CCS2 Exotropie
2018-19 Orthoptie Jaar 2
Elise de Ruiter
HOGESCHOOL UTRECHT
1
,Table of Contents
1 INTERMITTERENDE EXOTROPIE.......................................................................................4
LEERDOELEN.................................................................................................................................4
LITERATUUR.................................................................................................................................4
CLASSIFICATION OF PRIMARY EXOTROPIA...................................................................................4
PRIMARY INTERMITTENT EXOTROPIA..........................................................................................5
CLASSIFICATION..............................................................................................................................................5
INTERMITTENT DISTANCE AND NONSPECIFIC EXOTROPIA............................................................................6
INTERMITTENT NEAR EXOTROPIA................................................................................................................14
PRIMARY CONSTANT EXOTROPIA...............................................................................................16
INFANTILE (EARLY-ONSET) EXOTROPIA........................................................................................................16
DECOMPENSATED INTERMITTENT EXOTROPIA............................................................................................17
SECONDARY EXOTROPIA............................................................................................................18
SECONDARY (SENSORY) EXOTROPIA............................................................................................................18
CONSECUTIVE EXOTROPIA AND ESOTROPIA...............................................................................19
CONSECUTIVE EXOTROPIA............................................................................................................................19
CONSECUTIVE ESOTROPIA............................................................................................................................20
RESIDUAL EXOTROPIA AND ESOTROPIA.....................................................................................21
RESIDUAL EXOTROPIA...................................................................................................................................21
RESIDUAL ESOTROPIA...................................................................................................................................21
2 DOELHOEK BEPALEN EN CASUISTIEK..............................................................................22
LEERDOELEN...............................................................................................................................22
THE POSTOPERATIVE TARGET ANGLE.........................................................................................22
ARTIKELEN..................................................................................................................................23
CASUSSEN PRIMAIRE EXOTROPIE...............................................................................................24
CASUS MARC 8 JAAR.....................................................................................................................................24
CASUS BAS 4 JAAR.........................................................................................................................................25
CASUS MAN 68 JAAR.....................................................................................................................................27
CASUS MAN 35 JAAR.....................................................................................................................................28
CASUS PETER.................................................................................................................................................30
CASUS MEISJE 4 JAAR...................................................................................................................................30
CASUSSEN SECUNDAIRE STRABISMUS........................................................................................31
CASUS PIETER................................................................................................................................................31
CASUSSEN CONSECUTIEVE STRABISMUS....................................................................................32
CASUS MAN 45 JAAR.....................................................................................................................................32
CASUS MAN 23 JAAR.....................................................................................................................................32
CASUS NOOR.................................................................................................................................................33
CASUS VROUW 39 JAAR................................................................................................................................33
CASUSSEN REST STRABISMUS.....................................................................................................35
CASUS MAN 43 JAAR.....................................................................................................................................35
CASUS MEISJE 12 JAAR.................................................................................................................................36
CASUS JONGEN 3 JAAR.................................................................................................................................36
CASUS MAN 45 JAAR.....................................................................................................................................37
2
,3 CHIRURGIE & COMPLICATIES.........................................................................................38
LEERDOELEN...............................................................................................................................38
COMPLICATIES BIJ STRABISMUS CHIRURGIE...............................................................................38
PEROPERATIEVE COMPLICATIES...................................................................................................................38
POSTOPERATIEVE COMPLICATIES.................................................................................................................41
PRE- EN POSTOPERATIEF ONDERZOEK........................................................................................43
PREOPERATIEF INFORMEREN.......................................................................................................................43
POSTOPERATIEF ONDERZOEK.......................................................................................................................43
4 ASTHENOPE KLACHTEN..................................................................................................44
LEERDOELEN...............................................................................................................................44
LITERATUUR...............................................................................................................................44
ASTHENOPE KLACHTEN...............................................................................................................44
ACCOMMODATIE..........................................................................................................................................44
CASUS............................................................................................................................................................45
5 CASUISTIEK....................................................................................................................46
EXTRA CASUSSEN........................................................................................................................46
CASUS KAREL 10 JAAR...................................................................................................................................46
PROEFTOETS CASUS 1...................................................................................................................................47
3
,1 INTERMITTERENDE EXOTROPIE
LEERDOELEN
Na het volgen van deze les kun je:
intermitterende exotropie indelen volgens het COD
een differentiaaldiagnose maken voor een distance en near exotropie en
gedecompenseerde exoforie
verschillende behandelingsmethoden noemen voor intermitterende exotropie met
de voor- en nadelen
verschillende postoperatieve behandelingsmethoden noemen voor een over- en
ondercorrectie
de prognose noemen voor de operatieresultaten van een intermitterende exotropie
LITERATUUR
Ansons en Davis (2014) hoofdstuk 13 “Intermitterende exotropie”
Von Noorden en Campos (2002) hoofdstuk 17 “Intermitterende exotropie”
CLASSIFICATION OF PRIMARY EXOTROPIA
Primary exotropia is can be intermittent or constant. Primary exotropia is more commonly
intermittent.
