Prof. Paolo Nucci Direttore Clinica Oculistica, Università degli Studi di Milano Ospedale San Giuseppe Milano

Dimensione: px

Iniziare la visualizzazioe della pagina:

Download "Prof. Paolo Nucci Direttore Clinica Oculistica, Università degli Studi di Milano Ospedale San Giuseppe Milano"

Annalisa Magni
5 anni fa
Visualizzazioni

1 MODULO 1 Lezione 1 ESOTROPIA ACCOMODATIVA: OLTRE I CONFINI DEI LIBRI Prof. Paolo Nucci Direttore Clinica Oculistica, Università degli Studi di Milano Ospedale San Giuseppe Milano

2 L ESOTROPIA ACCOMMODATIVA è la forma di strabismo più comune in età infantile

3 DEFINIZIONE Una esotropia correlata a qualunque sforzo accomodativo

4 AC/A clinicamente elevato Tutte quelle condizioni per le quali l angolo per vicino è maggiore dell angolo per lontano

5 Attenzione E sempre vero che quando si ha un CA/A elevato l angolo per vicino è maggiore dell angolo per lontano? ECCEZIONI o In pazienti con atteggiamento alfabetico in V (In questo caso l angolo per vicino APPARE maggiore semplicemente perché il bambino guarda verso il basso) o In pazienti con exotropia intermittente Si rimanda all inconografia presente nella lezione video

6 COME SI MISURA? METODO DEL GRADIENTE 1. Il paziente deve essere totalmente corretto 2. Si misura la foria (D) al covertest alternante 3. Anteponiamo una lente di valore noto (i.e. -2sf) sopra la correzione e rimisuriamo l angolo per lontano 4. Misuriamo nuovamente la foria (D1) AC / A = D 1 D / 2

7 Esempio: AC/A= D 1 D/ L D: a di Ef con Correzione AC/A= D 1 D / L 24 8 / 2= 8 D 1 : a di Ef con Correzione dopo stimolo accomodativo noto L: lente negativa

8 Perché è importante misurare il CA/A? Per il trattamento dell ambliopia? Prescrizione delle lenti? Per la chirurgia?

9 Un test dalla nostra esperienza

10 ESOTROPIA ACCOMODATIVA Accomodativa Refrattiva (Pura) Accomodativa da CA/ A elevato (>4) (non Refrattiva?) ET angolo per vicino > angolo per lontano Molto spesso Parzialmente Accomodativa Ipermetropia non corretta Punto prox acc normale Tardiva (forma acquisita) Precoce o Congenita (variante EEI) Punto pross di Acc subnormale Per la fruizione dei video di taglio pratico, si rimanda alla lezione video Ipoaccomodatore

11 Perché solo alcune ipermetropie non corrette portano ad ET?

Ipermetropia non corretta Si rimanda all inconografia presente nella lezione video CA/A elevato o normale Accomodazione Convergenza CA/A 1 No Accomodazione

12 Ipermetropia non corretta Si rimanda all inconografia presente nella lezione video CA/A elevato o normale Accomodazione Convergenza CA/A 1 No Accomodazione Ortotropia Ambliopia ametropica bilaterale Insufficiente Divergenza Fusionale Sufficiente Divergenza Fusionale Ortotropia ET accomodativa refrattiva Esoforia ET manifesta

13 Le bifocali quando? Solo se stereopsi!

14 Bifocali vs Progressive

15 Bifocali vs Progressive

16 Chirurgia Faden Recessione aumentata Chirurgia per l angolo da vicino

17 Nucci P, Serafino M, Hutchinson AK. Photorefractive keratectomy for the treatment of purely refractive accommodative esotropia. J Cataract Refract Surg 2003 May;29(5): ASCRS and ESCRS

18 PURPOSE: To evaluate the results of photorefractive keratectomy (PRK) for the treatment of young adult patients with purely refractive accommodative esotropia. SETTING: Private practice and university hospital, Milan, Italy. METHODS: The medical records of consecutive patients who had PRK for hyperopia associated with purely refractive esotropia were reviewed retrospectively. Preoperative and postoperative visual acuity, alignment, and sensory data were recorded and analyzed. Surgical methods and complications were reviewed. Nucci P, Serafino M, Hutchinson AK. Photorefractive keratectomy for the treatment of purely refractive accommodative esotropia. J Cataract Refract Surg 2003 May;29(5): ASCRS and ESCRS

