phospholine iodide in the management of esotropia

Phospholine Iodide in the Phospholine Iodide in the management of esotropiamanagement of esotropia

Lionel KowalLionel KowalClaudia YahalomClaudia Yahalom

RVEEH / CERA MelbourneRVEEH / CERA Melbourne

SQUINT CLUB DUNEDIN 2005SQUINT CLUB DUNEDIN 2005

HISTORY France 120y, US HISTORY France 120y, US 55y55y

Javal ‘Manuel theorique et practique du Javal ‘Manuel theorique et practique du strabisme’: bifocals & miotics for ET 1886strabisme’: bifocals & miotics for ET 1886

Samuel Abraham: Pilo / eserine for ETSamuel Abraham: Pilo / eserine for ET 46 cases Amer J Ophth 1949: 16/46 46 cases Amer J Ophth 1949: 16/46

‘helpful’ ‘helpful’ AJO 1952,1961; JPO 1964,1966AJO 1952,1961; JPO 1964,1966

CURRENT STATUS:CURRENT STATUS:

Difficult to obtain : application to TGA for Difficult to obtain : application to TGA for each patienteach patient

Expensive [$A130 a bottle]Expensive [$A130 a bottle]

PARKS 1958PARKS 1958ABNORMAL ACCOMMODATIVE ABNORMAL ACCOMMODATIVE

CONVERGENCE IN SQUINT n=1249CONVERGENCE IN SQUINT n=1249

Old / difficult: Why Old / difficult: Why bother? bother?

because it sometimes because it sometimes works very well!works very well!


CONVERGENCE IN SQUINT n=1249CONVERGENCE IN SQUINT n=1249 No Rx: n=73No Rx: n=73

Isoflurophate n=47 .. after Rx is stoppedIsoflurophate n=47 .. after Rx is stopped

BMR n=104BMR n=104 18: no better18: no better

One MR n=74One MR n=74 26: no better26: no better

PARKS 1958PARKS 1958 number where A:AC improved [ result perfect]number where A:AC improved [ result perfect]

No RxNo Rx MioticMiotic BMR BMR One MROne MR

< 7y< 7y 9/319/3129%29%

4/154/1527%27%

7 -12y7 -12y 20/4020/40 28/32 28/32 87%87%

AllAll 69 / 10469 / 10466%66%[40;38%][40;38%]

27 /7427 /7436%36%[7;9.5%][7;9.5%]


CONVERGENCE IN SQUINTCONVERGENCE IN SQUINTThe lasting improvement of the The lasting improvement of the

abnormal A:AC produced by abnormal A:AC produced by miotic is similar to the miotic is similar to the permanent result attained by permanent result attained by surgerysurgery

Patients studiedPatients studied

Retrospective chart review of patients from Retrospective chart review of patients from a private strabismus practice.a private strabismus practice.

20 consecutive children with ET reluctant 20 consecutive children with ET reluctant to wear glassesto wear glasses

PI “second choice” for mgmt of ETPI “second choice” for mgmt of ET Ages 0.5 to 6 y [Parks : low expectations Ages 0.5 to 6 y [Parks : low expectations

of success - 25+%] of success - 25+%]

Four groups of children with ETFour groups of children with ET A. A. Hyperopes <+4Hyperopes <+4 who refuse glasses: n=5. who refuse glasses: n=5. B. B. Hyperopes >+4Hyperopes >+4 who refuse glasses: n=7 who refuse glasses: n=7

C. C. Uncosmetic near- only ETUncosmetic near- only ET: n=1: n=1

D. D. Recurrent ET Recurrent ET after initially successful outcome from after initially successful outcome from recent ET surgery. recent ET surgery.