*D=dichtbij / V=veraf
4
,PRIMARY INTERMITTENT EXOTROPIA
CLASSIFICATION
Intermittent exotropia is an exotropia that is intermittently manifest. It is classified on the
basis of whether it is manifest for distance or near fixation. A significant difference is taken
to be at least 10∆.
Intermittent distance exotropia.
Most common type! PCT is at least 10∆ larger in the distance than for near.
o Simulated distance exotropia with normal AC/A ratio
Near deviation increases to the distance deviation after uniocular
occlusion. Sprake van hoge tonische convergentie.
After diagnostic occlusion (DO): D=N
o Simulated distance exotropia with high AC/A ratio
Near deviation is unchanged after occlusion, but increases to the
distance deviation with S+3,00 lenses.
After DO no change in angle. With S+3,00: D=N
o True intermittent distance exotropia
No significant increase in near deviation after occlusion or with
S+3,00.
After DO and with S+3,00 no change in angle: D>N
Intermittent nonspecific exotropia.
The difference between PCT for near and distance does not exceed 10∆.
o The exotropia may be intermittently manifest for any distance, although
usually distance fixation.
Intermittent near exotropia.
PCT at near is at least 10∆ greater than for distance.
o Simulated near exotropia
Distance angle increases to near angle after uniocular occlusion.
Na diagnostische occlusie (DO): D=N
o True near exotropia.
No significant increase in near deviation after occlusion
Na DO: N>D
* Zie ook het document ‘schema ‘intermittent exotropia (D > N )’ in.
5
,INTERMITTENT DISTANCE AND NONSPECIFIC EXOTROPIA
Intermittent distance and nonspecific exotropia differ chiefly in their PCT measurements. To
all intents and purposes they are otherwise the same and will be considered together.
FEATURES
Onset after 6 months of age
More common in females.
Deviation better controlled at near.
Manifest phase precipitated by inattention, poor general health, fatigue, alcohol
and bright light.
o A high level of illumination is a decompensating factor. The reason is not well
understood.
o Closure of deviating eye in bright light is a common sign.
Suppression when manifest, occasionally panoramic vision.
o Image seen by deviating eye is more peripheral, giving an increased field of
view rather than confusion.
Manipulation of accommodation and/or vergence.
o Used to control the exotropia for distance or near, causing blurred vision.
Occasionally DSC is seen.
o These patients have an earlier onset of the strabismus and reduced binocular
function.
Often associated with V-pattern
Variable natural history
Kenmerken (werkcollege)
Ontstaan na de 6e maand.
