CONGENITAL ESOTROPIA Kowal CAUSE Subtle neurological developmental problem Nearly always in isolation CONGENITAL ESOTROPIA Kowal CONGENITAL ESOTROPIA CET ONSET < 3 MONTHS: RARE USUAL ONSET 3+ MONTHS CONGENITAL ESOTROPIA Kowal CORE DEFECTS NOT ET! Sensory: N-T asymmetry Motor: N-T asymmetry, LMLN [T&H] poor devpt of binocularity CONGENITAL ESOTROPIA Kowal CONGENITAL ESOTROPIA CET Large angle ET N- T asymmetry Amblyopia ?30% Cross fixation : LE used for right gaze, RE for L gaze CONGENITAL ESOTROPIA Kowal CONGENITAL ESOTROPIA CET Usual range of refraction 25% caucasian neonates > +4 ? Higher + more prone to CET CONGENITAL ESOTROPIA Kowal RACIAL Caucasians: poor binocularity + hyperopia : cong ET is commonmest type of cong strab No good comparative population studies CONGENITAL ESOTROPIA Kowal ASSOCIATIONS Downs Severe neonatal course IVH /HC PVL CONGENITAL ESOTROPIA Kowal IS IT CONGENITAL : SMOOTH PURSUIT ASYMMETRY All neonates develop N-T asymmetry, sensory and motor Age 6-8 mo: asymmetry lost in normals Persists CET a/w reduced potential for sensory & motor fusion CONGENITAL ESOTROPIA Kowal Motion detection: normal infants & CET infants Bosworth & Birch.Vision Res Asymmetry in detection of horizontal motion in normals and CET Motion detection thresholds measured in 75 normals and 36 eyes of 27 infants with CET FPL with random-dot patterns. CONGENITAL ESOTROPIA Kowal Motion detection: normal infants Asymmetries in sensitivity for nasalward (N) vs. temporalward (T) directions of motion were compared in normals & CETs, age 1 mo to 5 y. NORMALS : N = T under 2.5 mo N > T motion preference between 3.5 and 6.5 mo. N advantage gradually diminished to T = N by 8 mo = adults. CONGENITAL ESOTROPIA Kowal Motion detection: normal infants & CET infants No asymmetry in 15 normal infants who performed the task binocularly, hence, the asymmetry was not a L - R bias. In the youngest CET patients tested [5 mo], a nasalward superiority in motion detection was observed and was equivalent to that of same- age normal infants. CONGENITAL ESOTROPIA Kowal Motion detection: normal infants and infants with CET Unlike normals, this asymmetry persists in older CET patients and is close to the root cause / association of CET CONGENITAL ESOTROPIA Kowal VERTICALS IN CET > 2 types: 1. DVD: Non fixing eye drifts up 2. Oblique dysfunction Usu IO OA Can be SO OA CONGENITAL ESOTROPIA Kowal VERTICALS IN CET : DVD CONGENITAL ESOTROPIA Kowal VERTICALS IN CET : DVD Common pattern: Right fixation: L L fixation: R End result of braking the torsional component of LMLN in the fixing eye to try and improve acuity CONGENITAL ESOTROPIA Kowal CONGENITAL ESOTROPIA CET Head turns / face tilts CONGENITAL ESOTROPIA Kowal INFANTILE ET COCHRANE Cochrane Database Syst Rev ? most effective type of intervention ? age at intervention SELECTION CRITERIA: Randomised trials comparing any surgical or non- surgical intervention for infantile esotropia CONGENITAL ESOTROPIA Kowal INFANTILE ET COCHRANE NO adequate studies were found CONCLUSIONS:..literature on interventions for IE are either retrospective studies or prospective cohort studies...not been possible to resolve controversies regarding type of surgery, non-surgical intervention and age of intervention need for good quality trials to be conducted to improve the evidence base CONGENITAL ESOTROPIA Kowal The clinical spectrum of early-onset esotropia: If it looks like CET: is it CET? CONGENITAL ESOTROPIA Kowal The clinical spectrum of early-onset esotropia: Congenital Esotropia Observational Study.PEDIG. Am J Ophthal RESULTS: 175 infants. 3 1 mo. 55% constant, 25% variable, 20% intermittent 50% 40 Most larger angle ET constant Most smaller angle ET intermittent or variable. CONGENITAL ESOTROPIA Kowal CET Observational Study - PEDIG #1 Most first seen > 12 w constant ET (65%) Most seen I saw today a 15 week old baby with typical cong ET. >Confident exam findings >Little / no amblyopia. >Accurate measurement of misalignment of 45^. >Cyclo +4-2x180 OU > >My normal practice would be to tentatively book BMR 2-4 weeks hence and >see child again pre-op to confirm measurements > >This is however the youngest child I have seen with cong ET >Previously operated a 21 week child many years ago - ended up with >random dot stereo > >Any tips / thoughts about operating in 2-3 weeks at age weeks? CONGENITAL ESOTROPIA Kowal Case 1 - Alan Scott 1 Glasses trial for 2 weeks with over correction, say, +4, ou. Forget the astigmatism, it changes all the time at this age. Yes it could be accommodative and I have seen glasses work at this age. You may well need them later in any case. 2 Botox 3 units to each MR. This has a 60-80% chance of correction under age 6 mo. An office procedure under local as with adults. 3 BMR recession if the Botox doesnt hold. CONGENITAL ESOTROPIA Kowal Consec XT - Ciancia > Thank you for your interest in my results in operated Infantile Esotropia. >The percent of secondary XT was as follows: >Immediate 1% >At 6 months 2,3% >At 1 year 3,5% >At 2 years 5,4% >At 3 years 10% >At 4 years 8,2% >At 5 years 10% (roughly) >At 10 years 20% " >At 15 to 27 years 30% " CONGENITAL ESOTROPIA Kowal