Glasses not tolerated / refusedGlasses not tolerated / refusedn=9 n=9 2/9 had an unsuccessful trial of PI prior to surgery2/9 had an unsuccessful trial of PI prior to surgery

Definition of OutcomesDefinition of Outcomes

Success (Success (SS). Esophoria / tropia ≤10∆ ). Esophoria / tropia ≤10∆ whilst using +/- after stopping PIwhilst using +/- after stopping PI

Relative success (Relative success (RSRS). One of:). One of:*decreased angle of ET (either D or N = 0)*decreased angle of ET (either D or N = 0)*% of time strabismic reduced to < 25%*% of time strabismic reduced to < 25%

No success (No success (NSNS): little / no improvement in ): little / no improvement in angle or POTSangle or POTS

Table 1: Results of patients receiving PI according to indication for treatmentTable 1: Results of patients receiving PI according to indication for treatment

## A: Hyperopia <4A: Hyperopia <4 B: Hyperopia > +4B: Hyperopia > +4 C: Near only ETC: Near only ET D: ‘Rescue’ recurrent ET D: ‘Rescue’ recurrent ET

11 RS 4/12RS 4/12

22 RS: decreased angleRS: decreased angle

33 S (with later relapse)S (with later relapse)

44 RSRS

55 SS

66 NSNS

77 NSNS SS

88 NSNS

99 SS

1010 NSNS

1111 SS

1212 NSNS

1313 RSRS

1414 Lost f/uLost f/u

1515 Lost f/uLost f/u

1616 NSNS SS

1717 NSNS

1818 SS

1919 RS RS

2020 NS (not tolerated)NS (not tolerated)

HOW GOOD WAS IT?HOW GOOD WAS IT? A / B / C : 2 successes / 13 ptsA / B / C : 2 successes / 13 pts

D [recurrent ET]: 5-8 success / 9 ptsD [recurrent ET]: 5-8 success / 9 pts

13 + 9 = 22; 2 pts had PI @ 2 different stages of 13 + 9 = 22; 2 pts had PI @ 2 different stages of their coursetheir course

A/B/C: 2 lost to followup A/B/C: 2 lost to followup

PI RESCUE FOR RECURRENT ET PI RESCUE FOR RECURRENT ET #19 RS#19 RS

Cong ET. BMR 5.5 /LR Rs OU/ slipped LLR / Cong ET. BMR 5.5 /LR Rs OU/ slipped LLR / LLR advanced - all between 7 and 15 mo. CR LLR advanced - all between 7 and 15 mo. CR +2.+2.

Straight. Straight. 24 mo: recurrent ET. CR +4.25, +4.5.24 mo: recurrent ET. CR +4.25, +4.5. Gls refused - PI.Gls refused - PI. Usually straight. Usually straight.


BMR 4.5 @ 14 mo for ET onset 10 moBMR 4.5 @ 14 mo for ET onset 10 mo Initially perfectInitially perfect Later ET 0-15Later ET 0-15 ET’ 0-25ET’ 0-25 PI ET 0PI ET 0 ET’ 0-20 ET’ 0-20

PI RESCUE FOR RECURRENT ET PI RESCUE FOR RECURRENT ET #17 NS#17 NS

BMR 6.5mm for ET 35-40 / 40-57 BMR 6.5mm for ET 35-40 / 40-57 CR + 1.5CR + 1.5

W1 OrthotropiaW1 Orthotropia W8 ET 25 / 30 W8 ET 25 / 30 PI : No effectPI : No effect M6 : LR Rs OUM6 : LR Rs OU


3yo ET 25/35. 3yo ET 25/35. CR +2.25, +1.5 BUT +1 blurs OU.CR +2.25, +1.5 BUT +1 blurs OU. ET 0-40/ 30-60. BMR 6.5. ET 0-40/ 30-60. BMR 6.5. W1 Orthotropic D&N.W1 Orthotropic D&N. M3 ET 14 / 18. M3 ET 14 / 18. M7 ET 20 / 35M7 ET 20 / 35 PI ET 0 / 25 - 30PI ET 0 / 25 - 30 + 0.5 DS blurs OU + 0.5 DS blurs OU

PI RESCUE FOR RECURRENT ET PI RESCUE FOR RECURRENT ET #5 S#5 S

8 mo ET 50. CR +2. BMR 68 mo ET 50. CR +2. BMR 6 3w: [ET’]3w: [ET’] POTS bad day >50%POTS bad day >50% 6w: PI POTS 0%6w: PI POTS 0% Taper over 9 mo stays goodTaper over 9 mo stays good


