Download presentation

Presentation is loading. Please wait.

Published byChristine Forister Modified over 2 years ago

1
Phospholine Iodide in the management of esotropia Lionel Kowal Claudia Yahalom RVEEH / CERA Melbourne SQUINT CLUB DUNEDIN 2005

2
HISTORY France 120y, US 55y Javal ‘Manuel theorique et practique du strabisme’: bifocals & miotics for ET 1886 Samuel Abraham: Pilo / eserine for ET 46 cases Amer J Ophth 1949: 16/46 ‘helpful’ AJO 1952,1961; JPO 1964,1966

3
CURRENT STATUS: Difficult to obtain : application to TGA for each patient Expensive [$A130 a bottle]

4
PARKS 1958 ABNORMAL ACCOMMODATIVE CONVERGENCE IN SQUINT n=1249 Old / difficult: Why bother? because it sometimes works very well!

5
PARKS 1958 ABNORMAL ACCOMMODATIVE CONVERGENCE IN SQUINT n=1249 No Rx: n=73 Isoflurophate n=47.. after Rx is stopped BMR n=10418: no better One MR n=7426: no better

6
PARKS 1958 number where A:AC improved [ result perfect] No Rx MioticBMR One MR < 7y 9/3129%4/1527% 7 -12y 20/40 28/32 87% All 69 / 104 66%[40;38%] 27 /74 36%[7;9.5%]

7
PARKS 1958 ABNORMAL ACCOMMODATIVE CONVERGENCE IN SQUINT The lasting improvement of the abnormal A:AC produced by miotic is similar to the permanent result attained by surgery

8
Patients studied Retrospective chart review of patients from a private strabismus practice. 20 consecutive children with ET reluctant to wear glasses PI “second choice” for mgmt of ET Ages 0.5 to 6 y [Parks : low expectations of success - 25+%]

9
Four groups of children with ET A. Hyperopes <+4 who refuse glasses: n=5. A. Hyperopes <+4 who refuse glasses: n=5. B. Hyperopes >+4 who refuse glasses: n=7 B. Hyperopes >+4 who refuse glasses: n=7 C. Uncosmetic near- only ET: n=1 C. Uncosmetic near- only ET: n=1 D. Recurrent ET after initially successful outcome from recent ET surgery. D. Recurrent ET after initially successful outcome from recent ET surgery. Glasses not tolerated / refused n=9 2/9 had an unsuccessful trial of PI prior to surgery

10
Definition of Outcomes Success (S). Esophoria / tropia ≤10∆ whilst using +/- after stopping PI Relative success (RS). One of: *decreased angle of ET (either D or N = 0) *% of time strabismic reduced to < 25% No success (NS): little / no improvement in angle or POTS

11
Table 1: Results of patients receiving PI according to indication for treatment # A: Hyperopia <4 B: Hyperopia > +4 C: Near only ET D: ‘Rescue’ recurrent ET 1 RS 4/12 2 RS: decreased angle 3 S (with later relapse) 4RS 5S 6NS 7NSS 8NS 9S 10NS 11S 12NS 13RS 14 Lost f/u 15 16NSS 17NS 18S 19RS 20 NS (not tolerated)

12
HOW GOOD WAS IT? A / B / C : 2 successes / 13 pts D [recurrent ET]: 5-8 success / 9 pts 13 + 9 = 22; 2 pts had PI @ 2 different stages of their course A/B/C: 2 lost to followup

13
PI RESCUE FOR RECURRENT ET #19 RS Cong ET. BMR 5.5 /LR Rs OU/ slipped LLR / LLR advanced - all between 7 and 15 mo. CR +2. Straight. 24 mo: recurrent ET. CR +4.25, +4.5. Gls refused - PI. Usually straight.

