Introduction Introduction Curtis R. Baxstrom,MA,OD,FCOVD,FNORA - PDF document

Clinical Testing and Clinical Testing and Treatment of Infantile Strabismus Treatment of Infantile Strabismus Introduction Introduction Curtis R. Baxstrom,MA,OD,FCOVD,FNORA Curtis R. Baxstrom,MA,OD,FCOVD,FNORA th International Congress of Behavioral Optometry 5 th International Congress of Behavioral Optometry 5 Sydney, Australia Sydney, Australia April 22, 2006 April 22, 2006 Infant Binocularity Infant Binocularity Single vs. Multiple Factors Single vs. Multiple Factors � Is an infant binocular at birth ? Is an infant binocular at birth ? � � Exotropia Exotropia vs. vs. Esotropia Esotropia Leading to Strabismus Leading to Strabismus � � Congenital vs. Infantile Congenital vs. Infantile Esotropia Esotropia � � Single vs. Multiple Causal Factors Single vs. Multiple Causal Factors � � Esotropia Esotropia - - Time of Onset Time of Onset � 1

Possible Factors of Strabismus Possible Factors of Strabismus Genetics Interocular Differences Interocular Differences Genetics � � � � and Emmetropization Emmetropization Orientation and Localization Orientation and Localization and � � Reciprocal Interweaving Reciprocal Interweaving Motor to Sensory Motor to Sensory � � � � Development Development ( (bilaterality bilaterality, reflexes, etc.) , reflexes, etc.) Visual Field development Visual Field development � � Accommodation Accommodation � � and similarities within the and similarities within the Abduction Deficits Abduction Deficits � � visual fields visual fields Motion Processing Motion Processing � � Principles of development Principles of development � � Vestibular influences Vestibular influences � � Attentional Distribution Attentional Distribution � � Cross fixation Cross fixation � � Systemic Disease / Trauma Systemic Disease / Trauma � � Effects of treatment (lenses, Effects of treatment (lenses, � � Monodeprivation (cornea, Monodeprivation (cornea, � � etc) etc) lens) lens) Differential Diagnosis Differential Diagnosis Time of Onset for Strabismus Time of Onset for Strabismus � Accommodative Accommodative esotropia esotropia � � Pseudoesotropia Pseudoesotropia � � 4 Months 4 Months - - supine supine � � Duane Duane’ ’s Type I s Type I � � 9 Months 9 Months – – sitting / standing sitting / standing � � Nystagmus Nystagmus Blockage Syndrome Blockage Syndrome � � 18 Months 18 Months - - locomotion locomotion � th Nerve Paresis 6 th � 6 Nerve Paresis � � 3 Years 3 Years - - preschool, moving in space preschool, moving in space � � Others Others � 2

Infantile vs. Accommodative Esotropia Esotropia Infantile vs. Accommodative Developmental Considerations Developmental Considerations Infantile Accommodative and Unique Characteristics to and Unique Characteristics to Onset Birth to 6 months >6 months to 7 years Consider When Evaluating Consider When Evaluating Angle 25 to 60 PD 10 to 40 PD Refraction < + 3.00 sphere > + 3.00 sphere Amblyopia uncommon common Infants Infants L or ML nystagmus common uncommon DVD common uncommon IOOA common uncommon Motion Asymmetry common uncommon VOR common uncommon Developmental Considerations Developmental Considerations and Models and Models Three Fundamental Abilities Dealing with the Space Construct Information Movement Patterns Three Fundamental Abilities Processing Balance with Gravity Orientation Freedom to compute � Kraskin Kraskin – – “ “Three Fundamental Abilities Three Fundamental Abilities” ” � Where am I? � Rethy Rethy– –“ “Vision moves from motor to sensory Vision moves from motor to sensory” ” Balance with Task Localization Range to compute � Where is it? � Sutton Sutton – – “ “Movement is learning Movement is learning” ” � Manipulate Task Centering/Identification Facility to compute What is it? � Streff Streff – – “ “Vision is Motor Vision is Motor” ” � � Pepper Pepper – – “ “Principles of Movement Principles of Movement” ” � 3

