Partially Accommodative ET Management

Summary

This video discusses the management of partial accommodative esotropia, emphasizing the importance of full prescription correction, as well as the challenges of prescribing bifocals due to potential hypo-accommodation. It explores treatment options, including occlusion therapy for amblyopia and surgical considerations. The choice of full or under-correction surgery depends on whether the patient has potential for binocular vision. For non-accommodative deviations, surgery targets the residual non-accommodative angle, with a distinction between unilateral surgery for basic angles and bilateral surgery for convergence excess patterns.

Takeaways

• 😀 Prescribe full cycloplegic correction for patients with partial accommodative esotropia, matching the degree of hypertropia measured during the exam.
• 😀 Bifocals are not recommended for patients with partial accommodative esotropia because they can exacerbate hypo-accommodation and are not effective for improving near vision in these cases.
• 😀 Convergence excess patterns, where the deviation is more significant at near, may require surgery as an alternative when cosmesis is poor or other therapies fail.
• 😀 Occlusion therapy is necessary for patients who have developed amblyopia due to the constant deviation of the eyes.
• 😀 Orthoptic exercises may be prescribed post-surgery for patients with potential binocular function to help control deviation.
• 😀 The decision to perform surgery should be based on whether the patient has the potential for binocular vision or if the goal is cosmetic.
• 😀 When performing surgery, always target the non-accommodative component of the deviation, measured after the patient has been fully corrected with their glasses.
• 😀 In cases where the deviation is initially 30 diopters but reduces to 20 diopters with glasses, surgery should target the remaining 20 diopters, which is the non-accommodative component.
• 😀 For patients with a basic angle deviation, unilateral surgery may be sufficient, but for those with a convergence excess pattern, bilateral surgery is often required.
• 😀 It is important to ensure the patient is wearing their full prescription glasses when measuring the non-accommodative component of the deviation during pre-surgical assessment.

Q & A

What is the primary treatment for patients with partial accommodative esotropia?

The primary treatment is prescribing the full hypermetropic correction. The amount of correction should be equal to the hypertropia found during the examination, which helps reduce the deviation.

Why are bifocals not recommended for patients with partial accommodative esotropia?

Bifocals are not recommended because they do not help in controlling the deviation for patients with a convergence excess pattern. The bifocal segment may cause hypoaccommodation, which can worsen the condition in the long term.

What alternative treatment options are available for improving cosmesis in patients with convergence excess?

If cosmesis is a concern and bifocals are not effective, surgery may be considered as an alternative treatment option, particularly for patients with a convergence excess pattern.

How does amblyopia affect the treatment of patients with partial accommodative esotropia?

Patients with partial accommodative esotropia may develop amblyopia due to the constant deviation. Occlusion therapy is often required to address this issue and improve visual function.

What role do orthotic exercises play in the management of partial accommodative esotropia?

Orthotic exercises are not typically effective for patients with constant deviations, as they do not have binocular vision. However, post-operative orthotics may be used if the patient gains binocular potential after surgery.

How do you determine whether a patient requires full correction or under-correction in surgery for esotropia?

The decision depends on whether the patient has binocular potential. If the patient has potential for binocular single vision (BSV), full correction is aimed for. If no such potential exists, under-correction is preferred.

What is the significance of correcting the non-accommodative component of the deviation in surgery?

Correcting the non-accommodative component ensures that the surgery targets the part of the deviation that remains after full correction of the refractive error. This is crucial for achieving optimal surgical outcomes.

When measuring the non-accommodative component of the deviation, why is it essential for the patient to wear their full prescription?

Wearing the full prescription is necessary to accurately measure the non-accommodative component of the deviation. Without it, the full extent of the non-accommodative deviation may not be captured, potentially leading to suboptimal treatment.

What approach should be taken when treating patients with a convergence excess pattern?

For patients with a convergence excess pattern, surgery should focus on the near angle of deviation, as this is where the maximum isotropia is typically observed. The approach can involve bilateral surgery to correct the issue.

What type of surgery is recommended for patients with a basic angle of deviation?

For patients with a basic angle of deviation, unilateral surgery is generally recommended. This approach targets the deviation effectively without over-correcting the condition.