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STRABISMUS UPDATE
LIONEL KOWAL
PERTH
NOVEMBER 2007
Weird diplopia
22yo WCF with hyperopic astigmatism OU, L ET 20∆, L
amblyopia 20/100 part.
Some latent nystagmus.
With L fixation has R DVD.
No previous strabismus surgery.
Epilepsy as a child.
With recess / resect is improved to straight for distance,
ET' 8∆.
Now complains of crossed diplopia for objects on her L
- they are seen to her far R.
Weird diplopia 2
When the L is straightened, she has an
expanded field to the L
She is aware that the L visual field is expanded,
but that it is blurred. This new expanded field
has ARC and is the source of her diplopia!.
Beware of weird sensory responses in pts
with childhood strabismus who have late
surgery
Good news: better after 4-5 mo
REFRACTIVE FINDINGS IN CHILDREN WITH
ASTIGMATIC PARENTS: THE SYDNEY MYOPIA STUDY
AMER J OPHTH 8/07
1741 6yo [231 astigmats]
 2367 12 yo [237 astigmats]
 Cyclo autorefraction
 Parents: glasses scripts
 NO statistical relationship
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Objectively monitored patching regimens for
treatment of amblyopia: randomised trial
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Fielder AR ….. ROTAS Cooperative.
Department of Optometry and Visual Science,
City University, London
Compare visual outcome to two prescribed
rates of occlusion (6 & 12 h/d).
97 children with amblyopia due to strabismus
&/or anisometropia
Rx: 18 w of wearing gls (refractive adaptation)
then occlusion prescribed for 6 or 12 h/d
Objectively monitored patching regimens for
treatment of amblyopia: randomised trial
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OUTCOMES: VA & objectively monitored rate
of occlusion (h/d).
RESULTS: Change in VA of amblyopic eye not
significantly different (P=0.64) between the two
groups (0.26 log units in 6h group; 0.24 log
units in 12h group).
h/d actually received not significantly different
(4.2 in 6h group v 6.2 in 12h group; P=0.06).
Objectively monitored patching regimens for
treatment of amblyopia: randomised trial
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Visual outcome similar for children who
received >3h/d day [up to 12] & better than
children who received <3h/d.
Children aged < 4 required significantly less
occlusion than older children.
Visual outcome not influenced by type of
amblyopia.
Apparently ≠ PEDIG
AAPOS 2007 Costenbader Lecture
"Natural History of Treated Childhood Intermittent XT”
Dr
John [Jack] Baker
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20y follow-up study of 30 pts with childhood XT
21 required 1 surgery, 7 required 2 surgeries, and 3 required > 2 surgeries.
Patients who required >1 surgery: 6 had recurrent XT, 1 consecutive ET.
The level of stereopsis decreased as the number of surgeries increased.
Patients requiring only 1 surgery had excellent stereopsis; those requiring
2 had some stereopsis; and those requiring > 2 surgeries had none.
In patients with recurrent strabismus, surgery was typically
performed by the teen years; patients who were stable into
their teens tended to stay that way.
Visual function and ocular features in children and adolescents
with attention deficit hyperactivity disorder, with and without
treatment with stimulants.
Eye. 2007 Apr;21(4):494-502. Grönlund MA, …
Göteborg, Sweden.
42 children (37 boys) with AD/HD with /& -out
stimulants, mean age 12y, c.f. reference group
(n=50; mean age 11.9y; 44 boys).
RESULTS:
VA: 83% had visual acuity of >0.8 (<0.1 logMAR)
without treatment, 90% with stimulants (ref
98%; P=0.032 and n.s., respectively).
Visual function and ocular features in children and adolescents
with ADHD
Heterophoria in 29% without, and in 27% with,
stimulants (ref 10%; P=0.038 and n.s., respectively)
Subnormal stereovision (>60 s of arc) in 26% (ref 6%;
P=0.016) without stimulants, and in 27%, with
(P=0.014).
Abnormal convergence (>6 cm or absent) in 24% (ref
6%; P=0.031) without treatment and in 17% with
(n.s.).
