Surgical Outcomes in Intermittent Exotropia

Surgical Outcomes in Intermittent Exotropia
Presentation lecture by:
Jeffrey D. Colburn, M.D., PGY-3
Preceptor: David Morrison, M.D.
Vanderbilt Eye Institute

Intermittent Exotropia

* Intermittent exotropia x(t) is a latent tendency (phoria) for the eyes to turn out, which is intermittently controlled by fusional convergence.
* Characteristics
o Typically good bifoveal fusion and stereoacuity when aligned.
o Amblyopia is rare in x(t).
o X(t) Tends to remain stable or progress.
o Progression might result in dense suppression.

Intermittent Exotropia

* X(t) Sub-types
1. Basic
+ Angle is equal at near & distance

2. Pseudo-divergence excess (PDE)
+ Angle is equal at near & distance but appears larger in distance because of masking

3. True divergence excess (TDE)
+ Angle is larger in distance

4. Convergence insufficiency (CI)
+ Angle is larger at near

Surgical Treatment

* Goals
o Improve alignment & control
o Improve binocular vision
* Basic concepts
o Recession (weakening procedure)
o Resection (strengthening procedure)
* Two primary approaches
o Bilateral lateral rectus recession (BLRc)
o Unilateral recess & resect (R&R)

Predictors of Outcomes

age
pre-op deviation
pre-op control
sub-type
procedure type
asymmetric accommodation
pre-op deviation
central fusion or stereopsis
Observations

* Effect of pre-operative angle size on surgical outcomes in x(t) patients.
* Disparate opinions on the more successful procedure for x(t).
Hypotheses
* Larger angle x(t) patients have more successful surgical outcomes than smaller angle x(t) patients.
* R&R procedures have more successful surgical outcomes than BLRc in the management of x(t).
Methods

* Retrospective chart review
o Inclusion criteria
+ X(t) surgical cases
+ January, 2003 through January, 2008
+ Age ≤ 18 years
Methods

* Exclusion criteria
o Developmental delay
o Vertical deviation
o Pattern deviation
o Prior surgery
o Partially or untreated amblyopia
o Monocular exotropia
o Constant exotropia
o Secondary exotropia
o Nystagmus

Data collection

* Variables considered
o Gender
o Age at time of surgery
o X(t) sub-type
o Pre-op deviation
o Stereo-acuity
o Presence of fusion
o Presence of suppression
o Procedure type
o Deviation post-op visit #1
o Deviation post-op visit #2

Outcome Measures

* Surgical success:
o Intermittent exotropia ≤ 8 PD
o No esotropia
* Surgical failure:
o Not meeting above success criteria
o Repeat surgery for poor control
* Time to surgical failure
* Over-correction or under-correction

Demographics
History of amblyopia
Average pre-op deviation (PD)
Mean age at surgery (mos)
Characteristic Results

* Overall outcomes
o 61 BLRc, 19 R&R, 2 unilateral LRc
o 42 (51.2%) patients failed
o Mean time to failure was 6.9 months (1-34)
o 35 patients (43%) were under corrected
o 6 patients (7.3%) were over corrected

Other variables
Multivariate logistic regression
Surgical procedure (blrc vs. r&r)
Presence of suppression
Presence of fusion
Stereo acuity
Pre-operative deviation
Chi-square
Multivariate survival analysis
Cox proportional hazards model
Surgical procedure
Stereo Acuity
Presence of Suppression
Comment
Summary

Surgical Outcomes in Intermittent Exotropia.ppt

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Sex Menopause and Aging

Sex,Menopause and Aging
Presentation by: Dr. Penny Frohlich
University of Texas at Austin

Sex,Menopause and Aging

Overview
The menopause transition
Sexual changes during and after menopause
Early menopause
Hormone replacement therapy
Aging and sexuality in men and women
The “andropause” - male menopause?


MenopauseOvaries become less responsive to FSH and LH
Patterns of GnRH release from the hypothalamus become altered
Pituitary gland becomes less responsive to GnRH

PerimenopauseAverage age at onset in the late 40’s
Irregular menstrual cycles
Somatic and psychological symptoms emerge

Post-menopause12 months of amenorrhea
Elevated FSH levels
On average, reached by the early 50’s

Is that all?No! The ovaries continue to produce androgens after menopause!

Factors that may affect timing of menopauseSmoking
Genetics
Number of pregnancies
Body mass

Symptoms of menopause Hot flashes
Mood swings
Vaginal dryness
Vaginal atrophy
Fatigue, weight gain, sleep disorders, headache, cognitive changes…..

Menopause across culturesDo all women experience menopause as a major negative life event?

Sexual changes at menopauseDecreased sexual desire
Lower levels of vaginal lubrication
More painful sexual intercourse
What doesn’t change?

