Esodeviations



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Investigation:

Differential diagnosis:


  • exophoria

  • convergens paralysis

  • intermittent exotropia

  • paralytic strabismus

  • accommodative problems

  • consecutive exotropia

Treatment:


  • correction of any refraction error

  • convergence exercises

  • orthopic treatment

  • wearing the base- in prisms

  • surgery is indicated in severe asthenopic symptoms

  • sometimes botulinum toxin injection is helpful

Prognosis:


  • the patient be free of astenopic symtoms

  • recognize diplopia when convergence fails

  • have a good convergence fusional amplitude
Convergence paralysis

Convergence paralysis is often seen as a secondary status to the brain diseases and must not be confused with convergence weakness.Fig.11

Fig.11Convergens paralysis as a secondary status to the brain disorders.



Clinical findings:

.acute beginning

  • exotropic deviation of 25-30 PD at near with straight eyes at distance

  • total and complete inability to converge the eyes

  • presence of full adduction of each eye

  • normal accommodation

  • diplopia occurs at near fixation

Investigation:


  • cover-uncover test at near and distance

  • test the near point of convergence

  • test the near point of accommodation

  • measuring the eye alignment in all direction of gaze

  • neurological investigations

Differential diagnosis:


  • convergence insufficiency

  • intermittent exotropia

  • paralytic strabismus

  • accommodative problems

Treatment:


  • correction of any refraction error

  • convergence exercises

  • orthopic treatment

  • wearing the base- in prisms in bifocal glasses

  • surgery is not indicated

  • if it is possible -treatment any neurologic disorders

Prognosis:


  • usually is not possible to have a good binocular vision

  • recognize diplopia when convergence fails
Deprivation (sensory) exotropia.

Sensory exotropia is a secondary to unilateral blidness .Fig.12,13.

Fig.12Deprivation exotropia..Patient after congenital cataract surgery with RGP contact lens on the right eye.



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Fig.13 Deprivation exotropia. Patient with leucoma cornea on the left eye.


Clinical findings:

. unilateral eye diseases ( congenital cataract, leucoma cornea, atrophia nervi optici, toxoplasmosis, retinal tumors, foveal damage, trauma lesion)

  • anisometropia

Investigation:


  • full ophthalmology examination of anterior and posterior segment of eyes

  • visual test and checking fixation to evaluated amblyopia

Differential diagnosis:


  • congenital exotropia

  • intermittent exotropia

  • convergence insufficiency

  • consecutive exotropia

Treatment:


  • diagnosed and treated soon after the onset

  • elimination any organic lesion, if possible

  • full correction anisometropic eye with the contact lenses

  • amblyopia treatment

  • botulinum toxin injection

  • strabismus surgery

Prognosis:


  • depends of the organic lesion of the eye

  • if treated soon after the onset and patient have good anatomical condition it may be good

  • optimum optical correction and visual rehabilitation are very important
Consecutive exotropia

Consecutive exotropia or persistent exotropia may be present after esodeviation surgery.Fig.14

Fig.14 The child after esodeviation surgery. Consecutive exotropia.



Clinical findings:

  • too much esotropia surgery can provide to exodeviation

  • occasionally exotropia may increase

  • patients has learned to get rid of the diplopia

Investigation:


  • case history

  • Hirschberg and Krimsky test

  • cover –uncover test

  • Hess screening

  • evaluation of exotropia angle

  • diplopia testing

Differential diagnosis:


  • exophoria

  • congenital exotropia

  • convergens insufficiency

  • convergens paralysis

  • deprivation (sensory) exotropia

  • paralitic strabismus

Treatment:


  • prism glasses base -in over each eye

  • orthoptic exercises

  • botulinum toxin injection

  • strabismus surgery on the nonoperated muscles

Prognosis:


  • sometimes patients are able to hold their eye straight after a few months nonsurgical treatment

  • patients with good fusional potential and normal duction can be successfully treated with injection of botulinum toxin

  • reoperation of persistent exotropia are also satisfactory



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