Astigmatism (> or =1.0 D) in 24% (ref 6%; P=0.03)
Signs of visuoperceptual problems in 21% (ref 2%;
P=0.007).
Visual function and ocular features in children and adolescents
with ADHD…
Smaller optic discs (n=8/38) and neuroretinal rim areas
(n=7/38) (P<0.0001) and decreased tortuosity of
retinal arteries (n=6/34) (P=0.0002) than controls.
CONCLUSIONS: Children with AD/HD had a high
frequency of ophthalmologic findings, which
were not significantly improved with stimulants.
They presented subtle morphological changes of the
optic nerve and retinal vasculature, indicating an
early disturbance of the development of these
structures.
Infant Hyperopia: Detection, Distribution, Changes and Correlates.
Outcomes From the Cambridge Infant Screening Programs
ATKINSON, J; BRADDICK, O; et alii. London & Oxford
American Academy of Optometry Volume 84(2),February 2007,pp 84-96
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2 screening programs to detect significant refractive
errors in >8000 8-9 mo infants, examine sequelae of
infant hyperopia, and test whether early partial
spectacle correction improved visual outcome
(strabismus and acuity).
2nd program: also examined whether infant hyperopia
was associated with developmental differences across
various domains such as language, cognition, attention,
and visuomotor competencies up to age 7y.
Infant Hyperopia: Detection, Distribution, Changes and Correlates.
Outcomes From the Cambridge Infant Screening Programs
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#1: orthoptic examination and isotropic
photorefraction, with cycloplegia.
#2: no cycloplegia.
Hyperopic infants (≥+4D) were followed up
alongside an emmetropic control group, with
visual and developmental measures up to age
7y, and entered a controlled trial of partial
spectacle correction.
Cambridge Infant Screening Programs
RESULTS
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#2 : accommodative lag with a target at 75 cm (focus ≥+1.5 D)
was a marker for significant hyperopia.
In each program, prevalence of significant hyperopia at 9 to 11 mo
was around 5%
Infant hyperopia : increased strabismus at 4y.
Manifest strabismus was 0.3% at 9 mo and 2% by school age.
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Infant hyperopia : poor acuity at 4y.
The hyperopic group showed poorer overall performance than
controls between 1 - 7 y on visuoperceptual, cognitive, motor, and
attention tests …… no consistent differences in early language or
phonological awareness.
Cambridge Infant Screening Programs
RESULTS….continued
Spectacle wear by infant hyperopes :
 better visual outcome than uncorrected infants. Improvement in
strabismus with spectacle wear was found in the first program only.
.. did not affect emmetropization to 3.5y.
 Both corrected and uncorrected groups remained more hyperopic
than controls in the preschool years.
Conclusions.
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Visual outcomes may be improved by early
refractive correction.
Infant hyperopia is associated with mild delays
across many aspects of visuocognitive and
visuomotor development.
Eye advance online publication 2 February 2007
Ethnic differences in refraction and ocular biometry in a
population-based sample of 11–15-year-old Australian children
J M Ip1, …. P Mitchell
Sydney
2353 students (75% response) from a
random cluster-sample of 21 secondary
schools across Sydney.
 Examinations included cycloplegic
autorefraction, Ks, AC depth, and axial
length.
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Ethnic differences in refraction and ocular biometry in a
population-based sample of 11–15-year-old Australian children
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Participants mean age was 12.7 y (range 11-14); 49%
female.
60% European Caucasian ethnicity, 15% East Asian,
7% Middle Eastern, and 5% South Asian.
The most frequent refractive error was mild hyperopia
(59%), [SE +0.50 - +1.99D].
Myopia (≤-0.5D) was found in 12%,
Moderate hyperopia (+2D) in 3.5%.
Ethnic differences in refraction and ocular biometry in a
population-based sample of 11–15-year-old Australian children
Myopia prevalence was lower among European Caucasian children
(5%) and Middle Eastern children (6%) than among East Asian
(40%) and South Asian (32%) children.