ET 45/60. ET 45/60. CR +1.25. BMR 6.5CR +1.25. BMR 6.5 D6 Orthotropic D&ND6 Orthotropic D&N W4 ET 25-30W4 ET 25-30 PI Orthotropic 4mo f/upPI Orthotropic 4mo f/up

PI RESCUE FOR RECURRENT ET PI RESCUE FOR RECURRENT ET #7 NS then S#7 NS then S

i/mitt ET from 3moi/mitt ET from 3mo +4.5 DS OU+4.5 DS OU 9mo ET<30, ET’ 309mo ET<30, ET’ 30 Refused gls. Screamed with PIRefused gls. Screamed with PI 15 mo: ET’ 35 BMR 515 mo: ET’ 35 BMR 5 D1 slight XT.D1 slight XT. M2 ET 20. CR +3.75, +3M2 ET 20. CR +3.75, +3 Gls refused. PI. Gls refused. PI. 3.5 y: gls. Orthotropic D & N3.5 y: gls. Orthotropic D & N

PI RESCUE FOR RECURRENT ET PI RESCUE FOR RECURRENT ET #16 NS then S#16 NS then S

2 mo: [ET]. CR +3 DSOU2 mo: [ET]. CR +3 DSOU 6 mo: ET 30∆, CR +1.5, +1. 6 mo: ET 30∆, CR +1.5, +1. 9 -23 mo: I/mitt ET’9 -23 mo: I/mitt ET’ 23 mo: ET’ 25∆. 23 mo: ET’ 25∆. 32 mo: PI. Deteriorated to ET/ET’ 30-35/30-45∆ 32 mo: PI. Deteriorated to ET/ET’ 30-35/30-45∆ BMR BMR

5.5. 5.5. D6: XT8∆, small X’D6: XT8∆, small X’ D15: ET’6∆. D15: ET’6∆. W5: ET 10/16∆W5: ET 10/16∆ CR/MR +0.75.CR/MR +0.75. PI E/E’<10∆, FR D<6∆, N>6∆PI E/E’<10∆, FR D<6∆, N>6∆ 8 mo postop: uses PI on bad days8 mo postop: uses PI on bad days


54 mo: ET 30/ 50 [X2] & 25 / 30. CR +0.554 mo: ET 30/ 50 [X2] & 25 / 30. CR +0.5 BMR 5.5. [XT]. D3: Lang 3/3BMR 5.5. [XT]. D3: Lang 3/3 D 19: ET’ 30. Gls tried / refused. Rx: PID 19: ET’ 30. Gls tried / refused. Rx: PI Next 5 mo: reduced to 2ce weekly.Next 5 mo: reduced to 2ce weekly. 5mo: orthophoric, BIFR > 125mo: orthophoric, BIFR > 12 Stop PI @ 6 moStop PI @ 6 mo 10 mo: ET’ 35; EX=0, FR>6.10 mo: ET’ 35; EX=0, FR>6. MR= CR= +0.75 DS OUMR= CR= +0.75 DS OU Rx: bifocals with +3 add: STRAIGHTRx: bifocals with +3 add: STRAIGHT

Results: successResults: success

PI clearly successful in 2 pts [of 7] in group B PI clearly successful in 2 pts [of 7] in group B with >+4. PI treatment continues.with >+4. PI treatment continues.

5 pts [of 9] in group D had clear success, 5 pts [of 9] in group D had clear success, allowing these pts to avoid or delay repeat allowing these pts to avoid or delay repeat surgery. surgery.

2/5 still need daily PI. 2/5 still need daily PI. 1/5 uses PI if ET is seen (‘bad days’) 1/5 uses PI if ET is seen (‘bad days’) 2/9 patients in “successful” for 2-4 months, and 2/9 patients in “successful” for 2-4 months, and

then then to bifocals / SV glasses to bifocals / SV glasses

PROBLEMS WITH MIOTICSPROBLEMS WITH MIOTICS

Mims:Mims: 279 of his pts + 323 pediatric ophthalmologists 279 of his pts + 323 pediatric ophthalmologists

surveyed:surveyed: Iris cysts 1Iris cysts 1 Intolerance to hyperopic correction 1Intolerance to hyperopic correction 1

