Phospholine Iodide in the management of esotropia

1
Phospholine Iodide in the management of esotropia

• Lionel Kowal
• Claudia Yahalom
• RVEEH / CERA Melbourne
• SQUINT CLUB DUNEDIN 2005

2
HISTORY France 120y, US 55y

• Javal Manuel theorique et practique du
  strabisme bifocals miotics for ET 1886
• Samuel Abraham Pilo / eserine for ET
• 46 cases Amer J Ophth 1949 16/46 helpful AJO
  1952,1961 JPO 1964,1966

3
CURRENT STATUS

• Difficult to obtain application to TGA for each
  patient
• Expensive A130 a bottle

4
PARKS 1958 ABNORMAL ACCOMMODATIVE CONVERGENCE
IN SQUINT n1249

• Old / difficult Why bother?
• because it sometimes works very well!

5
PARKS 1958 ABNORMAL ACCOMMODATIVE CONVERGENCE
IN SQUINT n1249

• No Rx n73
• Isoflurophate n47 .. after Rx is stopped
• BMR n104 18 no better
• One MR n74 26 no better

6
PARKS 1958 number where AAC improved
result perfect
No Rx Miotic BMR One MR
lt 7y 9/31 29 4/15 27
7 -12y 20/40 28/32 87
All 69 / 104 66 4038 27 /74 36 79.5
7
PARKS 1958 ABNORMAL ACCOMMODATIVE CONVERGENCE
IN SQUINT

• The lasting improvement of the abnormal AAC
  produced by miotic is similar to the permanent
  result attained by surgery

8
Patients studied

• Retrospective chart review of patients from a
  private strabismus practice.
• 20 consecutive children with ET reluctant to wear
  glasses
• PI second choice for mgmt of ET
• Ages 0.5 to 6 y Parks low expectations of
  success - 25

9
Four groups of children with ET

• A. Hyperopes lt4 who refuse glasses n5.
• B. Hyperopes gt4 who refuse glasses n7
• C. Uncosmetic near- only ET n1
• D. Recurrent ET after initially successful
  outcome from recent ET surgery.
• Glasses not tolerated / refused
• n9
• 2/9 had an unsuccessful trial of PI prior to
  surgery

10
Definition of Outcomes

• Success (S). Esophoria / tropia 10? whilst using
  /- after stopping PI
• Relative success (RS). One of
• decreased angle of ET (either D or N 0)
• of time strabismic reduced to lt 25
• No success (NS) little / no improvement in angle
  or POTS

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Table 1 Results of patients receiving PI
according to indication for treatment
A Hyperopia lt4 B Hyperopia gt 4 C Near only ET D Rescue recurrent ET
1 RS 4/12
2 RS decreased angle
3 S (with later relapse)
4 RS
5 S
6 NS
7 NS S
8 NS
9 S
10 NS
11 S
12 NS
13 RS
14 Lost f/u
15 Lost f/u
16 NS S
17 NS
18 S
19 RS
20 NS (not tolerated)
12
HOW GOOD WAS IT?

• A / B / C 2 successes / 13 pts
• D recurrent ET 5-8 success / 9 pts
• 13 9 22 2 pts had PI _at_ 2 different stages of
  their course
• A/B/C 2 lost to followup

13
PI RESCUE FOR RECURRENT ET 19 RS

• Cong ET. BMR 5.5 /LR Rs OU/ slipped LLR / LLR
  advanced - all between 7 and 15 mo. CR 2.
• Straight.
• 24 mo recurrent ET. CR 4.25, 4.5.
• Gls refused - PI.
• Usually straight.

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PI RESCUE FOR RECURRENT ET 4 RS

• BMR 4.5 _at_ 14 mo for ET onset 10 mo
• Initially perfect
• Later ET 0-15 ET 0-25
• PI ET 0 ET 0-20

15
PI RESCUE FOR RECURRENT ET 17 NS

• BMR 6.5mm for ET 35-40 / 40-57
• CR 1.5
• W1 Orthotropia
• W8 ET 25 / 30
• PI No effect
• M6 LR Rs OU

16
PI RESCUE FOR RECURRENT ET 13 RS

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

17
PI RESCUE FOR RECURRENT ET 5 S

• 8 mo ET 50. CR 2. BMR 6
• 3w ET
• POTS bad day gt50
• 6w PI POTS 0
• Taper over 9 mo stays good

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PI RESCUE FOR RECURRENT ET 18 S

• ET 45/60.
• CR 1.25. BMR 6.5
• D6 Orthotropic DN
• W4 ET 25-30
• PI Orthotropic 4mo f/up

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PI RESCUE FOR RECURRENT ET 7 NS then S

• i/mitt ET from 3mo
• 4.5 DS OU
• 9mo ETlt30, ET 30
• Refused gls. Screamed with PI
• 15 mo ET 35 BMR 5
• D1 slight XT.
• M2 ET 20. CR 3.75, 3
• Gls refused. PI.
• 3.5 y gls. Orthotropic D N