Rethy Rethy – – Motor to Sensory Motor to Sensory Quantitative vs. Qualitative Quantitative vs. Qualitative Information - Information - RGMR RGMR � Skeletal Component Skeletal Component - - seek and hold image seek and hold image � � Visceral Component Visceral Component - - discriminates and discriminates and � defines the image defines the image � Cortical Component Cortical Component - - unifies and interprets unifies and interprets � the image the image Visual Models and RGMR Visual Models and RGMR � Optical Model Optical Model - - primarily skeletal primarily skeletal � • • Reach Reach - - vergence vergence • • Grasp Grasp - - accommodation accommodation Projection and Manipulation Projection and Manipulation • • Release Release - - change fixation or attention change fixation or attention � Developmental Model Developmental Model - - adds visceral and adds visceral and � cortical cortical • • Manipulate Manipulate � Projection Projection - - as if it were as if it were … … � � Prehension Prehension - - localize with hands, confirmation localize with hands, confirmation � � Locomotion Locomotion - - time and space beyond reach time and space beyond reach � 4

Principles of Movement (RGMR) Principles of Movement (RGMR) � Can I do it ? Can I do it ? � Evaluation of Infants Evaluation of Infants � How well can I do it ? How well can I do it ? � � How long can I do it ? How long can I do it ? � � Can I accept change ? Can I accept change ? � � Can I problem solve ? Can I problem solve ? � 5

Does the Case History tell us Does the Case History tell us everything? everything? What is the most important What is the most important component of an infant exam? component of an infant exam? How about motor development as an How about motor development as an indicator of visual development? indicator of visual development? Evidence for Developmental Hx Evidence for Developmental Hx Major A, Maples WC, Toomey S, DeRosier W, Gahn D. Retrospective Major A, Maples WC, Toomey S, DeRosier W, Gahn D. Retrospective study of factors associated with infantile esotropia. Submitted for study of factors associated with infantile esotropia. Submitted for Prematurity Prematurity publication Optom Vis Sci. 2005. publication Optom Vis Sci. 2005. � Pulled Hastings Records and Looked for Pulled Hastings Records and Looked for � 10 Years Ago 10 Years Ago Today Today Infantile Esotropia Dx that had not been Infantile Esotropia Dx that had not been � 28 weeks 50% lived 28 weeks 50% lived � 30 weeks >80% live 30 weeks >80% live � � previously treated previously treated � 26 weeks none lived 26 weeks none lived � 26 weeks 50% live 26 weeks 50% live � � � Compared to matched to non esotropes by Compared to matched to non esotropes by � � 24 weeks >25% live 24 weeks >25% live � age and gender age and gender • Twenty Six Factors Evaluated Twenty Six Factors Evaluated • • Twelve were significant at .05 or better • Twelve were significant at .05 or better 6

Evidence for Developmental Hx Evidence for Developmental Hx Behavioral Observations - - Behavioral Observations Major A, Maples WC, Toomey S, DeRosier W, Gahn D. Retrospective Major A, Maples WC, Toomey S, DeRosier W, Gahn D. Retrospective study of factors associated with infantile esotropia. Submitted for study of factors associated with infantile esotropia. Submitted for Manipulation and Projection Manipulation and Projection publication Optom Vis Sci. 2005. publication Optom Vis Sci. 2005. Premat 12 � Fundamental abilities to learn the Fundamental abilities to learn the Fam O Hx � 10 Cardio Dis construct of space and time construct of space and time Syst Dis 8 HBP Preg � Projection Projection - - static or dynamic? static or dynamic? � < Birth Wt 6 � Prehension Prehension Oxygen � GI Dis 4 � Development of Postural Control Development of Postural Control � Male Otit Med 2 � Locomotion Locomotion � C Sect 0 Augm Lab � Don Don’ ’t forget the factor of time t forget the factor of time � Odds Ratio Resp Dis Visual Acuity Visual Acuity � Changing optical properties, focusing Changing optical properties, focusing � � Differentiation of fovea, changes in Differentiation of fovea, changes in � photoreceptors and dendrites photoreceptors and dendrites � Myelination Myelination of visual pathway of visual pathway � � Increased synaptic connectivity and Increased synaptic connectivity and � pruning pruning � * Changes in arousal, sleep cycles * Changes in arousal, sleep cycles � 7

Methods and Probes Methods and Probes � Fix and follow, resistance to occlusion Fix and follow, resistance to occlusion � � OKN OKN � � Teller cards Teller cards � � Face Dot paddle Face Dot paddle � � Other FPL cards / paddles Other FPL cards / paddles � � Electrodiagnostic Electrodiagnostic – – VEP / VER VEP / VER � 8