LK:LK: Screaming after instillation n=1Screaming after instillation n=1 15+ yrs ago: Iris cysts15+ yrs ago: Iris cysts

ISOFLUROPHATE FOR ISOFLUROPHATE FOR RECURRENT ETRECURRENT ET

Mims & Wood BVQ 1993;8:11-20Mims & Wood BVQ 1993;8:11-20 n =117n =117 57/117: ET < 8∆, ET’ < 20∆57/117: ET < 8∆, ET’ < 20∆ 38/57 [67%]: initial response38/57 [67%]: initial response 16/57 [28%]: no other Rx16/57 [28%]: no other Rx

SummarySummary

PI is a useful adjunct in treatment of PI is a useful adjunct in treatment of recurrent ET.recurrent ET.

In patients for whom surgery was followed In patients for whom surgery was followed by an early recurrence of ET with + : PI by an early recurrence of ET with + : PI might help to avoid/delay further surgery might help to avoid/delay further surgery even if unsuccessful preop.even if unsuccessful preop.

Aphorism of Hippocrates 300BCAphorism of Hippocrates 300BC

Life is shortLife is shortThe art longThe art long

Opportunity fleetingOpportunity fleetingExperiment treacherousExperiment treacherous

Judgement difficultJudgement difficult

ConclusionConclusion

PI has a useful role in the treatment of PI has a useful role in the treatment of recurrent ET, if glasses will not be worn. recurrent ET, if glasses will not be worn.

Postoperative Miotics for patients with infantile esotropiaPostoperative Miotics for patients with infantile esotropiaSpierer A, Zeeli T. Ophthalmic surgery and lasers. Dec 1997(28) 1002-5Spierer A, Zeeli T. Ophthalmic surgery and lasers. Dec 1997(28) 1002-5

Retrospective study including 42 children who Retrospective study including 42 children who underwent BMR recession for cong. ET.underwent BMR recession for cong. ET.

2 groups: the treatment group (20 children) who 2 groups: the treatment group (20 children) who got PI 1 drop/day for 4/12 1 week after the got PI 1 drop/day for 4/12 1 week after the surgical procedure, and the control group (21 surgical procedure, and the control group (21 children)children)

Twelve months postoperatively, the Twelve months postoperatively, the residual/recurrent ET increased an average of residual/recurrent ET increased an average of 1.4 and 2.8 D in the treatment and control 1.4 and 2.8 D in the treatment and control groups respectively (not statistically significant)groups respectively (not statistically significant)

•Amblyopia was more prevalent in the treatment group (20% and 5% respectively)•Surgeons decided arbitrarily whom to treat with PI

ReferencesReferences Spierer A. Postoperative miotics for patients with infantile Spierer A. Postoperative miotics for patients with infantile

esotropia. Ophth surg and lasers. 1997;28:1002-5. esotropia. Ophth surg and lasers. 1997;28:1002-5. Parks M. Management of acquired esotropia. Brit J Parks M. Management of acquired esotropia. Brit J

Ophthal. 1974;58:240-6.Ophthal. 1974;58:240-6. Hiatt R. Miotics vs glasses in esodeviation. J Ped Hiatt R. Miotics vs glasses in esodeviation. J Ped

Ophthal and strabismus. 1979;16:213-7.Ophthal and strabismus. 1979;16:213-7. Hiatt. Medical management of accommodative esotropia. Hiatt. Medical management of accommodative esotropia.

J Ped Ophthal and strabismus. 1983;199-201.J Ped Ophthal and strabismus. 1983;199-201. Goldstein JH. The role of miotics in strabismus.Surv Goldstein JH. The role of miotics in strabismus.Surv

Ophthalmol. 1968;13:31-46.Ophthalmol. 1968;13:31-46. Abraham SV. The use of miotics in the treatment of Abraham SV. The use of miotics in the treatment of

nonparalytic convergent strabismus. A progress report . nonparalytic convergent strabismus. A progress report . Am J ophthalmol. 1952;35:1191-5.Am J ophthalmol. 1952;35:1191-5.

