ET DEL LACTANTE (CONGNITA) A A Ophthalmology, 2008

DESARROLLO MOTORSu funcin es mantener cada ojo derecho al frente para que la imagen del objeto visto caiga sobre la fvea y sta se desarrolle con su proyeccin derecho al frente.

Juega papel importante mielinizacin de fibras motoras y sensoriales.DESARROLLO DE VISIN BINOCULAREl recin nacido posee un potencial gentico de binocularidad desde el nacimiento que evoluciona los 6 primeros meses con la separacin de las columnas de dominancia y la aparicin de clulas corticales binoculares.

Para que exista VB se requiere:Dos imgenes ntidas de tamao y forma simtrica para cada ojo, aparato motor normal, desarrollo y maduracin sensorial

EVOLUCIN V.B.Nistagmo fisiolgico hasta tercera semanaLuego aparece reflejo de fijacinPrimeros tres meses superposicin de imgenes.Tercer mes: fusin gruesa (Sheiman,1994, citado por Camacho 2009) Movimientos cabeza ojos coordinados

OTROS PARMETROSSensibilidad al contraste: Mejora a medida que la AV progresa, nivel adulto edad escolarVisin cromtica: 2 mes (incompleta)Estereopsis: 3. 5 a 6 meses de edad, 8o. mes nivel adulto (Daw, 2006) 3 a 5 meses, 4 a 6 meses nivel adulto (Duckman, 2006)PERIODO CRTICOPeriodo de tiempo durante el cual la integridad del sistema visual es susceptible de modificacin por experiencia.PERIODO CRTICODe cero a seis mesesSensibilidad mximaPrimordial recibir estimulo visual claroDeprivacin produce disminucin visual irreversibleDeprivacin de patronesDesenfoque pticoEstrabismo(Adler, 1994)

CATEGORIAS DE RIESGO

ESTRABISMO

La ambliopa por estrabismo ocurre aproximadamente en el 50% de pacientes con endotropia congnita, pero es poco comn en pacientes con estrabismo intermitente (Wright, et al 2006)

Neutralizacin foveolar en ojo desviado (escotoma) para eliminar interferencia sensorial. La fvea pierde funcin como sitio ptimo de resolucin y como punto de referencia de organizacin y localizacin espacial.

Edad del pacienteSeveridad de la ambliopaTipo de ambliopaEdad de aparicin del factor ambliopizanteInstauracin del tratamiento(Wright, et al 2006)

PRONSTICOET DEL LACTANTE PRECOZ, INFANTIL (CONGNITA) AAO, 2008

Ha sido descrito como sndrome, por ejemplo Sndrome de Ciancia, Sndrome Congnito o Sndrome de Lang.Algunas endotropas de comienzo temprano no son necesariamente congnitas, xej refractivas precoces y las asociadas a desrdenes neurolgicosRealizar diagnostico diferencial con sndrome de Duane, paresia del VI nervio o fibrosis congnita (limitacin de ABD)

en quienes se identificaron y analizaron los cuatro elementos clnicos ms caractersticos para determinar el origen congnito de una endotropa: Limitacin de la abduccin (LABD) en 95.4%, incomitancia horizontal (IH) en 67.7%, desviacin vertical disociada (DVD) en 66.15% y nistagmo latente (NL) en 60%.CARACTERISTICASPresencia demostrada a los 6 mesesAntecedentes familiaresSe presenta en 30% de los nios con problemas neurolgicos y de desarrollo (parlisis cerebral-hidrocefalia)

AV similar en los dos ojos y alternancia en fijacin (Ferrer Ruiz, 1991) (Wright, 2000)

Fijacin cruzada (Ferrer Ruiz, 1991) (Wright, 2000)

Posible ambliopa (40-50% Wright, 2000)Hiperfuncin Oblicuo Inferior, DVD (50%) (Wright, 2000)Asimetra seguimiento nasal y temporal

Calcutt C; Murray AD. Untreated essential infantile esotropia: factors affecting the development of amblyopia. Eye 1998;12 ( Pt 2):167-72. PURPOSE: A concomitant esotropia, presenting within the first 6 months of life, associated with a high incidence of dissociated vertical deviation, manifest latent nystagmus and asymmetric optokinetic nystagmus is termed essential infantile esotropia. Most studies concern patients diagnosed in infancy and treated throughout childhood. This paper addresses the factors that may influence the development of amblyopia in patients who remain untreated until visual adulthood. The correlation between anisometropia and amblyopia was statistically significant. ET DEL LACTANTEHipermetropa Fuente+ 1.00, +2.00(AAO, 2008)

+ 2.25 a + 5.00 (Wright, 2000)+1.50, +2.00(Ferrer R, 1991)< 2.00(Ticho, 2003)

nguloFuenteMayor 30 ^

(AAO, 2008)(Ticho, 2003)

Entre 30 y 70^

(Wright, 2000)45-50 ^ mnimo(Ferrer R, 1991)

PATOGENIA (AAO, 2008)

Sensorial (Worth): Deficiencia centro enceflico de fusinMecnico (Chavasse)Costenbader, Taylor e Ing reportaron resultados favorables en bebes operados entre 6 meses y dos aos.Importante intervenciones tempranas

MANEJO (AAO, 2008)Congenital Esotropia Observational Study (CEOS) Clinical reports have demonstrated that surgical correction of the esotropia between 6 and 12 months of age provides for enhanced development of stereoacuity compared with later surgery.La ciruga se puede hacer en nios sanos entre 4 y 6 meses para lograr la mxima VB (estereopsis)

Drover JR, Stager DR Sr, Morale SE, Leffler JN, Birch EE. Improvement in motor development following surgery for infantile esotropia. J AAPOS. 2008 Apr;12(2):136-40. Epub 2007 Dec 21.