Komt vaker voor bij vrouwen
Oogstand nabij beter onder controle
Manifest:
o Bij staren
o Zwakke gezondheid
o Vermoeidheid
o Alcohol
o Fel licht
Suppressie, soms panorama zicht
Soms misbruik van accommodatie
Variabel natuurlijk beloop
6
,DIFFERENTIAAL DIAGNOSIS
DDx Intermitterende Exotropie en Decompenserende Exoforie
Kenmerk Intermitterende exotropie Decompenserende exoforie
Bewustzijn van deviatie Niet bewust Bewust als BEZ weg is
Reden van komst Cosmetisch Asthenope klachten
BEZ Asymptomatische BEZ als Symptomatische BEZ
deviatie onder controle is
Stabiliteit Kan toenemen in loop van Stabiel gedurende leven
het leven
Suppressie* Diep en uitgestrekt Niet of minimaal (diplopie!)
Retinacorrespondentie Normaal, abnormaal of Normaal
geen als deviatie manifest is
Prismafusie Vaak onbetrouwbaar en Betrouwbare metingen
niet te herhalen**
Behandeling gericht op… Sensorische en motorische Motorische problemen
problemen
Reactie op behandeling Matig/slecht Goed
*Suppressie is het grootste verschil tussen een decompenserende exoforie en
intermitterende exotropie. Er zal nooit suppressie aanwezig zijn bij een decompenserende
exoforie en deze zal diplopie klachten hebben.
**It is often hard to measure the prisma fusion amplitude at distance in patients with
intermittent exotropia. The act of simply placing the prism in front of the eye can lead to
decompensation.
7
, INVESTIGATION
Differentiaal Diagnosis of True and Simulated Distance Exotropia
True and simulated intermittent distance exotropia should be differentiated before
considering surgical management!
Diagnostic occlusion (DO)
o The squinting eye should be covered for about 1 hour. A shorter time is
insufficient.
o Should always done before AC/A ratio with lenses, otherwise a falsely high
ratio may be recorded!
AC/A Gradiënt Nabij
o If the deviation is still the same after DO, check if there is an increase of near
deviation with S+3,00 lenses (simulated distance exotropia with high AC/A
ratio).
Prisma Adaptation Test (PAT)
o The PAT is used to find the true maximal deviation and measure the potential
for BSV.
8
2018-19 Orthoptie Jaar 2
Elise de Ruiter
HOGESCHOOL UTRECHT
1
,Table of Contents
1 INTERMITTERENDE EXOTROPIE.......................................................................................4
LEERDOELEN.................................................................................................................................4
LITERATUUR.................................................................................................................................4
CLASSIFICATION OF PRIMARY EXOTROPIA...................................................................................4
PRIMARY INTERMITTENT EXOTROPIA..........................................................................................5
CLASSIFICATION..............................................................................................................................................5
INTERMITTENT DISTANCE AND NONSPECIFIC EXOTROPIA............................................................................6
INTERMITTENT NEAR EXOTROPIA................................................................................................................14
PRIMARY CONSTANT EXOTROPIA...............................................................................................16
INFANTILE (EARLY-ONSET) EXOTROPIA........................................................................................................16
DECOMPENSATED INTERMITTENT EXOTROPIA............................................................................................17
SECONDARY EXOTROPIA............................................................................................................18
SECONDARY (SENSORY) EXOTROPIA............................................................................................................18
CONSECUTIVE EXOTROPIA AND ESOTROPIA...............................................................................19
CONSECUTIVE EXOTROPIA............................................................................................................................19
CONSECUTIVE ESOTROPIA............................................................................................................................20
RESIDUAL EXOTROPIA AND ESOTROPIA.....................................................................................21
RESIDUAL EXOTROPIA...................................................................................................................................21
RESIDUAL ESOTROPIA...................................................................................................................................21
2 DOELHOEK BEPALEN EN CASUISTIEK..............................................................................22
LEERDOELEN...............................................................................................................................22
THE POSTOPERATIVE TARGET ANGLE.........................................................................................22
ARTIKELEN..................................................................................................................................23
CASUSSEN PRIMAIRE EXOTROPIE...............................................................................................24
CASUS MARC 8 JAAR.....................................................................................................................................24
CASUS BAS 4 JAAR.........................................................................................................................................25
CASUS MAN 68 JAAR.....................................................................................................................................27
CASUS MAN 35 JAAR.....................................................................................................................................28
CASUS PETER.................................................................................................................................................30