ReferencesReferences Parks M. Parks M. ABNORMAL ACCOMMODATIVE ABNORMAL ACCOMMODATIVE

CONVERGENCE IN SQUINTCONVERGENCE IN SQUINT AMA Archives of OphthalmologyAMA Archives of Ophthalmology 1958: ;364-3801958: ;364-380

Treatment groupsTreatment groups

Child with Esotropia

A- Low Hypermetropia B- High hypermetropia C- Near only ET

D- Residual / Recurrent ET s/p Sx

Kids with ET and low plus (<4), who didn’t accept glasses: group AKids with ET and low plus (<4), who didn’t accept glasses: group A

Age Age yrsyrs

CRCR ET typeET type PI txPI tx ResultsResults F/U (m)F/U (m)

22 44 +3.75 ou+3.75 ou Cong. 65Cong. 65^̂ 2/122/12 RSRS 88

77 0.50.5 +2.75 ou+2.75 ou Cong. Int.Cong. Int.4040^̂

Pre-op Pre-op Post op Post op

→→NSNS→→SS

3636

88 0.50.5 +1.50 ou+1.50 ou R s/p IO –R s/p IO –For SO palsy. For SO palsy.

ET 20ET 20^̂

3/123/12 NSNS 1010

1010 22 R + 1.50R + 1.50L + 3.00L + 3.00

ET 20ET 20^̂M/p no M/p no

amblyopiaamblyopia

2/122/12 NSNS 99

1616 66 +1.00 ou+1.00 ou Alt ET 20Alt ET 20^̂→→2 yrs later 352 yrs later 35^̂

Pre-opPre-opPost opPost op

→→NSNS→→SS

3838

Patient #2: ↓ angle of ET to 50 ^. Then BMR was done.Patients #7 and #16 had a residual ET 15-20^ shortly s/p Sx.

B: ET and >+4B: ET and >+4

## Age Age yrsyrs

CRCR ET type & sizeET type & size PI txPI tx ResultsResults F/U F/U (m)(m)

11 0.80.8 +4.50+4.50 Cong ET 25Cong ET 25∆∆ 4/124/12 RSRS 1414

66 1.41.4 R+ 6.75R+ 6.75L + 5.25L + 5.25

A. ET 30A. ET 30∆∆ 2/122/12 NSNS 1212

99 11 +6 OU+6 OU A. ET 25 ∆A. ET 25 ∆ Ongoing for Ongoing for 4/124/12

SS 66

1111 44 +5 OU+5 OU PA/A ET 20PA/A ET 20∆∆ Ongoing for Ongoing for 6/12 6/12

SS 66

1212 0.80.8 +4 OU+4 OU PA/A ETPA/A ET3030∆∆

1/121/12 NSNS 88

1515 44 +4 OU+4 OU Cong. ETCong. ET4545∆∆

1/121/12 NSNS Lost Lost f/uf/u

2020 1.51.5 +4 OU+4 OU PA/A ETPA/A ET4040∆∆

Not toleratedNot tolerated NSNS 66

#1:↓ POTS for 4/12. Later ET 60∆→BMR A.ET = accommodative ET. PA = partially accommodative

C: near only ETC: near only ET

## Age yrsAge yrs CRCR ET typeET type PI txPI tx ResultsResults F/U (m)F/U (m)

1414 1.91.9 +1.50 OU+1.50 OU Int. ET Int. ET for nearfor near

1/121/12 ?? 66(lost)(lost)

PI RESCUE FOR RECURRENT ET PI RESCUE FOR RECURRENT ET #19#19

‘‘Large’ cong ET. BMR 5.5 @ 7mo, residual ET, Large’ cong ET. BMR 5.5 @ 7mo, residual ET, LR Rs OU @ 15 mo. CR +2.LR Rs OU @ 15 mo. CR +2.

D1: ET 50. slipped LLR.D1: ET 50. slipped LLR. OR: RLR advanced, RMR 9 from limbus - Botox, OR: RLR advanced, RMR 9 from limbus - Botox,

LMR 11 from limbus.LMR 11 from limbus. Postop: XT, face turn. Straight. Postop: XT, face turn. Straight. 24 mo: recurrent ET. CR +4.25, +4.5.24 mo: recurrent ET. CR +4.25, +4.5. Gls refused - PI.Gls refused - PI. Usually straight. Usually straight.