 European Caucasian children had the most hyperopic mean SE
(+0.8D) and shortest mean axial length (23.2mm). East Asian
children had the most myopic mean SE (-0.7D) and greatest mean
axial length (23.9mm).
Conclusions
The overall myopia prevalence in this sample was lower than in
recent similar-aged European Caucasian population samples.
East Asian children in our sample had both a higher prevalence of
myopia and longer mean axial length.
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Prevalence of Hyperopia and Associations
with Eye Findings in 6- and 12-Year-Olds
Jenny M. Ip, MBBS,1 … Paul Mitchell, MD, PhD1
Ophthalmology 2007;xx:xxx © 2007 by the American Academy of Ophthalmology.
Purpose: To describe the prevalence of hyperopia and associated factors in a
representative sample of Australian schoolchildren 6 and 12 years old.
Participants: Schoolchildren ages 6 (n 1765) and 12 (n 2353) from 55
randomly selected schools across Sydney.
Methods: Detailed eye examinations included cycloplegic autorefraction,
ocular biometry, cover testing, and dilated fundus examination. Information
on birth and medical history were obtained from a parent questionnaire.
Main Outcome Measures: Moderate hyperopia defined as spherical
equivalent refraction of 2D), and eye conditions including amblyopia,
strabismus, astigmatism, and anisometropia.
Prevalence of Hyperopia and Associations
with Eye Findings in 6- and 12-Year-Olds…2
Results: Prevalences of moderate hyperopia among children ages 6 and 12
were 13.2% and 5.0% respectively
It was more frequent in children of Caucasian ethnicity (15.7% and 6.8%,
respectively) than in children of other ethnic groups.
Compared with children without significant ametropia, the prevalence of eye
conditions including amblyopia, strabismus, abnormal convergence, and
reduced stereoacuity was significantly greater in children with moderate
hyperopia (all Ps 0.01).
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Maternal smoking was significantly associated with moderate hyperopia
among 6-year-olds (P 0.03), but this association was borderline among
12-year-olds (P 0.055).
Smoking and hyperopia
PRELIMINARY ANALYSIS ON FIRST 70 Q'AIRES
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8 pts with mild hyperopia have either parent a
smoker,23 didn't.
16 pts with mod hyperopia (>+2) have either
parent a smoker and 20 didn't.
The odds of having either parent a smoker
is 2.3 times higher for kids with moderate
hyperopia than those with mild hyperopia
Longitudinal changes in the spherical equivalent refractive error
of children with accommodative esotropia
S R Lambert…. Atlanta, GA, USA
British Journal of Ophthalmology 2006;90:357-361
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Longitudinal changes in spherical equivalent (SE)
refractive errors of children with accommodative ET as
a function of the age when glasses were prescribed.
126 children with AET followed longitudinally for 4.4 (SD
2.5) years.
Cycloplegic refractions were performed using
autorefractor for older children and retinoscopy for
younger children.
The refractive data were analysed for three groups of
children based on their age at the time spectacles were
prescribed.
Longitudinal changes in the spherical equivalent refractive error
of children with accommodative esotropia
RESULTS…..
The initial SE refractive error was age dependent
 <2y
+5.1 (1.9) D
 2- <4y
+4.2 (1.9) D
 4-8y,
+3.8 (1.7) D.
 All ages : initial increase in refractive error, followed by later
decrease. Greatest decrease in oldest age group.
 Refractive error peaked 1y after glasses prescribed for
children 4-8y vs...... 6y after glasses prescribed for children <
2y.
Conclusion: Longitudinal changes in refraction for children with
accommodative ET vary as a function of age when glasses wear is
initiated.
Interesting pt #2 .1
2007: 31.
2004: i-mitt dip, L ET. Wearing +4 DS
EWSCLs. Childhood occlusion.
 ET 30. UG 40, DG 25. E’ 25 [adapts to
>35 without X]. SOOA / F intorsion.