Prior to surgery, patients with infantile esotropia were delayed in their achievement of developmental milestones. However, following surgery, a comparison group of patients showed rapid development and possessed motor skills comparable to those of normal children, suggesting that early surgery is beneficial to both visual and motor development

Von Noorden GK. Bowman lecture. Current concepts of infantile esotropia. Eye (Lond). 1988;2 ( Pt 4):343-57

Several forms of esotropia with a different pathophysiology that meet the criterion of an onset early in life must be distinguished from essential infantile esotropia. A hypothesis is presented, according to which a delayed development or a congenital defect of retinal disparity sensitivity (motor fusion) in an otherwise normal infant with immature sensory functions causes esotropia under the influence of various strabismogenic factors. Some of these factors are genetically determined, hence the familial occurrence of essential infantile esotropia. The absence or marked decrease of stereopsis and the asymmetry of optokinetic nystagmus are interpreted as the consequence of ocular misalignment early in life rather than of structural anomalies in the afferent visual pathways of esotropic patients. The therapeutic results after surgery are classified into four groups: subnormal binocular vision, microtropia, small angle eso- or exotropia and large angle residual or consecutive eso- or exodeviations. Analysis of data from 358 operated patients with a documented onset of esotropia prior to the sixth month of life has shown that the probability of obtaining an optimal functional result is increased when surgical alignment is completed before completion of the second year of life. However, surgery after the age of two or even four years of life does not preclude the development of binocular vision on a subnormal or anomalous basis

Birch EE, Fawcett S, Stager DR. Why does early surgical alignment improve stereoacuity outcomes in infantile esotropia? J AAPOS. 2000 Feb;4(1):10-4.

CONCLUSIONS: The results suggest that early surgical alignment is associated with better stereopsis in those patients with infantile esotropia who were treated during the first 24 months of life, because early surgery minimizes the duration of misalignment

Ruiz MF, Alvarez MT, Snchez-Garrido CM, Hernez JM, Rodrguez JM. Surgery and botulinum toxin in congenital esotropia. Can J Ophthalmol. 2004 :639-49.

Initial treatment with botulinum toxin, injected into both medial recti, is effective, reducing the amount of further horizontal surgery and favouring postoperative stability, except in children under 18 months, in whom injection of 5 units induces unbalanced dissociated vertical deviation.Baggesen K, Arnljot HM. Treatment of congenital esotropia with botulinum toxin type A. Acta Ophthalmol. 2009 Oct 30.

Conclusion: Botulinum toxin type A injections into the medial recti muscles are a valuable alternative to conventional strabismus surgery.Rowe F, Noonan C. Complications of botulinum toxin a and their adverse effects. Strabismus. 2009 Oc-Dc;17(4):139-42 A low incidence of complications per injection (12.4%) was found particularly for induced vertical deviations (2%) and hemorrhages (1%). Incidence for ptosis was the highest (8.4%). Notably, 10 additional cases of ptosis had resolved before follow-up. Two children were given occlusion therapy to prevent the possibility of stimulus deprivation occlusion until ptosis resolution.

Martn Gallegos-Duarte. Estigma y origen de la endotropa congnita. Rev Mex Oftalmol; En-Feb 2005; 79(1): 10-16Objetivo: Determinar los elementos nosolgicos bsicos que permiten conocer, de manera precisa, que una endotropa es de origen congnito independientemente de la edad en que se presente o se diagnostique, y cmo es que interactan estoselementos para comprender mejor la gnesis de la endotropa congnita (EC).Material y mtodos: Estudio prospectivo, longitudinal, observacional y descriptivo de pacientes con EC, a quienes se les realiz historia estrabolgica completa. Se analiz el estado sensorial, refractivo y motor: versin horizontal y vertical, hiper e hipofunciones, refraccin, movimientos disociados, tipo de nistagmo, tortcolis, capacidad visual, pruebas de fusin, deteccin y medicin del grado de ambliopa. Resultados: Se analizaron 65 pacientes con EC, en quienes se identificaron y analizaron los cuatro elementos clnicos ms caractersticos para determinar el origen congnito de una endotropa: Limitacin de la abduccin (LABD) en 95.4%, incomitancia horizontal (IH) en 67.7%, desviacin vertical disociada (DVD) en 66.15% y nistagmo latente (NL) en 60%.Conclusiones: Se demuestra la certitud diagnstica de EC a partir de la correlacin de cuatro elementos clnicos bsicos que determinan el estigma congnito independientemente de la edad del paciente.