10 mo [ET]10 mo [ET] 13 mo 2513 mo 25 14 mo 3014 mo 30 BMR 4.5BMR 4.5 ET 0-15ET 0-15 ET’ 0-25ET’ 0-25 PI ET 0PI ET 0 ET’ 0-20 ET’ 0-20


3yo ET for 6mo. ET 25/35. 3yo ET for 6mo. ET 25/35. CR +2.25, +1.5 BUT +1 blurs OU.CR +2.25, +1.5 BUT +1 blurs OU. ET 0/30, 25, 40/60. BMR 6.5. ET 0/30, 25, 40/60. BMR 6.5. W1 early XT by history. Orthotropic D&N.W1 early XT by history. Orthotropic D&N. M3 ET 14 / 18. M3 ET 14 / 18. M7 ET 20 / 35M7 ET 20 / 35 PI ET 0 / 25 - 30PI ET 0 / 25 - 30 + 0.5 DS blurs OU + 0.5 DS blurs OU


8 mo ET 50. CR +2. BMR 68 mo ET 50. CR +2. BMR 6 3w: [ET’]3w: [ET’] POTS bad day >50%POTS bad day >50% 6w: PI POTS 0%6w: PI POTS 0% Taper over 9 mo stays goodTaper over 9 mo stays good


ET since 12 moET since 12 mo 35-40 / 40-57 CR + 1.535-40 / 40-57 CR + 1.5 BMR 6.5BMR 6.5 W1 OrthotropiaW1 Orthotropia W8 ET 25 / 30 CR + 1.25W8 ET 25 / 30 CR + 1.25 PI : No effectPI : No effect M6 : LR Rs OUM6 : LR Rs OU


i/mitt ET from 3mo;1st seen 6 moi/mitt ET from 3mo;1st seen 6 mo +4.5 DS OU EX=0+4.5 DS OU EX=0 9mo ET<30, ET’ 309mo ET<30, ET’ 30 Refused gls. Screamed with PIRefused gls. Screamed with PI 15 mo: ET’ 35 BMR 515 mo: ET’ 35 BMR 5 D1 slight XT.D1 slight XT. M2 ET 20. CR +3.75, +3M2 ET 20. CR +3.75, +3 Gls refused. PI. Variable compliance. Gls refused. PI. Variable compliance. 3.5 y: gls. Orthotropic D & N3.5 y: gls. Orthotropic D & N


2 mo: [ET]. CR +3 DSOU2 mo: [ET]. CR +3 DSOU 6 mo: ET 30∆, CR +1.5, +1. 6 mo: ET 30∆, CR +1.5, +1. 9 -23 mo: varying POTS. [ET’].9 -23 mo: varying POTS. [ET’]. 23 mo: ET’ 25∆. 23 mo: ET’ 25∆. 32 mo: PI. Good response then deteriorated to 32 mo: PI. Good response then deteriorated to

ET/ET’ 30-35/30-45∆ ET/ET’ 30-35/30-45∆ BMR 5.5. BMR 5.5. D6: XT8∆, small X’D6: XT8∆, small X’ D15: ET’6∆. D15: ET’6∆. W5: ET 10/16∆W5: ET 10/16∆ CR/MR +0.75.CR/MR +0.75. PI E/E’<10∆, FR D<6∆, N>6∆PI E/E’<10∆, FR D<6∆, N>6∆ 8 mo: uses PI on bad days8 mo: uses PI on bad days


[ET’] onset 4. CR +0.50. [ET’] onset 4. CR +0.50. 54 mo: ET 30, ET’ 50 [X2]; 25 / 30 54 mo: ET 30, ET’ 50 [X2]; 25 / 30 BMR 5.5. [XT]. D3: Lang 3/3BMR 5.5. [XT]. D3: Lang 3/3 D 19: ET’ 30. Gls tried / refused. Rx: PID 19: ET’ 30. Gls tried / refused. Rx: PI Next 5 mo: reduced to 2ce weekly.Next 5 mo: reduced to 2ce weekly. 5mo: orthophoric, BIFR > 125mo: orthophoric, BIFR > 12 Stop PI @ 6 moStop PI @ 6 mo 10 mo: ET’ 35; EX=0, FR>6.10 mo: ET’ 35; EX=0, FR>6. MR= CR= +0.75 DS OUMR= CR= +0.75 DS OU Rx: bifocals with +3 addRx: bifocals with +3 add

