2024 When FCR is not right for Accommodative Esotropia.pdf

Lecture to St Luke's Medical Center on different situations when full cycloplegic refraction may not be the best for patients with accommodative esotropia.

1. When FCR is not
right for
Accommodative
Esotropia
Alvina Pauline Dy Santiago, MD
May 3, 2024
© APD Santiago 2024

2. Conflict of Interest
•None related to this report
•STADA lecturer
© APD Santiago 2024

3. Outcomes
Identify
situations when
FCR is not
appropriate for
accommodative
ET
Recommend
alternative
management
Discuss surgery
options for
accommodative
ET
© APD Santiago 2024

4. Accommodative Esotropia
Age: < 5 years
Cyclorefraction: > +2.00
Consult: within several weeks to
months of onset
Usually Pre-verbal
© APD Santiago 2024

5. Bifocals
Distance ET: cc < 10PD
Minimum Adds to
Control ET at near
© APD Santiago 2024

6. Bifocals
Correct bifocal segment
placement
Revise frames to better
fit
© APD Santiago 2024

7. Non Refractive Accommodative Esotropia
Age: < 5 years
Cyclorefraction: < +2.00
Small interpupillary distance
Trial of FCR
May require bifocals
© APD Santiago 2024

8. Situations when FCR not right
Patient Age
●> 5y
●Cannot tolerate
FCR
Anisometropia
●Forced to reduce
power
●Contact lens not
tolerated
Vision is
“compromised”
●Vision 20/40 or
worse not
acceptable
03
●Good VA but with
“strain”
Asthenopia
04
X(T) at
distance or near
●Excess plus
05
Surgery Candidate
●Real world not FCR
●Remeasure target
angle w best correction
06
020101
© APD Santiago 2024

9. Situations when FCR not right
Poor Follow-Up
●Less than full plus
corrects ET
●Avoids SCXT
ET controlled w full
plus for some time
●May not always
need full plus
●> 5y
Patient peeks
through Rx
●Glasses not clear
09
●Good VA sc
Low plus
10
ET only at near
●Low plus at D
11
Bifocals not tolerated
●Surgical candidate
12
080107
© APD Santiago 2024

10. Situations when FCR not right:
01. Patient Age
FCR +8.00 20/100
either eye, ET
controlled
Dry: +6.00 OU 20/80
dizzy
Subjective +4.00 OU
●> 5y
●Cannot tolerate
FCR
© APD Santiago 2024

11. Situations when FCR not right:
01. Patient Age
●Maximum tolerated
plus
(does not exceed FCR)
●VA >/= 20/40
●Prisms or surgery for
residual
●> 5y
●Cannot tolerate
FCR
●FCR +8.00 20/100
either eye
●Dry: +6.00 OU
20/80 dizzy
●Subjective +4.00
OU
© APD Santiago 2024

12. Situations when FCR not right:
02. Anisometropia
●13/M
●Screening showed
●+6.00 20/200
●-1.00 20/20
●Dizzy with glasses
© APD Santiago 2024
https://attachment.tapatalk-cdn.com/

13. Situations when FCR not right:
02. Anisometropia
●Usually the older child (>5y)
●May or may not control
deviation
●Compromised vision
●Visual potential compromised
●Prisms or surgery for residual
●Ideally contact lenses
●Forced to reduce power in glasses
© APD Santiago 2024
https://attachment.tapatalk-cdn.com/

14. Situations when FCR not right:
03. Vision is “compromised”
●FCR +8.00 OU
●Nondilated VA:
●+8.00 20/50
●+7.00 20/40
●+5.00 20/20
●Older child needs
better VA
●> 5y
●20/40 vision not
acceptable
© APD Santiago 2024

15. Situations when FCR not right:
03. Vision is “compromised”
●Best VA
●Older child
●Prisms or surgery
for residual
●> 5y
●20/40 vision not
acceptable
© APD Santiago 2024