20
PI RESCUE FOR RECURRENT ET 16 NS then S

• 2 mo ET. CR 3 DSOU
• 6 mo ET 30?, CR 1.5, 1.
• 9 -23 mo I/mitt ET
• 23 mo ET 25?.
• 32 mo PI. Deteriorated to ET/ET 30-35/30-45? ?
  BMR 5.5.
• D6 XT8?, small X D15 ET6?.
• W5 ET 10/16? CR/MR 0.75.
• PI E/Elt10?, FR Dlt6?, Ngt6?
• 8 mo postop uses PI on bad days

21
PI RESCUE FOR RECURRENT ET 3 S

• 54 mo ET 30/ 50 X2 25 / 30. CR 0.5
• BMR 5.5. XT. D3 Lang 3/3
• D 19 ET 30. Gls tried / refused. Rx PI
• Next 5 mo reduced to 2ce weekly.
• 5mo orthophoric, BIFR gt 12
• Stop PI _at_ 6 mo
• 10 mo ET 35 EX0, FRgt6.
• MR CR 0.75 DS OU
• Rx bifocals with 3 add STRAIGHT

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Results success

• PI clearly successful in 2 pts of 7 in group B
  with gt4. PI treatment continues.
• 5 pts of 9 in group D had clear success,
  allowing these pts to avoid or delay repeat
  surgery.
• 2/5 still need daily PI.
• 1/5 uses PI if ET is seen (bad days)
• 2/9 patients in successful for 2-4 months, and
  then ? to bifocals / SV glasses

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PROBLEMS WITH MIOTICS

• Mims
• 279 of his pts 323 pediatric ophthalmologists
  surveyed
• Iris cysts 1
• Intolerance to hyperopic correction 1
• LK
• Screaming after instillation n1
• 15 yrs ago Iris cysts

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ISOFLUROPHATE FOR RECURRENT ETMims Wood BVQ
1993811-20

• n 117
• 57/117 ET lt 8?, ET lt 20?
• 38/57 67 initial response
• 16/57 28 no other Rx

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Summary

• PI is a useful adjunct in treatment of recurrent
  ET.
• In patients for whom surgery was followed by an
  early recurrence of ET with PI might help to
  avoid/delay further surgery even if unsuccessful
  preop.

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Aphorism of Hippocrates 300BC

• Life is short
• The art long
• Opportunity fleeting
• Experiment treacherous
• Judgement difficult

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Conclusion

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

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

• Retrospective study including 42 children who
  underwent BMR recession for cong. ET.
• 2 groups the treatment group (20 children) who
  got PI 1 drop/day for 4/12 1 week after the
  surgical procedure, and the control group (21
  children)
• Twelve months postoperatively, the
  residual/recurrent ET increased an average of 1.4
  and 2.8 D in the treatment and control 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

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References

• Spierer A. Postoperative miotics for patients
  with infantile esotropia. Ophth surg and lasers.
  1997281002-5.
• Parks M. Management of acquired esotropia. Brit J
  Ophthal. 197458240-6.
• Hiatt R. Miotics vs glasses in esodeviation. J
  Ped Ophthal and strabismus. 197916213-7.
• Hiatt. Medical management of accommodative
  esotropia. J Ped Ophthal and strabismus.
  1983199-201.
• Goldstein JH. The role of miotics in
  strabismus.Surv Ophthalmol. 19681331-46.
• Abraham SV. The use of miotics in the treatment
  of nonparalytic convergent strabismus. A progress
  report . Am J ophthalmol. 1952351191-5.

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References

• Parks M.
• ABNORMAL ACCOMMODATIVE CONVERGENCE IN SQUINT
• AMA Archives of Ophthalmology
• 1958 364-380

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Treatment groups
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Kids with ET and low plus (lt4), who didnt accept
glasses group A
Age yrs CR ET type PI tx Results F/U (m)
2 4 3.75 ou Cong. 65 2/12 RS 8
7 0.5 2.75 ou Cong. Int. 40 Pre-op Post op ?NS ?S 36
8 0.5 1.50 ou R s/p IO For SO palsy. ET 20 3/12 NS 10
10 2 R 1.50 L 3.00 ET 20 M/p no amblyopia 2/12 NS 9
16 6 1.00 ou Alt ET 20? 2 yrs later 35 Pre-op Post op ?NS ?S 38
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.
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B ET and gt4
Age yrs CR ET type size PI tx Results F/U (m)
1 0.8 4.50 Cong ET 25? 4/12 RS 14
6 1.4 R 6.75 L 5.25 A. ET 30? 2/12 NS 12
9 1 6 OU A. ET 25 ? Ongoing for 4/12 S 6
11 4 5 OU PA/A ET 20? Ongoing for 6/12 S 6
12 0.8 4 OU PA/A ET 30? 1/12 NS 8
15 4 4 OU Cong. ET 45? 1/12 NS Lost f/u
20 1.5 4 OU PA/A ET 40? Not tolerated NS 6
1? POTS for 4/12. Later ET 60??BMR A.ET
accommodative ET. PA partially accommodative
34
C near only ET
Age yrs CR ET type PI tx Results F/U (m)
14 1.9 1.50 OU Int. ET for near 1/12 ? 6 (lost)
35
PI RESCUE FOR RECURRENT ET 19

• Large cong ET. BMR 5.5 _at_ 7mo, residual ET, LR
  Rs OU _at_ 15 mo. CR 2.
• D1 ET 50. slipped LLR.
• OR RLR advanced, RMR 9 from limbus - Botox, LMR
  11 from limbus.
• Postop XT, face turn. Straight.
• 24 mo recurrent ET. CR 4.25, 4.5.
• Gls refused - PI.
• Usually straight.

