ISMAIL
STRABISMUS ACADEMYLearning Without Limits
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ISMAIL STRABISMUS ACADEMY

Library

Clinical, surgical and educational resources in strabismus.

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Surgical

Surgical techniques, reoperations, operative pearls and pitfalls.
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Gallery

Clinical photographs, surgical images, diagnostic signs and selected cases.
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Videos

Surgical and educational video library.
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Cases

Interesting and challenging strabismus cases.
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Pearls & Pitfalls

Quick practical surgical and clinical lessons.

Diplopia Flowchart Myopia Control Straatsma Syndrome — Ismail et al. · American Academy of Ophthalmology Causes of Leukocoria — Ophtha Capsule

LIBRARY · SURGICAL

Surgical Tips

LIBRARY

Videos

CLINICAL CASE LIBRARY

Case 1 — Isolated Microvascular Palsy in a Diabetic Patient

63 yearsType 2 diabetes + hypertensionHorizontal diplopiaRight abduction −2

Presentation

A 63-year-old man with type 2 diabetes and hypertension noticed horizontal double vision on waking, worse when looking at the television and when turning to the right. He had a dull ache above the right eye for two days before. He had no other symptoms.

Examination

Acuity 6/6 in each eye; pupils equal and reactive; no ptosis; normal fundi without disc swelling. Esotropia 18 PD at distance and 8 PD at near, increasing to 30 PD in right gaze and 6 PD in left gaze. Right abduction −2 with slowed abducting saccades. Facial sensation, facial movement, and hearing normal. No other neurological signs. Blood pressure 162/94.

Clinical Reasoning

An acute, isolated, painful-onset abduction deficit in an older patient with vascular risk factors is most likely microvascular. Pain in the first days does not exclude it. However, giant cell arteritis must be screened for, and a minority of such palsies prove to have another cause.

Investigation

ESR 14 mm/h, CRP normal, platelets normal; HbA1c 8.4%. MRI brain with contrast, including the skull base and cavernous sinus, was normal.

Management

  • Explanation of the expected course.
  • Frosted tape over the right spectacle lens for driving and reading; advice not to drive until diplopia controlled.
  • Referral to the physician for control of glucose and blood pressure.
  • Review at 4, 8, and 12 weeks with prism cover test and Hess chart.

Outcome

8 weeks: deviation fell to 6 PD at distance and abduction was −0.5.

12 weeks: orthophoric with full abduction and normal saccades.

Learning Points

  • Microvascular palsy typically recovers within three to six months.
  • Check inflammatory markers in everyone over about 50.
  • Failure to improve by three months, progression, or any new sign changes the diagnosis.

CLINICAL CASE LIBRARY

Infantile esotropia clinical photograph

Case 2 — Infantile Esotropia: Bimedial Recession

14 months45 PD ETCross-fixationFull abduction

Presentation

A 14-month-old girl had had a large inward turn since she was about 3 months old, confirmed in photographs.

Examination

Constant esotropia 45 PD at distance and near, comitant; cross-fixation; full abduction on doll's head manoeuvre and after brief occlusion of each eye; free alternation. No nystagmus. Cycloplegic refraction +1.00 in each eye. Normal fundi and development.

Clinical Reasoning

Onset before 6 months, a large constant angle, cross-fixation, full ductions on the doll's head test, and low hypermetropia indicate infantile esotropia. There is no accommodative component to treat and no amblyopia because she alternates.

Management

  • No glasses (refraction normal for age).
  • Bimedial recession at 15 months, 10.5 mm from the limbus for 45 PD (Helveston table).
  • Parents counselled about later DVD, IOOA, and the likelihood of further surgery.

Outcome

Esophoria 4 PD at one year, with gross stereopsis and peripheral fusion (monofixation).

Learning Points

  • Alignment within about 8 to 10 PD by 2 years favours peripheral fusion; bifoveal stereopsis is rare.