16. Situations when FCR not right:
04. Asthenopia
●FCR +8.00
●+8.00 20/30
●But with
asthenopia
●>/= 20/40 vision
●Asthenopic
symptoms
●Headache
●Dizziness
●Nausea
●Vomiting
© APD Santiago 2024

17. Situations when FCR not right:
04. Asthenopia
●Cycloplegia
●Reduce plus
●Tolerated
●Best VA
●Prisms or surgery
for residual
●>/= 20/40 vision
●Asthenopic
symptoms
●Headache
●Dizziness
●Nausea
●Vomiting
© APD Santiago 2024

18. Situations when FCR not right:
05. X(T) or MXT at either distance or near
●16yr old
●ET without correction
●FCR +8.00
●W +8.00:
●XT 15deg, 20/20
●+6.00 20/25, MET 3PD
●Excess plus
© APD Santiago 2024
https://www.reddit.com/r/Strabismus/

19. Situations when FCR not right:
05. X(T) or MXT at either distance or near
●16 yrold
●ET sc
●FCR +8.00
●cc +8.00: 20/20, ortho
●Cc +8.00 X(T) 5 PD
●Excess plus
© APD Santiago 2024
https://www.reddit.com/r/Strabismus/

20. Situations when FCR not right:
05. X(T) or MXT at either distance or near
●Reduce plus, usually best VA
●If X(T)’, reduce plus to where
no X(T)
●Consider best VA
●May be enough to control ET
●Prisms or surgery for residual
●Excess plus
© APD Santiago 2024
https://www.reddit.com/r/Strabismus/

21. Situations when FCR not right:
06. Surgical Candidate
●FCR not “real world”
●Best VA
●Surgery for residual
●Not tolerating full
plus
●Reduced plus with
residual ET
●Too large for
ground-in prisms
●Membrane prisms
not tolerated
© APD Santiago 2024
https://www.aao.org/

22. Situations when FCR not right:
07. Poor follow-up
●Pandemic sequalae:
SCXT
●Less than full plus can
control ET
●Less risk of SCXT
●Glasses last longer
Poor follow-up
“guaranteed”
●Geographic
●Financial
●OFW parents
●Separated
parents
© APD Santiago 2024

23. Spontaneous Consecutive Exotropia
Mild to Severe amblyopia
not addressed
Amblyopia
Relaxed
accommodation
Over plus
Convergence exercises not
continued
Remote Near Point of
Convergence and/or
Accommodation
Tapering of bifocals
not done
Bifocals not
necessary

24. Spontaneous Consecutive Exotropia
Reduce plusPatchingSurgeryOrthoptics
https://www.seevividly.com/

25. Situations when FCR not right:
08. ET controlled w full plus for some time
●Try to reduce plus 1-1.5 D
●If still with good control,
consider taper or best
correction
Full plus control
●2 cycles
●Early taper
© APD Santiago 2024

26. Situations when FCR not right:
09. Patient peeks through glasses
●Try to reduce FCR / full
plus 1-1.5 D
●If still with good
control, consider taper
or best correction
●Prisms or surgery for
residual
●Preverbal child
●Too much plus
●Not tolerating
full plus
© APD Santiago 2024

27. Situations when FCR not right:
10. Low plus
●Good VA without
glasses
●Full plus not
tolerated
●Very little plus to
reduce
© APD Santiago 2024

28. Situations when FCR not right:
11. ET only at near
●If MET or ortho at
distance, consider
bifocals
●Consider prisms
●Consider surgery
●Usually low plus
●Good VA without
glasses
●Full plus not
tolerated
●Very little plus to
reduce
© APD Santiago 2024

29. Situations when FCR not right:
12. Bifocals not tolerated
●Best correction at
distance
●Surgery for residual ET
●Consider faden
operation or posterior
fixation
●MET or ortho at
distance
●Cannot use
bifocals
© APD Santiago 2024

30. Surgery for
Accommodative
Esotropia
•Exhausted plus
•Started amblyopia tx
•Too large for ground-
in prisms
Bimedialrecession
MR Rec + LR Res
Fadenoperation
01
02
03
Unilateralmedial
recession04

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