19 RESULTS: Sixteen eyes of 8 patients were treated. The mean patient age at the time of treatment was 24.6 years (range 17 to 38 years). All patients were followed for 1 year. At the 1-year follow-up evaluation, the uncorrected visual acuity was 20/40 or better in all eyes. No patient lost a line of best spectacle-corrected visual acuity. The mean spherical equivalent was -3.7 diopters (D) preoperatively and -0.7 D postoperatively. All patients were within +/-0.37 D of emmetropia at the 1-year evaluation. Preoperatively, the mean esotropic deviation was prism diopters. Postoperatively, all patients were orthophoric without correction. Stereopsis was unaffected by PRK in all patients. There were no intraoperative or postoperative complications. Nucci P, Serafino M, Hutchinson AK. Photorefractive keratectomy for the treatment of purely refractive accommodative esotropia. J Cataract Refract Surg 2003 May;29(5): ASCRS and ESCRS

20 CONCLUSION: Photorefractive keratectomy was an effective treatment for esotropia associated with mild to moderate hyperopia in young adults with purely refractive accommodative esotropia. These findings should not be widely applied to children with accommodative esotropia. Nucci P, Serafino M, Hutchinson AK. Photorefractive keratectomy for the treatment of purely refractive accommodative esotropia. J Cataract Refract Surg 2003 May;29(5): ASCRS and ESCRS

$Photorefractive keratectomy followed by strabismus surgery for the treatment of partly$

21 Nucci P, Serafino M, Hutchinson AK. Photorefractive keratectomy followed by strabismus surgery for the treatment of partly accommodative esotropia. J AAPOS 2004 Dec;8(6):555-9 ):555-9.

22 PURPOSE: To evaluate photorefractive keratectomy (PRK) followed by bilateral medial rectus muscle recessions (BMR) to treat adults with partly accommodative esotropia. METHODS: We reviewed medical records of 10 consecutive patients with partly accommodative esotropia who underwent PRK to correct hyperopia followed 6 months later by BMR to treat the accommodative and nonaccommodative components of their esotropia, respectively. Visual acuity, spherical equivalent of refractive error, alignment, and sensory data were collected and analyzed. RESULTS: Twenty eyes of 10 patients were treated and followed for 1 year. PRK was successful in treating the hyperopia (mean post-prk spherical equivalent was 0.14 D (SD = 0.22)) and the accommodative portion of the esotropia (the mean percentage of the distance accommodative component eliminated by PRK was % and the mean percentage of the near accommodative component eliminated by PRK was 115%). However, subsequent BMR using standard surgical tables based on the distance deviation to treat the post-prk residual (nonaccommodative) esotropia resulted in uniform undercorrection. CONCLUSION: PRK may be useful to treat the accommodative portion of partly accommodative esotropia. Bilateral medial rectus muscle recession can be used to treat the residual, nonaccommodative component; however, it may be necessary to base the surgical dosage on the near deviation. Nucci P, Serafino M, Hutchinson AK. Photorefractive keratectomy followed by strabismus surgery for the treatment of partly accommodative esotropia. J AAPOS 2004 Dec;8(6):555-9

23 Bibliografia essenziale Nucci P, Serafino M, Hutchinson AK. Photorefractive keratectomy for the treatment of purely refractive accommodative esotropia. J Cataract Refract Surg 2003 May;29(5): ASCRS and ESCRS Nucci P, Serafino M, Hutchinson AK. Photorefractive keratectomy followed by strabismus surgery for the treatment of partly accommodative esotropia. J AAPOS 2004 Dec;8(6):555-9

Documenti analoghi

OFP - 2012 Ipermetropia e deviazione strabica 1

OFP - 2012 Ipermetropia e deviazione strabica 1 Ipermetropia e deviazione strabica 1 R. Frosini Influenza dell ipermetropia nella deviazione strabica Bosisio Parini 17 marzo 2012 Ipermetropia e deviazione strabica 2 il nostro progetto brevi cenni introduttivi