August 2015

This is our first strabismus rounds for this academic year. I'll present 3 recent cases that have gone to the OR, and your job is to come up with a surgical plan for each and submit it in the comments section. After devising your surgical plan, you will demonstrate your ability to perform the surgery in the wet lab. So prior to the session, pick a case and a friend or two, go to the wet lab, and record your surgical procedure.

Case 1: This 5 year old girl has had “wandering eyes” for the past 2 years per her mother. She seems to have a tough time refocusing, even after multiple blinks.

http://www.cybersight.org/bins/content_page.asp?cid=1-2161-2380-2509-2522

Her vision is 20/20 in both eyes, with a cycloplegic refraction of +1D ou. You measure her alignment as X(T) 35 in all fields of gaze and at near. This is similar to her last exam 4 months ago. She fuses the W4D at distance and near. Her stereo has decreased from 60 to 100 to 200 over the last 6 months.

What is your surgical plan? 

Case 2: This 14 year old girl has a history of frontonasal dysplasia with multiple cranial and facial reconstructive surgeries. She is concerned that her left eye goes up.

www.patooral.bravepages.com

Her vision is 20/20 OD and 20/50 OS with moderate oblique astigmatism in both eyes. Ocular rotations show marked over-elevation in adduction OS. Alignment shows LHT 15 in primary, increasing to LHT 25 in right gaze. She demonstrates a large degree of excyclotorsion of the left fundus.

What is your surgical plan?



Case 3: This 64 y/o man has been having diplopia for the past 10 years, and requiring increasing prism in his glasses for the past 6 years. His doctor told him he couldn't have any more prism.

http://shermaneye.com/wp-content/uploads/2014/08/AdultStrabPre-O1-300x216.jpg

His acuity is 20/25 in both eyes with minimal astigmatic correction and 10∆ BO ou. He has 1+NS, but an otherwise unremarkable exam.
Ocular rotations are full, and he measures ET 25 in all fields of gaze.

What is your surgical plan?

October 2014 Strabismus Rounds

So this is our 2nd strabismus rounds of the year- same rules as last time. Pick a case, devise a rational surgical plan, submit your plan in the comments section, and then go to the wet lab and show me what you can do.


Case 1: This 18 year old girl has had double vision since suffering a head injury in a car accident 6 months ago:

http://avserver.lib.uthsc.edu:8080/Medicine/eye_exam/page51.htm

She has an inability to abduct the right eye past midline and has an otherwise normal ocular exam. She measures ET 35 in primary, ET 50+ in right gaze, and ET 10 in left gaze. (Top photo is left gaze, bottom photo is attempted right gaze.)

What is your surgical plan?




Case 2: This 15 year old boy has had double vision since suffering a concussion in a football game last year.

http://avserver.lib.uthsc.edu:8080/Medicine/eye_exam/page53.htm

He had a left inferior oblique recession by a trusted colleague 3 months ago, but has persistent diplopia, especially in primary and right gaze. He has LHT 8 in primary, LHT 20 in right, orthotropia in left gaze, and LHT 8 in downgaze. Double Maddox Rod testing shows minimal (2 degrees) of excyclotorsion.

What is your surgical plan? (Hint- let's not mess with the obliques in the wet lab yet.)




Case 3: A 25 year old woman seeks your care for correction of her strabismus. She notes that she tends to adopt a chin-up head position.

http://openi.nlm.nih.gov/detailedresult.php?img=2612973_IndianJOphthalmol-56-504-g008&req=4

You note XT25 in primary, increasing to XT 40 in upgaze, and XT 8 in downgaze. There is no inferior oblique or superior oblique dysfunction, and her ocular exam is normal. Of note, she was diagnosed with plagiocephly as an infant, but is otherwise healthy.

What is your surgical plan?

August 2014 Strabismus Rounds

This is our first strabismus rounds for the year. I'll present 3 recent cases that have gone to the OR, and your job is to come up with a surgical plan for each and submit it in the comments section. The new twist for this year: you will demonstrate your ability to perform the surgery in the wet lab. So prior to the session, pick a case and a few friends, go to the wet lab, and record your surgical correction with the appropriate model.


