Case of the week 23 (
January 2012
)
"V" Pattern Congenital Esotropia
The mother of this 4 years old girl complains about the
inward deviation of her daughter's eyes .
She noticed that 3 months after birth , no history of
pregnancy or delivery troubles .
The girl can fixate with both eyes , VA and refraction
are within normal values , no history of brain disease
or any general illness else .
See video for this patient
This girl obviously has a ‘V’ pattern congenital
esotropia with bilateral overaction of the inferior
obliques ( + 4 ) without underaction of the
superior obliques ( see the video again )
Also note the antimongoloid fissure which could be associated with pulley
heterotopy. In this case the medial pulleys would be
displaced upward and the lateral pulleys displaced
downward. According to the pulley theory, the ‘V’
pattern is caused by the vertical displacement of the
horizontal rectus muscle action. Of Course pulley
displacement must be confirmed by coronal imaging of the
mid-orbit, but this is not readily available because of
cost . The traditional treatment for a case like this is
bimedial rectus recession with bilateral inferior
oblique weakening. However, some cases treated this way
have persistent overaction of the inferior obliques.
This could result from unrecognized, or untreated,
pulley displacement contributing to the vertical
incomitance. Combined inferior oblique weakening and
down shift of the recessed medial recti could also be
done. As an extreme, weakening of the inferior obliques
and tuck of the superior oblique, if they are loose,
could be done along with bimedial rectus recession, but
I think that is too much surgery for this girl.
My decision here is to do BMR rec with downshift +
Bilateral IO myotomy ,
24h Post operative : Although the IO overaction
completely cured , a residual ET is present .Follow up
for 4 weeks , if still , I will re- recess one of the MR
.
post operative photos
الموقع المصري للحول
وامراض الجهاز الحركي للعين
The Egyptian Site of
Strabismus & Oculomotor Disorders
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