Friday, August 6, 2010


8 years old/Female/Malay

Patient was diagnosed with alternating ET with LE as a fixating eye associated with RE hypertropia.

Patient came for follow up assesment and spectacle delivery.

This is the continuation case from week 1.

Patient came with face turn to right.

Below are the results from the examinations performed.


-Spectacle was delivered.

Kindly refer to week 1 case for previous assesment results.


-What is your expectation when this patient came for next follow up in 1 month time?

-How can you relate face turn to the right and the diagnosis given?

-Do you think the prognosis will be good?

-What is your next step in managing this patient when she came for next TCA?


GROUP 1 & 4 :)


  1. hi..

    1) my expectation: degree of Esotropia may reduced as well as her hypertropia with full time used of wet RX. if it is still not reduce, monitor the progression for another 2 months. if the degree is still not reduced in 3 months monitoring, we may advised the patient for surgery. however, if the degree is reduced, continue wearing the RX with close monitoring.

    2) LE is the fixating eye. LE is the dominant eye i guess. RE deviates IN most of the times. therefore, her face turn to the right (the sever eye)

    3) prognosis? im not very sure...anyone?

    4) for the next TCA, we might want to reassess the degree of esotopia after wearing the RX for 1 month as well as her RE accommodation since during this visit, her RE AA is out of normal range.

  2. Her face turn to right, so which muscles involve or affected?

  3. I think the muscle involved would be the right lateral rectus muscle. This head turns occurs because best binocular vision can be obtain in this position.

  4. Salam.. :)

    For next follow up, I expect that the degree of her esotropia will decrease and her hyperdeviation will be eliminated. As well as the primary gaze will remain straight.

    From the previous Hess chart, we can see that the affected muscles are the o/a of RMR as well as u/a RLR. So, in order to have a good fixation, the pt will turn her head to the right. So, the left eye is able to fixate.

    Although the prognosis will not achieve 100%, but i think might be good. Because for the first visit, with wet Rx her esodeviation decrease from 70BO to 32 BO. The eye also align straight but deviate when tired.

    For next TCA, recheck her PCT at near and distance as well as AA with wet spectacle. Then, repeat the refraction to look is there is any increase or decrease with her power. As well as the PCT with her new refraction. ;)

  5. To answer br.muziman's question, i agree with atikah..
    face turn to right reflecting the RLR is the affected muscle. As it is the best position that resulting the least deviation compared to the other position. If measuring PCT at different gaze, at this position of eye (whereby the pt look at the left side) will result in the least prism diopter compared to the other side.

  6. 1) for next follow-up, i think her horizontal deviation might reduce to approx. 32prism BO if she worn full-time. for vertical deviation, i think there will be no reduction or maybe a little bit reduction will happen as based on the above findings.

    2) as i said before, face turn to right signify the LR on right eye is the affected one. so, if she looked straight, the RE will tend to move inward at most of the time compared to the LE. hence, the LE will become the fixating eye.

    3) i'm not sure about the prognosis.

    4) if she came for the next TCA, assess her VA, AA, deviation by doing PCT to know whether all the findings improve, worsen or unchanged.

  7. yes, i agree with ela and tikah. the affected muscle is RLR. Less degree of ET was obtained when face turn to the right..

  8. salam
    i agree with noely, tiqah n ela...the affected muscle is RLR. that's why the patient need to right face turn to find the least deviation.
    about the prognosis, i think for alternating cases, the prognosis is poor.
    however, we can try to reduce the deviation by giving therapy to patient.
    that's why monitoring is very important to avoid horror fusionis(HF) from occuring . as we all know, one of the reason for HF to occur is due to unsuccessful therapy given and HF is usually occur in congenital ET and strabismus since childhood.
    *p/s: please correct me if i'm wrong...

  9. Yup, i'm also think the affected muscle is RLR since the patient tend to have face turn to right, whereby it is the least of strabismus.

  10. im totally agree with the rest where the reason of pt has right face turn is due to the affected muscle is RLR. face turn is one way to compensate the double vision whereby when the pt is turning the face to the right, the diplopia will be lesser. may be we can confirm it with perform PCT on each gaze and compare it. theoretically, the deviation is minimal in the gaze which the pt has turned.

    for the prognosis, as im concern, alternating cases has poor prognosis. (correct me if wrong)

    however, for this pt, we can monitor the deviation with her new RX for next 1 to 3 months. as we can see the deviation is lesser when wearing RX compared to without RX. monitor any changes in her VA, refraction, AA and her deviation.

  11. The affected muscle is RLR. The patient turn her face to the right in order to avoid from the diplopia. At this position, the deviation is the least.

    for the next, visit, the ET may reduced more as well as the hypertropia. During the nest visit, review the VA, degree of tropia using PCT and AA.

  12. yeah...the pt will turn her face to the side which has least diplopia (in this case, the pt turn to the right and the affecte dmuscle is RLR). we can comfirm it by performing PCT at each gaze.

  13. we supposed to have conclusion now... exam will be on next monday already.

    Since everyone were repeating the same thing on the affeted muscle involved. Again, the affected muscle will be the one with under action right? so, it's RLR. But the patient had also RE hypertropia which might be due to under action of RSO and RIR.

    The management suitable for this patient is rely on each progression of strabismus on next visit. The deviation is large. definately poor prognosis if it is alternating.

    Not enough tests were performed, so the treatment may not be conclusive enough. I dont know about patient stereopsis. If he/she don't have stereopsis. Eventhough surgery is the last choice, it can be considered if patient agree for it and symptoms are severe.

    lalala....good luck. that's all



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