14
PI RESCUE FOR RECURRENT ET #4 RS BMR 4.5 @ 14 mo for ET onset 10 mo Initially perfect Later ET 0-15ET’ 0-25 PI ET 0ET’ 0-20

15
PI RESCUE FOR RECURRENT ET #17 NS BMR 6.5mm for ET 35-40 / 40-57 BMR 6.5mm for ET 35-40 / 40-57 CR + 1.5 W1 Orthotropia W8 ET 25 / 30 PI : No effect M6 : LR Rs OU

16
PI RESCUE FOR RECURRENT ET #13 RS 3yo ET 25/35. CR +2.25, +1.5 BUT +1 blurs OU. ET 0-40/ 30-60. BMR 6.5. W1 Orthotropic D&N. M3 ET 14 / 18. M7 ET 20 / 35 PI ET 0 / 25 - 30 + 0.5 DS blurs OU

17
PI RESCUE FOR RECURRENT ET #5 S 8 mo ET 50. CR +2. BMR 6 3w: [ET’] POTS bad day >50% 6w: PI POTS 0% Taper over 9 mo stays good

18
PI RESCUE FOR RECURRENT ET #18 S ET 45/60. CR +1.25. BMR 6.5 D6 Orthotropic D&N W4 ET 25-30 PI Orthotropic 4mo f/up

19
PI RESCUE FOR RECURRENT ET #7 NS then S i/mitt ET from 3mo +4.5 DS OU 9mo ET<30, ET’ 30 Refused gls. Screamed with PI 15 mo: ET’ 35 BMR 5 D1 slight XT. M2 ET 20. CR +3.75, +3 Gls refused. PI. 3.5 y: gls. Orthotropic D & N

20
PI RESCUE FOR RECURRENT ET #16 NS then S 2 mo: [ET]. CR +3 DSOU 6 mo: ET 30∆, CR +1.5, +1. 9 -23 mo: I/mitt ET’ 23 mo: ET’ 25∆. 32 mo: PI. Deteriorated to ET/ET’ 30-35/30-45∆ BMR 5.5. D6: XT8∆, small X’D15: ET’6∆. W5: ET 10/16∆CR/MR +0.75. PI E/E’ 6∆ 8 mo postop: uses PI on bad days

21
PI RESCUE FOR RECURRENT ET #3 S 54 mo: ET 30/ 50 [X2] & 25 / 30. CR +0.5 BMR 5.5. [XT]. D3: Lang 3/3 D 19: ET’ 30. Gls tried / refused. Rx: PI Next 5 mo: reduced to 2ce weekly. 5mo: orthophoric, BIFR > 12 Stop PI @ 6 mo 10 mo: ET’ 35; EX=0, FR>6. MR= CR= +0.75 DS OU Rx: bifocals with +3 add: STRAIGHT

22
Results: success PI clearly successful in 2 pts [of 7] in group B with >+4. PI treatment continues. 5 pts [of 9] in group D had clear success, allowing these pts to avoid or delay repeat surgery. 2/5 still need daily PI. 1/5 uses PI if ET is seen (‘bad days’) 2/9 patients in “successful” for 2-4 months, and then to bifocals / SV glasses

23
PROBLEMS WITH MIOTICS Mims: 279 of his pts + 323 pediatric ophthalmologists surveyed: Iris cysts 1 Intolerance to hyperopic correction 1 LK: Screaming after instillation n=1 15+ yrs ago: Iris cysts

24
ISOFLUROPHATE FOR RECURRENT ET Mims & Wood BVQ 1993;8:11-20 n =117 57/117: ET < 8∆, ET’ < 20∆ 38/57 [67%]: initial response 16/57 [28%]: no other Rx

25
Summary PI is a useful adjunct in treatment of recurrent ET. In patients for whom surgery was followed by an early recurrence of ET with + : PI might help to avoid/delay further surgery even if unsuccessful preop.

26
Aphorism of Hippocrates 300BC Life is short The art long Opportunity fleeting Experiment treacherous Judgement difficult

27
Conclusion PI has a useful role in the treatment of recurrent ET, if glasses will not be worn.

28
Postoperative Miotics for patients with infantile esotropia Spierer A, Zeeli T. Ophthalmic surgery and lasers. Dec 1997(28) 1002-5 Retrospective study including 42 children who underwent BMR recession for cong. ET. 2 groups: the treatment group (20 children) who got PI 1 drop/day for 4/12 1 week after the surgical procedure, and the control group (21 children) Twelve months postoperatively, the residual/recurrent ET increased an average of 1.4 and 2.8 D in the treatment and control groups respectively (not statistically significant) Amblyopia was more prevalent in the treatment group (20% and 5% respectively) Surgeons decided arbitrarily whom to treat with PI