 Cyclo: some latent +
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Interesting pt #2. 2
2007: wants Sx for ET & diplopia. Wants to
look better sc.
 cc ET 20+,ET’ 18.
 sc 45 ACA 45-20+/4= 5+
 Cut + by +1.25: ET 30
 Plan: largest surgery that will not give
diplopia while wearing 1.25 less than MR
[& bilateral sup obl weakening]
Interesting pt #2.3
Day 2: little / no ET/ ET’ sc/ cc
 Day 5: sc ET 10, ET’ 12, A 8
 Week 3 Peter McClurg : slight myopic
shift. sc ET/ ET’ 6-7. cc E/E’ 3. 100”
 Month 2 PMc: small E sc/cc. UG E4, E’8.
Diplopia on RG. cc 80”, sc 100”. Intermitt
use of CLs.
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Management of Childhood Hyperopia: A
Pediatric Optometrist's Perspective
COTTER, SUSAN A. California
American Academy of Optometry Volume 84(2),February 2007, pp 103-109
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Variations in prescribing patterns for childhood + occur
within & between optometry & ophthalmology.
Differences : due to a greater level of concern among
optometrists about associated vision functions such as
accommodation, vergence, & stereopsis, & potential
impact of uncorrected + on reading & school
performance.
Conclusions. If indications for prescribing spectacles for
children with hyperopia are to be validated, randomized
controlled trials need to be performed.
Management of Childhood Hyperopia: A Pediatric Optometrist's Perspective
Survey 1: Prescribing for bilateral
asymptomatic + in young children
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65% of pediatric optometrists use +3 D of
bilateral hyperopia as their prescribing
threshold for 2yo.
28% used a higher threshold with 25% using +5
D as their threshold.
Pediatric ophthalmologists: 66% use +5D as
their threshold. 25% use a +3D threshold.
Survey 2: What magnitude of + in asymptomatic
children should be referred in a vision screening
because it is worrisome
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College of Optometrists in Vision Development (COVD)
& American Association of Pediatric Ophthalmology and
Strabismus (AAPOS)
AAPOS
COVD
Months
0-6
+5
+3.5
6-24
+4
+3
24-30
+4
+2,5
30-48
+4
+2
Management of Childhood Hyperopia: A Pediatric Optometrist's Perspective
Hyperopic children who have
strabismus and/or amblyopia
Teachings of Donders (1864) and Worth (1903) used
similarly within both professions
 maximum + to produce alignment in ET,
 full amounts of correction for anisometropia and
astigmatism to provide equal retinal image clarity
between the eyes,
 symmetrically reduced + prescriptions when needed
to ensure or promote acceptance of spectacles.
 Greatest prescribing variability: children ≤12 y who
have approximately equal + in the 2 eyes with neither
strabismus nor amblyopia.
Ocular Dominance Diagnosis and
Its Influence in Monovision
Olga Seijasa … Pilar Gomez de Liano, Rosario Gomez de Liano, …
American Journal of Ophthalmology Volume 144, Issue 2, August 2007, Pages 209-216
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9 different tests were carried out in a group of
51 emmetropic subjects to determine both
motor and sensory ocular dominance.
For analysis, patients were divided into 2
groups according to age.
Normal ophthalmologic examination results
were the inclusion requirement, with normal
binocular vision and good stereoacuity.
Ocular Dominance Diagnosis and Its
Influence in Monovision
RESULTS
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A significant % of uncertain or ambiguous results in all tests
performed was found, except in the hole-in-card and
kaleidoscope tests.
When the tests were compared, two by two, the correlation or
equivalence found was low and was much lower if tests were
compared three by three.
No clear ocular dominance was found in most studied
subjects; instead, there must be a constant alternating
balance between both eyes in most emmetropic persons,
but not in those with pathologic features. This fact would
explain the great variability both between and within different
kinds of tests.
Ocular Dominance Diagnosis and Its
Influence in Monovision
RESULTS
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Also, it would explain why monovision
technique is well tolerated in most patients,
with unsuccessful results only in those
patients with strong or clear dominance.
