and nonsurgical treatments havebeen described, but some patients remain symptomatic despitetreatment. The role of botulinum toxin in strabismus managementis well established, but its use in the treatment of convergence insuf-ficiency has not been previously reported.Our aim is to describe the results of lateral rectus injection in the
management of convergence insufficiency.Methods: A retrospective review of the toxin clinic database of allconvergence insufficiency patients treated with botulinum toxinbetween 1982 and 2010.Results: Ten patients were identified, 8 female and 2 male. The meanage at treatment was 32 years with a range of 9 to 62 years. Conver-gence ranged from 18cm to complete paralysis in 3 patients. Previousmanagement included convergence exercises in all patients, prismsin 7 (70%) and surgery in 4 (40%). Eight (80%) patients had improve-ment in symptoms 2 to 3 weeks post botulinum toxin injection intoa single lateral rectus muscle. One patient declined further treat-ment. Of the remaining 9 patients their symptoms returned after 3months to 6 years of follow-up. Seven patients were managed withmaintenance toxin treatment, with a mean of 4 injections (range 2to 11). Two patients proceeded to surgery. The mean follow-upwas 3.8 years.Discussion: Botulinum toxin, though not always successful, can beuseful in the treatment of convergence insufficiency patients whohave failed other management.Conclusions: To our knowledge, this is the first time botulinum toxinhas been used in the role of these patients.
050 Analysis of visual acuity and foveal abnormalities in albinismusing digital fundus images. Alejandra Decanini Mancera, Patti S.Harvey, Ann Holleschau, C. Gail SummersBackground/Purpose: Albinism is an inherited disorder of melaninbiosynthesis. Patients with albinism have foveal maldevelopmentand decreased visual function. The purpose of this study was touse retinal images to describe foveal abnormalities in albinism andto correlate the results with visual acuity.