D: PI “rescue ” for recurrent / residual ET following surgeryD: PI “rescue ” for recurrent / residual ET following surgery

Age Age yrsyrs

CRCR ET type & size ET type & size in ∆in ∆

PI tx PI tx ResultsResults Time off PITime off PI F/u monthsF/u months

33 44 PlanoPlano N 50N 50D 30 D 30

Res. N ET. Res. N ET. Tx for 4/12Tx for 4/12

S S →→Later relapseLater relapse

4/124/12→Rec N →Rec N ET→Bif.ET→Bif.

1818

44 0.80.8 PlanoPlano Cong. ET 20Cong. ET 20 Rec.ET20Rec.ET20∆∆Tx for 3/12Tx for 3/12

S S OngoingOngoing 1616

55 0.80.8 +2.00 ou+2.00 ou Cong.ET50Cong.ET50^̂ Res N ET Res N ET Tx for 6/12Tx for 6/12

SS OngoingOngoingPI on bad PI on bad days onlydays only

1212

77 0.50.5 +2.75 ou+2.75 ou Cong. Int.40Cong. Int.40 Res.ET20Res.ET20^.^.Tx for?Tx for?

SS 15/1215/12 3636

1313 33 R +2.50R +2.50L +1.50L +1.50

R ET Int.30R ET Int.30 Res.ET25Res.ET25^.^. Tx for ?Tx for ?

S S →→Later relapseLater relapse

2/12 2/12 →→ Rec Rec N ET→Bif.N ET→Bif.

2020

1616 66 +0,75 ou+0,75 ou Alt ET 35Alt ET 35 Pre BMR : NSPre BMR : NS SS Ongoing for Ongoing for post op post op

recurrencerecurrence

3838

1717 1.81.8 +2.00 ou+2.00 ou N 50N 50D 35D 35

Res.ET25Res.ET25^.^. Tx for 2/12Tx for 2/12

NSNS 1414

1818 55 +1.00 ou+1.00 ou ET 45 ET 45 Res.ET25Res.ET25^.^. Tx for 1/12Tx for 1/12

SS ongoingongoing 33

1919 11 +4.50 ou+4.50 ou Cong ET s/p 2 Cong ET s/p 2 sx. 50sx. 50^̂

Res.ET25Res.ET25^.^. Tx for 3/12Tx for 3/12

RS for 3/12RS for 3/12 2424

Results: (RS) Relative success Results: (RS) Relative success

RS was seen in: RS was seen in: 1 patient in group A (1 patient in group A (↓strabismic angle)↓strabismic angle) 1 patient in group B (1 patient in group B (↓POTS)↓POTS) 1 in group C (ortho for 3 months)1 in group C (ortho for 3 months)


ET onset 3. 1st seen age 5. ET 45/60. ET onset 3. 1st seen age 5. ET 45/60. CR +1.25. BMR 6.5CR +1.25. BMR 6.5 D6 Orthotropic D&ND6 Orthotropic D&N W4 ET 25-30W4 ET 25-30 PI Orthotropic 4mo f/upPI Orthotropic 4mo f/up

PROBLEMS WITH MIOTICSPROBLEMS WITH MIOTICS

1. Cataract - only in the elderly glaucoma 1. Cataract - only in the elderly glaucoma populationpopulation

2. Cholinergic crisis in unrecognised myesthenic 2. Cholinergic crisis in unrecognised myesthenic n=1n=1

3. Iris cysts3. Iris cysts 4. Reduced plasma cholinesterase4. Reduced plasma cholinesterase 5. Transient myopia5. Transient myopia 6. Retinal detachment 6. Retinal detachment 7. SLUD salivation / lacrimation / urination/ 7. SLUD salivation / lacrimation / urination/

defecationdefecation

phospholine iodide in the management of esotropia

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