Strabismus Surgery and the Late Elderly

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Strabismus Surgery and the Late Elderly

• Logan Mitchell
• Lionel Kowal
• RVEEH, Melbourne
• Private Eye Clinic, Melbourne

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Elderly - who?

• Older than me?
• Older than my parents?
• WHO No definition
• Geriatric literature
• Early elderly 65 75 years old
• Late elderly 75 years old

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Elderly - how many?

• Australian population data
• 22.5 million (2010 est.)
• Life expectancy at birth 82 yrs

• Ageing population
• 65 yrs and older
• 13.5 (2009 est.) 3 million
• 25 (2042 est.) 6.2 million

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Elderly and Strabismus

• Prevalence 4 (adult strabismus)
• No population-based data on elderly population

• 6600 Medicare-billed strabismus operations
• 27 million eligible patients
• 2.4

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Elderly and Strabismus

• Prevalence of strabismus in gt65 year olds
  (assumptive)
• 4 prevalence adult strabismus
• 120,000 in 2009
• 250,000 in 2042

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Elderly Strabismus the literature

• 4 papers
• Paper 1
• Repka JAAPOS 2007 as described
• 70 horizontal surgery
• 14 reported as re-operations (?low)

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Elderly Strabismus the literature

• Paper 2 Magramm Schlossman JPOS 1991
• Retrospective
• 104 pts
• mean 69 yrs old (60-89)
• ¼ cosmetic indication, ¾ diplopic
• 1/3 childhood onset
• Adult onset
• Mean delay to
• surgery 8 yrs

Aetiologies
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Elderly Strabismus the literature

• Paper 3 Dawson et al Strabismus 2001
• Retrospective
• 111 patients
• mean 67 yrs old (60-90)
• ½ cosmetic, ½ diplopic
• 1/3 childhood onset
• Adult onset similar aetiologies
• Outcomes
• 60 orthotropic /- 10?
• 21 re-operation rate

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Elderly Strabismus the literature

• Paper 4 Rutar Demer JAAPOS 2009
• Heavy eye syndrome in elderly
• A la, but different from, myopic strabismus
  fixus
• Degeneration of SR-LR aponeurotic band

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Adult Strabismus (as substitute)

• Adults delay seeking surgical correction
• Mean delay 19 years
• diplopic 15 yrs vs 28 yrs non-diplopic
• Reasons

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Strabismus Surgery in the 'Late Elderly'

• Aim
• To Identify the characteristics and outcomes of
  patients undergoing strabismus surgery aged 75
  years or older between October 2005 October
  2010
• Methods
• Retrospective chart review
• Locations
• Private Eye Clinic (Dr Lionel Kowal)
• RVEEH

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Results

• 35 patients
• Age mean 79 years (75-95)
• MaleFemale 1619
• Indications
• Cosmesis 6 (17)
• Diplopia 29 (83)
• Duration of symptoms mean 12 years (0-69)

• 19 done with adjustable sutures
• 3 surgeries performed under regional anaesthetic

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Results

• Previous surgeries
• (plus 2 with previous botox)

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Aetiology of Strabismus
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Neuroparalytic Strabismus

• 14 patients
• CNVI in 9 patients
• 5 compressive
• 2 ICA aneurysm
• (1 previous surgery)
• 2 meningioma
• 1 ependymoma
• 3 ischaemic / uncertain cause
• 1 traumatic (CHI)
• (1 previous surgery)

• CNIV in 6 patients
• 3 congenital
• 1 with 2 previous surgeries
• Remaining 2 average duration of diplopia 6
  years
• 3 uncertain aetiology
• CNIII in 1 patient
• Combined with CNVI in ICA aneurysm patient

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Restrictive Strabismus

• 8 patients
• 3 thyroid eye disease
• Mean duration on symptoms 1.3 years
• 4 traumatic / iatrogenic
• 2 previous retinal detachment surgery
• 1 previous sinus surgery
• 1 previous orbital trauma
• 1 Browns syndrome
• Symptoms for gt50 years

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Decompensated Phoria

• 7 patients
• 5 with decompensated intermittent exotropia
• 2 decompensated divergence insufficiency
• Mean duration of symptoms 37 years

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Consecutive Exotropia

• Only 2 patients
• Childhood esotropia
• Previous surgery x 1, and x 3
• Mean duration of misalignment gt40 years

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Outcomes

• Mean follow-up 8 months
• Overall

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Outcomes

• Diplopia

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Outcomes in Neuroparalytic Cases

• Overall result
• Diplopia

Perfect 3 (21)
Significant improvement 2 (14)
Little/no improvement 8 (57)
Worse 1 (7)
Free of diplopia 11 (79)
(with AHP) 2 (14)
(with prism) 6 (43)
(with AHP and prism) 1 (7)
Diplopic 3 (21)
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Outcomes in Other Cases

• Significant improvement or better
• Restrictive strabismus 88
• Decompensated phoria 86
• Consecutive exotropia 100

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Complications

• Couldnt find a muscle (2)
• Post-childhood trauma, consecutive XT
• Re-operations (3 8.6)
• 2 on one patient (SOP), 1 on 95 year old lady
  (XT)
• Recurrences (6)
• Dealt with prisms in 4 cases
• No known systemic complications

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Conclusions (I)

• Strabismus in the very elderly
• Exists
• Is not extremely rare
• Will increase
• Is under-represented in the literature
• Diplopia is a frequent indication for surgery
• Patients delay surgery
• Often at our (medical) behest
• Varied aetiologies
• Neuroparalytic causes common (note compressive
  causes)

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Conclusions (II)

• Surgical considerations
• Systemic risk of general anaesthetic
• ?risk of regional anaesthetic
• Thinner conjunctiva
• Risk of anterior segment ischaemia
• Probably 2 muscles maximum
• Diplopic indication common
• More accurate surgery, adjustable sutures

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Conclusions (III)

• Surgery is reasonably successful
• Very low risk of making things worse (1/35)
• 68 achieved at least significant improvement
• ?More guarded success in neuroparalytic patients
• 83 free of diplopia (with/without prisms/AHP)

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Thank You