Workshop 20

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Loosening the Tension – Evaluation, Differential Diagnosis and Treatment of Restrictive Strabismus

Daniel J. Salchow, MD; Oliver Ehrt, MD; Michael Schittkowski, MD
Charite – University Medicine Berlin


Purpose/Relevance: Evaluation and treatment of restrictive strabismus is challenging. Many causes for restrictive strabismus exist. Treatment for underlying causes includes conservative measures (e.g. medical treatment for orbital inflammation) and surgery (e.g. repair of an orbital fracture or excision of an orbital mass). Diplopia secondary to strabismus may be treated optically (prisms, occlusion) or surgically. This workshop aims at improving the ability to differentiate causes for restrictive strabismus, expanding the knowledge about their respective treatments, and to optimize strabismus treatment to improve the patient’s health and quality of life.

Target Audience: Physicians, particularly strabismologists and orbital surgeons; orthoptists; physician assistants; ophthalmic technicians.

Current Practice: While some causes for restrictive strabismus are well known (e.g. thyroid related orbitopathy or orbital fracture), others may be overlooked or underdiagnosed. Standard strabismus surgery techniques and dosage tables may not be appropriate to treat patients with restrictive strabismus.

Best Practice: Knowledge about new entities causing restrictive strabismus has emerged (e.g. IgE4-associated orbital inflammation). Treatment of these causes should employ the least invasive option. Examination modalities such as the Harms tangent screen help to characterize the ocular deviation more comprehensively, enabling the physician to design effective surgical plans. Techniques beyond standard strabismus surgery include the use of tissue surrogates (irradiated bovine pericardium for eye muscle lengthening or amniotic membrane as a substitute for conjunctiva) and may be helpful in complicated cases. Surgery is not always aimed at correcting the deviation but sometimes at improving ocular motility by relieving restrictions. Recent advances in the conservative treatment of orbital vascular malformations including lymphangioma and capillary hemangioma may improve ocular motility and obviate the need for surgical intervention.

Expected Outcomes: Using the knowledge transferred in this workshop, clinicians will be better equipped to diagnose and treat restrictive strabismus and to recognize its underlying causes.

Format: Lectures, interactive case discussion, audience quiz and polling

Summary: Restrictive strabismus has many facettes, and its treatment may be challenging. In this workshop we interactively discuss the causes of restrictive strabismus, its treatment options as well different approaches to treating the strabismus itself. Diagnostic and therapeutic advances including the use of tissue grafts in the surgical treatment of restrictive strabismus is the focus of this workshop

References: Esser J, Schittkowski M, Eckstein A. Graves’ orbitopaty: inferior rectus tendon elongation for large vertical squint angles that cannot be corrected by simple muscle recession. Klin Monbl Augenheilkd 2011;228:880-6
Flanders M. Restrictive strabismus: diagnosis and management. Am Orthopt J 2014;64:54-63

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