…. it seems appropriate to evaluate patient’s
dominance before monovision surgery to
exclude those individuals with clear
dominance.
Association between fixation preference
testing and strabismic pseudoamblyopia Hakim
OM Saudi Arabia
J Pediatr Ophthalmol Strabismus. 2007 May-Jun;44(3):174-7
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.. to evaluate the strength of the association between
fixation preference and strabismic amblyopia.
80 pts (3 to 8y) with manifest strabismus and ability to
do a Snellen E test ….
Fixation preference was graded from 0 (free alternation)
to 3 (strong uniocular fixation).
We compared acuity and the grade of fixation
preference.
Association between fixation preference
testing and strabismic pseudoamblyopia
RESULTS
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60 pts had strong uniocular fixation (grade 3). Of these patients, 50
had no amblyopia and only 10 had deep amblyopia.
10 pts had moderate fixation (grades 1 and 2). Of these patients, 5 had no
amblyopia and 5 had moderate amblyopia.
10 patients had free alternation (grade 0). These patients had equal vision.
Treatment of strabismic amblyopia on the basis that
the sound eye will show strong fixation preference
can be hazardous. Fixation preference could be a
severe form of eye dominance
Age at strabismus diagnosis in an incidence
cohort of children.
Mohney BG, …. Mayo Clinic, Minnesota Am J Ophthalmol. 2007 Sep;144(3):4679
Medical records of all Olmsted County,
Minnesota, residents < 19 y diagnosed with ET,
XT or hypertropia from 1985-94 reviewed.
The median age at diagnosis of
 esotropia (n = 380) : 3.1y
 exotropia (n = 205): 7.2y
 hypertropia (n = 42) : 6.1y
(P = .001).
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Age at strabismus diagnosis in an
incidence cohort of children.
 First
6 y, ET had highest
incidence
 XT predominated age 7-12.
 Each form similarly likely to
occur 13 -18 y P = .001
incidence cohort.
Mohney BG. Mayo Clinic
Am J Ophthalmol. 2007 Sep;144(3):465-7.
Medical records of all Olmsted County, Minnesota,
residents < 19 y with ET, XT or hypertropia 1985 - 94.
627 new cases of childhood strabismus identified
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ET 380 (60%)
accomm 28%, nonaccomm 10%, neurological 7%,
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XT 205 (33%)
I-mitt 17%, convergence insufficiency 6%
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Hypertropia 42 (7%).
Refractive effect of the horizontal
rectus muscle recession
Int Ophthalmol. 2007 Jul 19 Rajavi Z, …. Tehran, Iran
49 eyes of 27 patients :
(1) XT (24 eyes) - LR (s) Rc
(2) ET (25 eyes) who underwent MR (s) Rc.
Full ophthalmic examination including cycloplegic
automated refraction before, 1 & 3 mo after
surgery.
Corneal topography preoperatively, repeated 3
mo postop.
Refractive effect of the horizontal
rectus muscle recession
MR Rc: statistically significant myopic shifts @ mo 1 (from
+ 2.09 +/- 1.82 to + 1.88 +/- 1.83 DS, P = 0.03)
,,, in astigmatic power @ both mo 1 (from -0.85 +/- 0.67 to
-1.15 +/- 0.65 DC, P = 0.04) and mo 3 (from -0.85 +/0.67 to -1.16 +/- 0.65 DC, P = 0.01).
LR Rc: Myopic shifts not statistically meaningful.
…Significant astigmatic axis shift, which was toward with
the rule astigmatism @ both mo 1 (P = 0.02) and mo 3
(P = 0.02).
Refractive effect of the horizontal
rectus muscle recession
Corneal power measured by topography : statistically
significant reduction (less than 0.3 D) after recession
of either MR(P < 0.001) or LR (P < 0.001). Amounts of
refractive and corneal topographic changes were not
clinically remarkable.
Therefore, it does not seem necessary to perform
cycloplegic refraction early after horizontal rectus
muscle recession; however, a precise refraction in all
cases of strabismus should not be deferred later than
3 months.