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

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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

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

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

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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

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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%]

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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

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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+%]

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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

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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

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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)

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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

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

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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

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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.

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

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

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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.

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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

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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)

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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)

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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

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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

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