CASUS MEISJE 4 JAAR...................................................................................................................................30
CASUSSEN SECUNDAIRE STRABISMUS........................................................................................31
CASUS PIETER................................................................................................................................................31
CASUSSEN CONSECUTIEVE STRABISMUS....................................................................................32
CASUS MAN 45 JAAR.....................................................................................................................................32
CASUS MAN 23 JAAR.....................................................................................................................................32
CASUS NOOR.................................................................................................................................................33
CASUS VROUW 39 JAAR................................................................................................................................33
CASUSSEN REST STRABISMUS.....................................................................................................35
CASUS MAN 43 JAAR.....................................................................................................................................35
CASUS MEISJE 12 JAAR.................................................................................................................................36
CASUS JONGEN 3 JAAR.................................................................................................................................36
CASUS MAN 45 JAAR.....................................................................................................................................37
2
,3 CHIRURGIE & COMPLICATIES.........................................................................................38
LEERDOELEN...............................................................................................................................38
COMPLICATIES BIJ STRABISMUS CHIRURGIE...............................................................................38
PEROPERATIEVE COMPLICATIES...................................................................................................................38
POSTOPERATIEVE COMPLICATIES.................................................................................................................41
PRE- EN POSTOPERATIEF ONDERZOEK........................................................................................43
PREOPERATIEF INFORMEREN.......................................................................................................................43
POSTOPERATIEF ONDERZOEK.......................................................................................................................43
4 ASTHENOPE KLACHTEN..................................................................................................44
LEERDOELEN...............................................................................................................................44
LITERATUUR...............................................................................................................................44
ASTHENOPE KLACHTEN...............................................................................................................44
ACCOMMODATIE..........................................................................................................................................44
CASUS............................................................................................................................................................45
5 CASUISTIEK....................................................................................................................46
EXTRA CASUSSEN........................................................................................................................46
CASUS KAREL 10 JAAR...................................................................................................................................46
PROEFTOETS CASUS 1...................................................................................................................................47
3
,1 INTERMITTERENDE EXOTROPIE
LEERDOELEN
Na het volgen van deze les kun je:
intermitterende exotropie indelen volgens het COD
een differentiaaldiagnose maken voor een distance en near exotropie en
gedecompenseerde exoforie
verschillende behandelingsmethoden noemen voor intermitterende exotropie met
de voor- en nadelen
verschillende postoperatieve behandelingsmethoden noemen voor een over- en
ondercorrectie
de prognose noemen voor de operatieresultaten van een intermitterende exotropie
LITERATUUR
Ansons en Davis (2014) hoofdstuk 13 “Intermitterende exotropie”
Von Noorden en Campos (2002) hoofdstuk 17 “Intermitterende exotropie”
CLASSIFICATION OF PRIMARY EXOTROPIA
Primary exotropia is can be intermittent or constant. Primary exotropia is more commonly
intermittent.
*D=dichtbij / V=veraf
4
,PRIMARY INTERMITTENT EXOTROPIA
CLASSIFICATION
Intermittent exotropia is an exotropia that is intermittently manifest. It is classified on the
basis of whether it is manifest for distance or near fixation. A significant difference is taken
to be at least 10∆.
Intermittent distance exotropia.
Most common type! PCT is at least 10∆ larger in the distance than for near.
o Simulated distance exotropia with normal AC/A ratio
Near deviation increases to the distance deviation after uniocular
occlusion. Sprake van hoge tonische convergentie.
After diagnostic occlusion (DO): D=N
o Simulated distance exotropia with high AC/A ratio
Near deviation is unchanged after occlusion, but increases to the
distance deviation with S+3,00 lenses.
After DO no change in angle. With S+3,00: D=N
o True intermittent distance exotropia
No significant increase in near deviation after occlusion or with
S+3,00.
