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Volume 48, 1998, p. 12

Symposium: Strabismus Management

Stephen P. Kraft, M.D., F.R.C.S.C.

The format of this year's Sunday Night Symposium deviates from that of previous symposia which have been traditionally organized around specific topics. The 1997 edition presents an update in the management of several strabismus conditions commonly encountered in a general ophthalmology practice. The symposium is structured as a series of one-on-one encounters, whereby two experts will provide alternative opinions for each of four issues. Each presenter has been asked to justify his or her position by drawing from his or her own clinical experience as well as from work documented in the literature.


Following the presentations, Jill Thalacker Clark of Waycross, GA, will make a brief summary of the proceedings.

1. Treatment of Unilateral Amblyopia: Pharmacologic versus Occlusion Therapy
Functional amblyopia is one of the most common disorders encountered in childhood strabismus practice. The most common causes include strabismus and anisometropia. If refractive correction is not required or if it is indicated but does not lead to resolution of the vision deficit in the amblyopic eye, then the vision in the better-seeing eye has to be blurred or blocked to reverse this deficit. This is accomplished by either pharmacologic penalization or occlusion of the preferred eye. Each option can be used with different regimens and each has its advantages and disadvantages. For this segment, two experienced orthoptists will present the positions for pharmacologic and occlusion therapy and justify their choices. Ms. Jana Sinelli from Baltimore, MD, will deal with the pharmacologic option and Ms. Paula Edelman from Los Angeles, CA, will present the case for occlusion.


2. Surgical Treatment of Convergence Excess Esotropia: Prism Adaptation versus Augmented Surgery
Among the various forms of comitant esotropia seen in children, one of the most common is that characterized by a deviation larger at near than at distance. Patients whose deviation is not controlled by refractive correction require surgery to align their eyes, with the goal being satisfactory alignment both for distance and near fixation. There have been several approaches put forth to deal with such cases. One option popularized in recent years is the application of paste-on prisms to match the near deviation, allowing the surgeon to determine the response to correction of the entire near angle and the optimal surgery dosage for correcting the esodeviation. Another common approach is the augmenting of the usual dosage of surgery for the distance deviation in order to account for the greater angle at near.


Ms. Pam Kutschke from Iowa City, IA, has had a great deal of experience with paste-on prisms prior to esotropia surgery and will address this option. Dr. Mark Greenwald from Chicago, IL, will present his position justifying the use of augmented surgery.


3. Management of Intermittent Exotropia: Non-Surgical versus Surgical Therapy
Intermittent exotropia is one of the most frequent strabismus conditions encountered in general practice. The most common type is that characterized by a larger exodeviation at distance than at near, such that the deviation is more poorly controlled when the child fixates at distance. There are two commonly-held philosophies for managing the young child with this condition. One involves the use of non-surgical therapy, which encompasses several options including patching, minus lenses, and orthoptic treatments such as antisuppression. Another approach advocates surgery early in the course of the problem to eliminate the deviation.


Ms. Cindy Pritchard from New Orleans, LA, will present the case for use of non-surgical therapy in managing intermittent exotropia. Dr. Edward Raab from New York, NY, will justify the use of surgery as a primary modality in treating this condition.


4. Surgery for Dissociated Vertical Deviation: Superior Rectus Recession versus Inferior Oblique Anteroposition
The infantile (or congenital) esotropia complex includes vertical deviations which usually manifest later than the presenting sign of a large angle esotropia. These vertical tropias occur in at least 50 per-cent of cases and are of two forms: overaction of the inferior oblique muscles and dissociated vertical deviations (DVD). There have been many recommendations for the surgical treatment of DVD over the years. Until the mid 1980's the most common procedure was the recession of the superior rectus. In the past ten years there has been a popularizing of the anterior transposition of the inferior oblique which converts the muscle into a depressor.


Dr. Sprague Eustis from New Orleans, LA, will present the case for superior rectus surgery for DVD. Dr. David Stager of Dallas, TX, has studied the physiology of the inferior oblique and will present the case for using the transposition of this muscle.