25. …Contd…
CT
MRI Brain
<45 years (if –ve then LP)
45-55 years with no hx of vasculopathy
VI th nerve palsy + severe pain or neurological
signs
Any Hx of Ca
Bilateral VI th Nerve palsy
Papilledema
26. In children
Emphasis on
Trauma
Recent illness
Ear infections
Otoscopic examination
MRI brain for all children
27. Treatment
Tx underlying cause
Orthoptic TX
Base out prism
Patching or fogging
Botulinum toxin in ipsilateral MR
Surgery
28. Surgery
If persists for > 6 months
Recession/resection
Transposition of SR/IR insertions
Jansen procedure
Hummelsceim procedure
29. Medial Rectus Restriction
Causes
Thyroid myopathy
Medial orbital wall fracture
Excessive resection of MR
30. THYROID MYOPATHY
Subset of Thyroid eye disease i.e. also
called*
Graves eye disease
Thyroid ophthalmopathy
Thyroid related ophthalmopathy
Thyroid orbitopathy
Thyroid related immune orbitopathy
Thyroid eye disease
*american academy of ophthalmology. 2008-2009,Section 6
31. Pathogenesis
Autoimmune
Infiltration of
Lymphocytes
Plasma cells
Mast cells
Deposition of mucopolysaccharides
especially hyaluronic acid
Leads to edema and later fibrosis that cause
restriction
32. …Contd…
Muscles may increase up to 6-8 times of
normal size
Non-tendinuous part involved
Frequency*
Inferior rectus (60-70%)
Medial rectus (25%)
Then superior and lateral rectus
*Char DH, Norman D. The use of computed tomography and ultrasonography in the evaluation of orbital masses. Surv Ophthalmol
1982;27:29.
38. …Contd…
TFTs
EMG & tensilon tests show no abnormality
Orbital ultrasound
CT
Axial/coronal views
MRI
39. Treatment
General
Smoking cessation
Medical internist or endocrinologist opinion
Prisms temporarily used for diplopia in
primary positions
40. Surgery
Indications
Diplopia in primary or reading positions
Abnormal head position
When to do??*
Angle of deviation stable for > 6 months
In chronic & inactive cases
After orbital decompression surgery
*Scot WF, Thalaker JA. Diagnosis an treatment of thyroid myopathy, Ophthalmology 1974;73:437.
41. …Contd…
Goal
To achieve BSV in primary & reading position
Technique
Recession is preferred Tx bcz resections worsen
the restriction
Adjustable & non-absorbable sutures used
Initial under correction is desirable
42. Medical
Chemodenervation
Botulinum toxin A in affected muscle
1.5-5 units
Onset of action…1-3 days
Duration…3 months
44. DUANE SYNDROME
Characteristics
Failure of innervation of LR by 6th nerve
Innervation of LR by 3rd nerve
Imaging studies
Hypoplasia / aplasia of 6th N. Nucleus
46. History
First described by
Sinclair in 1895
Bahr in 1896
Stilling in 1887
Wolff in 1900
Duane described in 1905*
54 cases and offered theories
*Duane A. Congenital deficiency of abduction, associated with impairment of adduction, retraction movements,
contraction of the palpebral fissure and oblique movements of the eye. 1905. Arch
Ophthalmol. Oct 1996;114(10):1255-6; discussion 1257
47. Clinical Features
BSV intact in primary position
Limited horizontal movements
Restricted abduction
Restricted adduction
Both
Upshoot or downshoot
Retraction of the globe
48. Classification
Two types
Brown*
Huber**
*Brown HW., (1950) Congenital structural muscle anomalies in: Allen JH ed. Strabismus Ophthalmic
Symposium. St Louis, Mosby, pp 205-36
**Huber A., (1974) Electrophysiology of the retraction syndrome. British journal of ophthalmology 58, 293-300
49. Brown’s Classification
Based on clinical observations
Type A
Limited abduction and less limited adduction
Type B
Limited abduction but normal adduction
Type C
Limited adduction > limited abduction
50. Huber’s Classification
Type 1 (70%-80%):
Inability or limited abduction
Normal or minimal defect in adduction
Esotropia with head straight
Globe retraction & palpebral-fissure
narrowing on adduction
Usual face turn to affected side
51. Type 1 must be differentiated from 6th nerve
palsy
Globe retraction
Mild Esotropia
Fissure changes
Upshoot and downshoot
52. Type 2 (about 7%)
Limited adduction
Normal or minimal defect in abduction
Exotropia of the affected eye
Globe retraction and palpebral-fissure
narrowing on adduction
Face turn to normal side
53. Type 3 (about 15%)
Limited abduction and adduction
Globe retraction and palpebral-fissure
narrowing on attempted adduction
Possible upshoot and downshoot on
adduction
Straight or nearly straight head position
55. Management
General measures
Prisms: up to 25 error
Special seating arrangement for children in
schools
Vision therapy for secondary convergence
insufficiency
Special rear mirrors while driving
56. Surgery
Standard management
Indications
Unacceptable face turn
Significant misalignment
Severe retraction
Upshoot & downshoot
57. Procedures
Type 1
Recession of MR
Recommended for > 20 deviation
LR resection not favorable
Partial or full transposition of vertical recti
58. Type 2
Recession of involved LR for small deviations
Recession of both LR in large deviations
Resection of MR not favorable
59. Type 3
For Severe globe retraction
Recession of both MR & LR
60. MÖBIUS SYNDROME
Very rare
Paul julius Möbius, a German neurologist, in
1888 and 1892
Both congenital facial diplegia and bilateral
Abducent nerve palsies
In 1939, henderson
Congenital unilateral facial palsy
68. Take Home Message
Complete Hx
Thorough Ophthalmic examination
Tests interpretation
Enough knowledge
Physician/endocrinologist/neurologist opinion
69.
70. MCQs
1. 9 month girl has abnormal movement of Rt eye
which started shortly after birth but stable over
time. Good VA, left face turn, with face turn eyes
are straight, Rt eye moves normally but Lt fails to
abduct past midline. Esotropia = 20 PD, cycloplegic
refraction +1.00 sphere. Next step in management
should be:
a. Neurological evaluation with neuro imaging
b. Prescription of full cyclolegic refraction
c. Observation only
d. Strabismus surgery for deviation in primary position
Ans. C… case of duane syndrome with little face turn
71. 2. A 30 year-old man developed a right sixth nerve
palsy and facial pain. CT scan revealed opacity of
the mastoid air cells. Diagnosis is…
a. Wallenberg's syndrome
b. Millard-Gubler's syndrome
c. Gradenigo's syndrome
d. Möebius' syndrome
Ans: c
72. 3. A 6 year-old girl had bilateral Esotropia and absent
facial expression. There are also punctate corneal
staining due to exposure keratopathy. Corneal
sensation appears normal. Diagnosis..
a. Duane's syndrome
b. Möbius syndrome
c. accommodative Esotropia
d. intermittent divergent squint
Ans: b
73. 4. All of the following would be expected to show
restriction during forced duction testing except:
a. Thyroid associated orbitopathy
b. Internuclear ophthalmoplegia
c. Orbital fracture with IR entrapment
d. Congenital fibrosis of extra ocular muscles
Ans. b
77. a. What is the primary position of the affected
eye?
Ans. Left Hypotropia
b. In which direction is the eye movement
affected?
Ans. Left up gaze and abduction
c. Type of strabismus
Ans. Mechanical
d. Diagnosis
Ans. Thyroid eye disease