36
PI RESCUE FOR RECURRENT ET 4

• 10 mo ET
• 13 mo 25 14 mo 30
• BMR 4.5
• ET 0-15 ET 0-25
• PI ET 0 ET 0-20

37
PI RESCUE FOR RECURRENT ET 13

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

38
PI RESCUE FOR RECURRENT ET 5

• 8 mo ET 50. CR 2. BMR 6
• 3w ET
• POTS bad day gt50
• 6w PI POTS 0
• Taper over 9 mo stays good

39
PI RESCUE FOR RECURRENT ET 17

• ET since 12 mo
• 35-40 / 40-57 CR 1.5
• BMR 6.5
• W1 Orthotropia
• W8 ET 25 / 30 CR 1.25
• PI No effect
• M6 LR Rs OU

40
PI RESCUE FOR RECURRENT ET 7

• i/mitt ET from 3mo1st seen 6 mo
• 4.5 DS OU EX0
• 9mo ETlt30, ET 30
• Refused gls. Screamed with PI
• 15 mo ET 35 BMR 5
• D1 slight XT.
• M2 ET 20. CR 3.75, 3
• Gls refused. PI. Variable compliance.
• 3.5 y gls. Orthotropic D N

41
PI RESCUE FOR RECURRENT ET 16

• 2 mo ET. CR 3 DSOU
• 6 mo ET 30?, CR 1.5, 1.
• 9 -23 mo varying POTS. ET.
• 23 mo ET 25?.
• 32 mo PI. Good response then deteriorated to
  ET/ET 30-35/30-45? ? BMR 5.5.
• D6 XT8?, small X D15 ET6?.
• W5 ET 10/16? CR/MR 0.75.
• PI E/Elt10?, FR Dlt6?, Ngt6?
• 8 mo uses PI on bad days

42
PI RESCUE FOR RECURRENT ET 3

• ET onset 4. CR 0.50.
• 54 mo ET 30, ET 50 X2 25 / 30
• BMR 5.5. XT. D3 Lang 3/3
• D 19 ET 30. Gls tried / refused. Rx PI
• Next 5 mo reduced to 2ce weekly.
• 5mo orthophoric, BIFR gt 12
• Stop PI _at_ 6 mo
• 10 mo ET 35 EX0, FRgt6.
• MR CR 0.75 DS OU
• Rx bifocals with 3 add

43
D PI rescue for recurrent / residual ET
following surgery
Age yrs CR ET type size in ? PI tx Results Time off PI F/u months
3 4 Plano N 50 D 30 Res. N ET. Tx for 4/12 S ? Later relapse 4/12?Rec N ET?Bif. 18
4 0.8 Plano Cong. ET 20 Rec.ET20? Tx for 3/12 S Ongoing 16
5 0.8 2.00 ou Cong.ET50 Res N ET Tx for 6/12 S Ongoing PI on bad days only 12
7 0.5 2.75 ou Cong. Int.40 Res.ET20. Tx for? S 15/12 36
13 3 R 2.50 L 1.50 R ET Int.30 Res.ET25. Tx for ? S ? Later relapse 2/12 ? Rec N ET?Bif. 20
16 6 0,75 ou Alt ET 35 Pre BMR NS S Ongoing for post op recurrence 38
17 1.8 2.00 ou N 50 D 35 Res.ET25. Tx for 2/12 NS 14
18 5 1.00 ou ET 45 Res.ET25. Tx for 1/12 S ongoing 3
19 1 4.50 ou Cong ET s/p 2 sx. 50 Res.ET25. Tx for 3/12 RS for 3/12 24
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Results (RS) Relative success

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

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PI RESCUE FOR RECURRENT ET 18

• ET onset 3. 1st seen age 5. ET 45/60.
• CR 1.25. BMR 6.5
• D6 Orthotropic DN
• W4 ET 25-30
• PI Orthotropic 4mo f/up

46
PROBLEMS WITH MIOTICS

• 1. Cataract - only in the elderly glaucoma
  population
• 2. Cholinergic crisis in unrecognised myesthenic
  n1
• 3. Iris cysts
• 4. Reduced plasma cholinesterase
• 5. Transient myopia
• 6. Retinal detachment
• 7. SLUD salivation / lacrimation / urination/
  defecation