29
References Spierer A. Postoperative miotics for patients with infantile esotropia. Ophth surg and lasers. 1997;28:1002-5. Parks M. Management of acquired esotropia. Brit J Ophthal. 1974;58:240-6. Hiatt R. Miotics vs glasses in esodeviation. J Ped Ophthal and strabismus. 1979;16:213-7. Hiatt. Medical management of accommodative esotropia. J Ped Ophthal and strabismus. 1983;199-201. Goldstein JH. The role of miotics in strabismus.Surv Ophthalmol. 1968;13:31-46. Abraham SV. The use of miotics in the treatment of nonparalytic convergent strabismus. A progress report. Am J ophthalmol. 1952;35:1191-5.

30
References Parks M. ABNORMAL ACCOMMODATIVE CONVERGENCE IN SQUINT AMA Archives of Ophthalmology 1958: ;364-380

31
Treatment groups Child with Esotropia A- Low Hypermetropia B- High hypermetropia C- Near only ET D- Residual / Recurrent ET s/p Sx

32
Kids with ET and low plus (<4), who didn’t accept glasses: group A Age yrs CR ET type PI tx Results F/U (m) 24 +3.75 ou Cong. 65^ 2/12RS8 70.5 +2.75 ou Cong. Int. 40^ Pre-op Post op →NS→S36 80.5 +1.50 ou R s/p IO – For SO palsy. ET 20^ 3/12NS10 102 R + 1.50 L + 3.00 ET 20^ M/p no amblyopia 2/12NS9 166 +1.00 ou Alt ET 20^→ 2 yrs later 35^ Pre-op Post op →NS→S38 Patient #2: ↓ angle of ET to 50 ^. Then BMR was done. Patients #7 and #16 had a residual ET 15-20^ shortly s/p Sx.

33
B: ET and >+4 # Age yrs CR ET type & size PI tx Results F/U (m) 10.8+4.50 Cong ET 25∆ 4/12RS14 61.4 R+ 6.75 L + 5.25 A. ET 30∆ 2/12NS12 91 +6 OU A. ET 25 ∆ Ongoing for 4/12 S6 114 +5 OU PA/A ET 20∆ Ongoing for 6/12 S6 120.8 +4 OU PA/A ET 30∆ 1/12NS8 154 +4 OU Cong. ET 45∆ 1/12NS Lost f/u 201.5 +4 OU PA/A ET 40∆ Not tolerated NS6 #1:↓ POTS for 4/12. Later ET 60∆→BMR A.ET = accommodative ET. PA = partially accommodative

34
C: near only ET # Age yrs CR ET type PI tx Results F/U (m) 141.9 +1.50 OU Int. ET for near 1/12?6(lost)

35
PI RESCUE FOR RECURRENT ET #19 ‘Large’ cong ET. BMR 5.5 @ 7mo, residual ET, LR Rs OU @ 15 mo. CR +2. D1: ET 50. slipped LLR. OR: RLR advanced, RMR 9 from limbus - Botox, LMR 11 from limbus. Postop: XT, face turn. Straight. 24 mo: recurrent ET. CR +4.25, +4.5. Gls refused - PI. Usually straight.

36
PI RESCUE FOR RECURRENT ET #4 10 mo [ET] 13 mo 2514 mo 30 BMR 4.5 ET 0-15ET’ 0-25 PI ET 0ET’ 0-20

37
PI RESCUE FOR RECURRENT ET #13 3yo ET for 6mo. ET 25/35. CR +2.25, +1.5 BUT +1 blurs OU. ET 0/30, 25, 40/60. BMR 6.5. W1 early XT by history. Orthotropic D&N. M3 ET 14 / 18. M7 ET 20 / 35 PI ET 0 / 25 - 30 + 0.5 DS blurs OU

38
PI RESCUE FOR RECURRENT ET #5 8 mo ET 50. CR +2. BMR 6 3w: [ET’] POTS bad day >50% 6w: PI POTS 0% Taper over 9 mo stays good

39
PI RESCUE FOR RECURRENT ET #17 ET since 12 mo 35-40 / 40-57 CR + 1.5 BMR 6.5 W1 Orthotropia W8 ET 25 / 30 CR + 1.25 PI : No effect M6 : LR Rs OU

