Strabismus Surgery and the Late Elderly Logan Mitchell Lionel Kowal RVEEH, Melbourne Private Eye Clinic, Melbourne

“Elderly” - who? Older than me? Older than my parents? WHO: No definition Geriatric literature Early elderly = 65 – 75 years old Late elderly = ≥75 years old

“Elderly” - how many? Australian population data 22.5 million (2010 est.) Life expectancy at birth: 82 yrs Ageing population 65 yrs and older  13.5% (2009 est.) = 3 million  25% (2042 est.) = 6.2 million

“Elderly” and Strabismus Prevalence ~ 4% (adult strabismus) No population-based data on “elderly” population 6600 Medicare-billed strabismus operations 27 million eligible patients 2.4%

“Elderly” and Strabismus Prevalence of strabismus in >65 year olds (assumptive) 4% prevalence adult strabismus 120,000 in ,000 in 2042

Elderly Strabismus – the literature 4 papers Paper #1 Repka JAAPOS 2007 as described 70% horizontal surgery 14% reported as re-operations (?low)

Elderly Strabismus – the literature Paper #2: Magramm & Schlossman JPOS 1991 Retrospective 104 pts  mean 69 yrs old (60-89) ¼ cosmetic indication, ¾ diplopic 1/3 childhood onset Adult onset  Mean delay to surgery 8 yrs Aetiologies

Elderly Strabismus – the literature Paper #3: Dawson et al Strabismus 2001 Retrospective 111 patients  mean 67 yrs old (60-90) ½ cosmetic, ½ diplopic 1/3 childhood onset Adult onset – similar aetiologies Outcomes  ~60% orthotropic +/- 10∆  21% re-operation rate

Elderly Strabismus – the literature Paper #4: Rutar & Demer JAAPOS 2009 “Heavy eye syndrome” in elderly A la, but different from, ‘myopic strabismus fixus’ Degeneration of SR-LR aponeurotic band

Adult Strabismus (as substitute) Adults delay seeking surgical correction Mean delay 19 years  diplopic 15 yrs vs 28 yrs non-diplopic  Reasons

Strabismus Surgery in the 'Late Elderly' Aim To Identify the characteristics and outcomes of patients undergoing strabismus surgery aged 75 years or older between October 2005 – October 2010 Methods Retrospective chart review Locations  Private Eye Clinic (Dr Lionel Kowal)  RVEEH

Results 35 patients Age: mean 79 years (75-95) Male:Female 16:19 Indications Cosmesis – 6 (17%) Diplopia – 29 (83%) Duration of symptoms: mean 12 years (0-69) 19 done with adjustable sutures 3 surgeries performed under regional anaesthetic

Results Previous surgeries (plus 2 with previous botox)

Aetiology of Strabismus

Neuroparalytic Strabismus 14 patients CNVI in 9 patients 5 compressive  2 ICA aneurysm  (1 previous surgery)  2 meningioma  1 ependymoma 3 ischaemic / uncertain cause 1 traumatic (CHI)  (1 previous surgery) CNIV in 6 patients 3 congenital  1 with 2 previous surgeries  Remaining 2: average duration of diplopia = 6 years 3 uncertain aetiology CNIII in 1 patient Combined with CNVI in ICA aneurysm patient

Restrictive Strabismus 8 patients 3 thyroid eye disease Mean duration on symptoms: 1.3 years 4 traumatic / iatrogenic 2 previous retinal detachment surgery 1 previous sinus surgery 1 previous orbital trauma 1 Brown’s syndrome Symptoms for >50 years

Decompensated Phoria 7 patients 5 with decompensated intermittent exotropia 2 decompensated divergence insufficiency Mean duration of symptoms: 37 years

Consecutive Exotropia Only 2 patients Childhood esotropia Previous surgery x 1, and x 3 Mean duration of misalignment: >40 years

Outcomes Mean follow-up 8 months “Overall”

Outcomes Diplopia

Outcomes in Neuroparalytic Cases “Overall” result Diplopia Perfect3 (21%) Significant improvement2 (14%) Little/no improvement8 (57%) Worse1 (7%) Free of diplopia11 (79%) (with AHP)2 (14%) (with prism)6 (43%) (with AHP and prism)1 (7%) Diplopic3 (21%)

Outcomes in Other Cases “Significant improvement” or better Restrictive strabismus 88% Decompensated phoria 86% Consecutive exotropia 100%

Complications Couldn’t find a muscle (2) Post-childhood trauma, consecutive XT Re-operations (3 = 8.6%) 2 on one patient (SOP), 1 on 95 year old lady (XT) Recurrences (6) Dealt with prisms in 4 cases No known systemic complications

Conclusions (I) Strabismus in the very elderly Exists Is not extremely rare Will increase Is under-represented in the literature Diplopia is a frequent indication for surgery Patients delay surgery Often at our (medical) behest Varied aetiologies Neuroparalytic causes common (note compressive causes)

Conclusions (II) Surgical considerations Systemic risk of general anaesthetic ?risk of regional anaesthetic Thinner conjunctiva Risk of anterior segment ischaemia Probably 2 muscles maximum Diplopic indication common More accurate surgery, adjustable sutures

Conclusions (III) Surgery is reasonably successful Very low risk of making things worse (1/35) 68% achieved at least significant improvement ?More guarded success in neuroparalytic patients 83% free of diplopia (with/without prisms/AHP)

Thank You