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The largest angle is the target for buy Manforce in hanoi correction Intermiltent Exotropia Most buy Manforce in hanoi form of XT Onset varies from infancy to age 4 May Manofrce progressive Buy Manforce in hanoi have reflex closure of 1 eye in bright light Suppression only when eyes are deviated (facultative suppression) Amblyopia uncommon Natural history Phase1 X(T)at distance and straight at near Present when fatigued May see double Most maintain excellent stereovision Phase 2 X(T) Buy Tadalista more constant at distance with X(T) at near Suppression increases Phase 3 XT hanьi far and near Often no diplopia because of suppression Most buy Manforce in hanoi cause of a constant XT Treatment Treat amblyopia Alternate occlusion therapy Induce accommodative convergence by prescrib- ing overminus spectacles (also for consecutive exotropia) Prism therapy with base-in prisms Fusional convergence training (progressive base- out prism to induce convergence) Surgery for increased tropic phase, poor recovery of fusion once tropic, increasing ease of dissoci- ation, XT greater than 50 of time at home PROCEDURES Buy Manforce in hanoi lateral rectus buy Manforce in hanoi Recess lateral rectus and resect medial rectus of 1 eye 3 of 4 muscle surgeries for Mafnorce deviation Congenital Exotropia Rare May be primary (otherwise healthy patients) or sec- ondary (from ocular or systemic abnormalities) Usually large angle of deviation (average 35prism diopters) Amblyopia is uncommon; similar refractive error to general population Most resolve by age 6 months; if not, consider surgery Associations DVD and oblique muscle overaction; orbital or skull defects, neurologic disease, or other ocular, genetic, or systemic conditions пппппппппппппп Page 161 пCHAPTER5- PediatricsStrabismus Convergence Insufficiency Exophoria greater at near than at distance Buy Manforce in hanoi exotropic at near) Reduced near point of convergence and amplitudes of convergence Female male Common in teenagers and young adults Associations can be exacerbated by fatigue, drugs, uveitis, or Adies tonic pupil; may also follow buy Manforce in hanoi trauma Associated with systemic illnesses, or as a conver- sion reaction Findings asthenopia, diplopia; may have reduced amplitude of accommodation and remote near point of accommodation Treatment b Observation Orthoptic exercises to improve fusional amplitudes Base-out prisms Rarely surgery (medial rectus resection) Convergence Paralysis Secondary to lntracranial Lesion Normal adduction and accommodation XT and diplopia on attempted near fixation Associations Parinauds syndrome Treatment base-in prisms or occlusion of 1 eye to relieve diplopia Sensory Exotropia Due to loss of vision or buy Manforce in hanoi poor vision in 1 eye Children younger than age 5 with unilateral vision loss may develop ET or XT;adults usually develop XT Angle of deviation may be aMnforce and usually increases with time Consecutive Exotropia Follows previous strabismus surgery for esotropia Vertical Deviations Dissociated Vertical Deviation (DVD; DHD Dissociated Horizontal Deviation; DTD Dissociated Torsional Deviation) Intermittent deviation of nonfixing eye consisting of upward excursion, extorsion, excyclotorsion, abduc- tion, or lateral deviation Exact etiology unknown but associated with early disruption of binocular development Usually asymptomatic because of poor fusion and suppression Often asymmetric Does not obey Herings law (fellow eye does not ex- hibit refixation movement in opposite direction) Occurs with eye occlusion or visual inattention May be latent or manifest Usually presents before 12 months of age Usually more marked when patient is fatigued, day- dreaming, buy Manforce in hanoi stress, or sick Associations nystagmus (latent or manifest latent), inferior oblique overaction, often occurs in patients with history of congenital ET; in in 40 of patients Findings slow movement buy Manforce in hanoi eye in the characteris- tic direction Amount of deviation variable; therefore, accurate measurements difficult to obtain Dissociated deviation occurs in all directions of gaze Diagnosis Bielschowskys phenomenon 50 of patients with DVD Elevated eye will drift downward when light in fixing eye is reduced Conversely, increased illumination in an eye with DVD will Manfoce it to drift buy Manforce in hanoi Red lens phenomenon Place red lens over either eye while patient fixates on light source Red image is always seen below the white image In patients with a true hypertropia, the red image is seen above or below the primary image, dep- ending on whether the red filter is placed in front of the hyperdeviated or hypodeviated eye Treatment Increase ficsional mechanisms give optimal spec- taclecorrection;switchfixationto nonpreferredeye Surgery INDICATIONS Increasing buy Manforce in hanoi or frequency of manifest DVD Abnormal head position PROCEDURES SR recession IR resection I 0 weakening or anterior transposition (in patients with IOOA and DVD) CAUTIONS perform bilateral surgery (unilateral surgery often reveals occult contralateral DVD); often recurs or persists after surgery Inferior Oblique Overaction (IOOA) Occurs in 23 of patients with congenital ET пппппппппппппппп Page 162 ппUsually bilateral and asymmetric Early surgery for ET is important for development of binocular vision but does not reduce incidence of I 0 dysfunction May be primary (due to paralysis buy Manforce in hanoi the antagonist SO) or secondary Findings when fixing eye is abducted, buy Manforce in hanoi eye is elevated When fixing eye is adducted, abducted eye is depressed V-pattern deviation Primary position extorsion of fundus on indirect Superior Oblique Palsy Ocular Alignment ппппophthalmoscopy Most common isolated cyclovertical muscle palsy Congenital (75) Large fusional amplitudes (as much as 15 prism diopters or more) SO tendon often long or floppy; sometimes absent Long-standing CN 4 palsy results in ocular torti- collis, which can lead to facial asymmetry Examine old photographs to determine duration of head tilt Can mimic a double elevator palsy (if fixation pref- erence is for the affected eye, the contralateral SR muscle can appear to underact (inhibitional palsy of the contralateral Manfrce and the contralateral IR can undergo contracture, lead- ing to double elevator palsy) Acquired often due to trauma (long course of 4th nerve makes it especially vulnerable) Findings diplopia (vertical, horizontal, or torsional) In long-standing cases of SO palsy, comitance develops and the deviation becomes more dif- ficult to localize (hypertropia can be present in all fields of gaze) Bilateral Buy Filagra Kentucky torsion is often lo0 of excyclotorsion (measure Buy Zhewitra in Laredo double Maddox rod) Often have inferior oblique overaction with V- pattern ET and chin-down head posture Alternate hypertropia with head tilt Diagnosis Parks-Bielschowsky 3-step test (i.

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