40
PI RESCUE FOR RECURRENT ET #7 i/mitt ET from 3mo;1st seen 6 mo +4.5 DS OU EX=0 9mo ET<30, ET’ 30 Refused gls. Screamed with PI 15 mo: ET’ 35 BMR 5 D1 slight XT. M2 ET 20. CR +3.75, +3 Gls refused. PI. Variable compliance. 3.5 y: gls. Orthotropic D & N

41
PI RESCUE FOR RECURRENT ET #16 2 mo: [ET]. CR +3 DSOU 6 mo: ET 30∆, CR +1.5, +1. 9 -23 mo: varying POTS. [ET’]. 23 mo: ET’ 25∆. 32 mo: PI. Good response then deteriorated to ET/ET’ 30-35/30-45∆ BMR 5.5. D6: XT8∆, small X’D15: ET’6∆. W5: ET 10/16∆CR/MR +0.75. PI E/E’ 6∆ 8 mo: uses PI on bad days

42
PI RESCUE FOR RECURRENT ET #3 [ET’] onset 4. CR +0.50. 54 mo: ET 30, ET’ 50 [X2]; 25 / 30 BMR 5.5. [XT]. D3: Lang 3/3 D 19: ET’ 30. Gls tried / refused. Rx: PI Next 5 mo: reduced to 2ce weekly. 5mo: orthophoric, BIFR > 12 Stop PI @ 6 mo 10 mo: ET’ 35; EX=0, FR>6. MR= CR= +0.75 DS OU Rx: bifocals with +3 add

43
D: PI “rescue ” for recurrent / residual ET following surgery Age yrs CR ET type & size in ∆ PI tx Results Time off PI F/u months 34Plano N 50 D 30 Res. N ET. Tx for 4/12 S → Later relapse 4/12→Rec N ET→Bif. 18 40.8Plano Cong. ET 20 Rec.ET20∆ Tx for 3/12 SOngoing16 50.8 +2.00 ou Cong.ET50^ Res N ET Tx for 6/12 SOngoing PI on bad days only 12 70.5 +2.75 ou Cong. Int.40 Res.ET20^. Tx for? S15/1236 133 R +2.50 L +1.50 R ET Int.30 Res.ET25^. Tx for ? S → Later relapse 2/12 → Rec N ET→Bif. 20 166 +0,75 ou Alt ET 35 Pre BMR : NS S Ongoing for post op recurrence 38 171.8 +2.00 ou N 50 D 35 Res.ET25^. Tx for 2/12 NS14 185 +1.00 ou ET 45 Res.ET25^. Tx for 1/12 Songoing3 191 +4.50 ou Cong ET s/p 2 sx. 50^ Res.ET25^. Tx for 3/12 RS for 3/12 24

44
Results: (RS) Relative success RS was seen in: RS was seen in: 1 patient in group A (↓strabismic angle) 1 patient in group B (↓POTS) 1 in group C (ortho for 3 months)

45
PI RESCUE FOR RECURRENT ET #18 ET onset 3. 1st seen age 5. ET 45/60. CR +1.25. BMR 6.5 D6 Orthotropic D&N W4 ET 25-30 PI Orthotropic 4mo f/up

46
PROBLEMS WITH MIOTICS 1. Cataract - only in the elderly glaucoma population 2. Cholinergic crisis in unrecognised myesthenic n=1 3. Iris cysts 4. Reduced plasma cholinesterase 5. Transient myopia 6. Retinal detachment 7. SLUD salivation / lacrimation / urination/ defecation

Similar presentations

Presentation is loading. Please wait....

OK

Resistência dos Materiais, 5ª ed.

Resistência dos Materiais, 5ª ed.

© 2017 SlidePlayer.com Inc.

All rights reserved.

Ads by Google

Ppt on careers in information technology Ppt on biodegradable and non biodegradable meaning Slides for ppt on internet Ppt on decimals for class 7 Ppt on conservation and management of forest Ppt on varactor diode modulator Elements of one act play ppt on website Ppt on weapons of mass destruction definition Ppt on indian construction industry Ppt on asp dot net project