Strabismus Surgery
and
the Late Elderly
Logan Mitchell
Lionel Kowal
RVEEH, Melbourne
Private Eye Clinic, Melbourne
“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
“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
“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%
“Elderly” and Strabismus

Prevalence of strabismus in >65 year olds
(assumptive)



4% prevalence adult strabismus
120,000 in 2009
250,000 in 2042
Elderly Strabismus – the literature

4 papers

Paper #1



Repka JAAPOS 2007 as described
70% horizontal surgery
14% reported as re-operations (?low)
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
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
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
Adult Strabismus (as substitute)

Adults delay seeking surgical correction

Mean delay 19 years


diplopic 15 yrs vs 28 yrs non-diplopic
Reasons
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
Results




35 patients
Age: mean 79 years
(75-95)
Male:Female 16:19
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
Results

Previous surgeries
35
30
29
25
20
15
10
4
5
1
1
2
3
0
0

1
(plus 2 with previous botox)
Aetiology of Strabismus
6%
3%
9%
20%
39%
23%
neuroparalytic
restrictive
decompensated phoria
consecutive
sensory
unknown
Neuroparalytic Strabismus

14 patients

CNVI in 9 patients



5 compressive

3 ischaemic / uncertain
cause
1 traumatic (CHI)
 (1 previous surgery)
3 congenital
 1 with 2 previous
surgeries
 Remaining 2:
average duration of
diplopia = 6 years
 2 ICA aneurysm
 (1 previous
surgery)
 2 meningioma
 1 ependymoma

CNIV in 6 patients


3 uncertain aetiology
CNIII in 1 patient

Combined with CNVI in
ICA aneurysm patient
Restrictive Strabismus

8 patients

3 thyroid eye disease


4 traumatic / iatrogenic




Mean duration on symptoms: 1.3 years
2 previous retinal detachment surgery
1 previous sinus surgery
1 previous orbital trauma
1 Brown’s syndrome

Symptoms for >50 years
Decompensated Phoria

7 patients


5 with decompensated intermittent exotropia
2 decompensated divergence insufficiency

Mean duration of symptoms: 37 years
Consecutive Exotropia

Only 2 patients



Childhood esotropia
Previous surgery x 1, and x 3
Mean duration of misalignment: >40 years
Outcomes


Mean follow-up 8 months
“Overall”
3%
29%
31%
Perfect
Significant improvement
Little/no improvement
Worse
37%
Outcomes

Diplopia
17%
35%
3%
Free of diplopia
(with AHP)
(with prism)
(with AHP and prism)
DIPLOPIC
3%
42%
Outcomes in Neuroparalytic Cases


“Overall” result
Perfect
3 (21%)
Significant improvement
2 (14%)
Little/no improvement
8 (57%)
Worse
1 (7%)
Diplopia
Free of diplopia
11 (79%)
(with AHP)
2 (14%)
(with prism)
6 (43%)
(with AHP and prism)
1 (7%)
Diplopic
3 (21%)
Outcomes in Other Cases

“Significant improvement” or better



Restrictive strabismus 88%
Decompensated phoria 86%
Consecutive exotropia 100%
Complications

Couldn’t find a muscle (2)


Re-operations (3 = 8.6%)


2 on one patient (SOP), 1 on 95 year old lady
(XT)
Recurrences (6)


Post-childhood trauma, consecutive XT
Dealt with prisms in 4 cases
No known systemic complications
Conclusions (I)

Strabismus in the very elderly


Exists
Is not extremely rare




Is under-represented in the literature
Diplopia is a frequent indication for surgery
Patients delay surgery


Will increase
Often at our (medical) behest
Varied aetiologies

Neuroparalytic causes common (note compressive
causes)
Conclusions (II)

Surgical considerations

Systemic risk of general anaesthetic



Thinner conjunctiva
Risk of anterior segment ischaemia


?risk of regional anaesthetic
Probably 2 muscles maximum
Diplopic indication common

More accurate surgery, adjustable sutures
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)
Thank You