Case 1: This is a 10 month old boy who has had crossed eyes since birth.

He cross-fixates, and does not object to occluding either eye. His ocular exam is otherwise normal, and his cycloplegic refraction is +1D in both eyes. His alignment is stable from his initial exam 2 months ago. You estimate he is ET 40 by Krimsky. What is your surgical plan?


Case 2: This is a 12 year old girl who has been concerned about her friends noticing her eye drifting.

You find her acuity to be 20/20 in both eyes without correction. Her X(T) measures 45PD, she becomes tropic spontaneously, and will often remain tropic through a blink. Her stereoacuity has decreased over the past 6 months from 40 sec to 200 sec. What is your surgical plan?


Case 3: This is a 7 year old girl, who had surgery for esotropia when she was 8 months old. For the past year, she has been turning her face to the right, and sometimes adopting a small tilt to the right.

Her acuity is 20/20 in both eyes without correction. You measure LHT 6 in forced primary gaze, LHT 15 in right gaze, Ortho in left gaze and downgaze. Her LHT increases on left head tilt. What is your surgical plan?

October 18 session

We'll be covering the chapters on Vertical and A- and V-patterns strabismus in an interactive session.
The link to the Brainshark is here.
As usual, 1st years review the chapter and lecture and send questions my way- either comment on the blog, or e-mail me. 2nd years should pull a relevant article and circulate it to the group prior to the session. 3rd years prepare a 5 minute teaching session for us.

I'll be doing a traditional lecture/webinar on the chapter on Special Forms of Strabismus. The slides (without audio) are here.

The link to the webinar is here

Exotropia webinar

For those who missed the exotropia talk in the classroom, the recording can be found here.

September 20 lectures

We will be covering Esotropia and Exotropia this week.

Both talks are on Brainshark:

Exotropia

Esotropia

The Exotropia talk has no audio- I will cover it in class as a webinar and add the link afterwards.

The Esotropia talk has audio. In class, we will have an open discussion about the work-up and management of ET:

Each 1st year should review the chapter in BCSC and review the Brainshark presentation. Add any questions or areas that need clarification in the comment section of this blog.

Each 2nd year should pull an article on esotropia, send it to all of us, and prepare a 2-3 minute "digest" of its clinical relevance.

Each 3rd year should create a 3-5 minute teaching session on some aspect of esotropia.

4/3/13 Cases

Case 3

36 y/o man with longstanding strabismus, concerned that left eye "goes off" and he has trouble in social situations.
No prior eye surgery or patching. Specs for myopia.

Exam:

Va cc 20/20 ou

Rotations: Trace limitation to elevation in adduction OD

Alignment:
R gaze: LHT 8    Primary: LHT 12     L gaze: LHT 15

Double Maddox Rod: No torsion ou

Worth 4 dot: Suppresses left eye distance and near

Stereo: Nil

Displays a left head tilt ~5-10 degrees

Photos:

Questions:

Q 3.1 What is your working diagnosis? Are there additional tests that may help confirm your diagnosis?

Q3.2 What is your surgical plan?





Case 4

42 y/o woman with 2 day history of left-sided numbness (face, arm, torso, leg) and bilateral dysacusis, presents with "right eye turning in."
MRI shows 1.2 cm ring-enhancing lesion of  the right pons consistent with tumefactive demyelination.
Remote history of subfoveal CNV OD secondary to ocular histoplasmosis, had submacular surgery with no recurrence.

Exam:

Va cc: 20/400 OD (central scotoma stable), 20/20 OS

Rotations: Severe limitation to abduction OD

Alignment:
R gaze: ET 45     Primary: ET 25     L gaze: ET 4

Ocular exam: Stable 2+ NS, foveal RPE atrophy; optic nerves pink and flat ou with no RAPD

Photos:

Upper photo: Left gaze; Lower photo: Attempted right gaze

 

 

 

Representative photo from http://bingskee.hubpages.com

Questions

Q 4.1 Assuming her alignment is stable in 4-6 mos, what is your surgical plan?