After DO and with S+3,00 no change in angle: D>N
Intermittent nonspecific exotropia.
The difference between PCT for near and distance does not exceed 10∆.
o The exotropia may be intermittently manifest for any distance, although
usually distance fixation.
Intermittent near exotropia.
PCT at near is at least 10∆ greater than for distance.
o Simulated near exotropia
Distance angle increases to near angle after uniocular occlusion.
Na diagnostische occlusie (DO): D=N
o True near exotropia.
No significant increase in near deviation after occlusion
Na DO: N>D
* Zie ook het document ‘schema ‘intermittent exotropia (D > N )’ in.
5
,INTERMITTENT DISTANCE AND NONSPECIFIC EXOTROPIA
Intermittent distance and nonspecific exotropia differ chiefly in their PCT measurements. To
all intents and purposes they are otherwise the same and will be considered together.
FEATURES
Onset after 6 months of age
More common in females.
Deviation better controlled at near.
Manifest phase precipitated by inattention, poor general health, fatigue, alcohol
and bright light.
o A high level of illumination is a decompensating factor. The reason is not well
understood.
o Closure of deviating eye in bright light is a common sign.
Suppression when manifest, occasionally panoramic vision.
o Image seen by deviating eye is more peripheral, giving an increased field of
view rather than confusion.
Manipulation of accommodation and/or vergence.
o Used to control the exotropia for distance or near, causing blurred vision.
Occasionally DSC is seen.
o These patients have an earlier onset of the strabismus and reduced binocular
function.
Often associated with V-pattern
Variable natural history
Kenmerken (werkcollege)
Ontstaan na de 6e maand.
Komt vaker voor bij vrouwen
Oogstand nabij beter onder controle
Manifest:
o Bij staren
o Zwakke gezondheid
o Vermoeidheid
o Alcohol
o Fel licht
Suppressie, soms panorama zicht
Soms misbruik van accommodatie
Variabel natuurlijk beloop
6
,DIFFERENTIAAL DIAGNOSIS
DDx Intermitterende Exotropie en Decompenserende Exoforie
Kenmerk Intermitterende exotropie Decompenserende exoforie
Bewustzijn van deviatie Niet bewust Bewust als BEZ weg is
Reden van komst Cosmetisch Asthenope klachten
BEZ Asymptomatische BEZ als Symptomatische BEZ
deviatie onder controle is
Stabiliteit Kan toenemen in loop van Stabiel gedurende leven
het leven
Suppressie* Diep en uitgestrekt Niet of minimaal (diplopie!)
Retinacorrespondentie Normaal, abnormaal of Normaal
geen als deviatie manifest is
Prismafusie Vaak onbetrouwbaar en Betrouwbare metingen
niet te herhalen**
Behandeling gericht op… Sensorische en motorische Motorische problemen
problemen
Reactie op behandeling Matig/slecht Goed
*Suppressie is het grootste verschil tussen een decompenserende exoforie en
intermitterende exotropie. Er zal nooit suppressie aanwezig zijn bij een decompenserende
exoforie en deze zal diplopie klachten hebben.
**It is often hard to measure the prisma fusion amplitude at distance in patients with
intermittent exotropia. The act of simply placing the prism in front of the eye can lead to
decompensation.
7
, INVESTIGATION
Differentiaal Diagnosis of True and Simulated Distance Exotropia
True and simulated intermittent distance exotropia should be differentiated before
considering surgical management!
Diagnostic occlusion (DO)
o The squinting eye should be covered for about 1 hour. A shorter time is
insufficient.
o Should always done before AC/A ratio with lenses, otherwise a falsely high
ratio may be recorded!
AC/A Gradiënt Nabij
o If the deviation is still the same after DO, check if there is an increase of near
deviation with S+3,00 lenses (simulated distance exotropia with high AC/A
ratio).
Prisma Adaptation Test (PAT)
o The PAT is used to find the true maximal deviation and measure the potential
for BSV.
8