Early menopauseSurgical menopause
Removal of the ovaries, usually accompanied by hysterectomy
Menopause induced by treatment for cancer
Radiation therapy
Chemotherapy
Early natural menopause

Early natural menopauseAutoimmune disorders
Genetics
Problems in ovarian development
Chromosomal irregularity
Triple X syndrome
Faulty second X chromosome

Hormone replacementEstrogen: systemic or local
Estrogen + progesterone
Androgen replacement?
Potential benefits
Possible side effects

Aging and sexualityHow do you tell what is caused by menopause and what is caused by natural aging?
A recent longitudinal study concluded that sexual arousal and orgasm are affected by both aging and menopause

Sexuality in the elderlyHealthy sexual relationships may continue into old age
Common problems associated with aging include:
Sexual dysfunction
Death of partner
Cultural attitudes towards sexuality
Health problems

The “andropause”Progressive decline of androgens over time
Symptoms: erectile dysfunction, cognitive impairment, fatigue, vague somatic symptoms
40% of men have ED by age 40
Over two-thirds of men by age 70
Is the andropause a disorder?

Sex,Menopause and Aging.ppt

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Recreational Drug Use and Sexual Functioning

Recreational Drug Use and Sexual Functioning

Presentation by: Dr. Penny Frohlich
University of Texas at Austin

Recreational Drug Use and Sexual Functioning

Nicotine(Complex impact on hormones & neurotransmitters.)
Short term = interferes with erection
Decreases blood flow to penis
Increases venous outflow from penis
Long term use destroys penile tissues = erectile dysfunction
Passive smoking can have similar impact



Alcohol(Diffuse affects on neurotransmitter processes)
(Affects hippocampus)
Males
Self-report
Increased latency to orgasm (reduced likelihood of premature ejaculation)
Increased likelihood of erectile failure
Alcoholic males: erectile dysfunction (59%); anorgasmic dysfunction (48%); at least one sexual dysfunction (84%) (Mandell et al., 1983)
Laboratory Studies
Inhibits erection (dose dependent)
Increased latency to ejaculation (dose dependent)

Alcohol: FemalesSelf-report:
No change in sexual functioning when intoxicated
Moderate alcohol use (2 per week – 2 per day) associated with lowest rates of sexual dysfunction
Alcoholic females report decrease in sex drive and difficulty achieving orgasm/anorgasmia
Laboratory Studies:
Decreased arousal (Wilson & Lawson, 1976)

Alcohol: FemalesSelf-report:
No change in sexual functioning when intoxicated
Moderate alcohol use (2 per week – 2 per day) associated with lowest rates of sexual dysfunction
Alcoholic females report decrease in sex drive and difficulty achieving orgasm/anorgasmia
Laboratory Studies:
Decreased arousal (Wilson & Lawson, 1976)
Longer latency to orgasm (Malatesta et al, 1982)
Decreased intensity of orgasm (Malatesta et al, 1982)
Increased subjective arousal and orgasm pleasure (Malatesta et al, 1982)

Marijuana(THC (active ingredient) – THC receptors rich in the hippocampus)
lowers testosterone (mixed evidence)
Enhances sexual enjoyment in both men and women (83% and 81% respectively)
Does not affect erection, lubrication, or orgasm.
Increases relaxation, sociability, touch, and comfort.
high doses = sedation and impaired sexual performance.
In animals, decreases sexual activity – general decrease in physical activity.

Amphetamines “speed”(Enhanced release and block reuptake of norepinephrine, and at higher doses, dopamine.)
Can cause vasoconstriction of genital tissue
Sexual Performance:
Increased libido (increased energy)
Erectile failure; prolonged erection (up to 18 hours!)
Anorgasmia; multiple orgasms
Long term use: loss of interest in sex

MDMA “Ecstasy”(Similar to amphetamines, stimulates SNS)
Purported effects:
increased energy
increased endurance
feelings of euphoria
increased sociability
feelings of intimacy
altered visual perception
enhanced libido

MDMA “Ecstasy”Sexual functioning
Subjective ratings: 20 men, 15 women (Zemishlany et al., 2001)
Desire: moderately to profoundly increased
Erection: impaired in 40%
Orgasm: delayed but more intense
Satisfaction: moderately to profoundly increased
Laboratory studies?

MDMA “Ecstasy”Acute side effects/adverse effects (Smith, Larive & Romanelli, 2002):
agitation, anxiety, tachycardia, hypertension
arrhythmias, hyperthermia
Chronic adverse effects:
Toxicity to serotonin system
cardiovascular system
CNS serotonin
Overlap between recreational and fatal dose (Kalant, 2001)

Crystal Methamphetamine
“Crank,” “Crystal,” “Speed”(Increased release of dopamine, adrenaline)
Purported effects:
sense of exhilaration
sharpening of focus
sense of sexual liberation
Sexual Functioning
constricts blood vessels
erectile dysfunction
Risks: similar to amphetamines, risk greater

Physiology of penile erection
Viagra (Sildenafil): Inhibitor of cGMP PDE5
Nitric Oxide & Penile/Clitoral Tumescence
20 SextasyCombining Viagra with ecstasy, “hammerheading”
headache, prolonged erection (priapism)
high risk sexual behavior
long-term heart damage
Viagra with:
crystal methamphetamine
amyl nitrate
any drug that produces erectile dysfunction
Viagra and illegal recreational drugs (40%)

Amyl Nitrate “Poppers”Organic nitrate
Short-acting vasodilator
Increased blood flow to heart and brain
Purported to make sexual organs feel “Herculean”

CocaineInhibits reuptake of dopamine
Potent vasoconstrictor
Increased sexual desire
Arousal:
Men:
low doses – prolonged erection
high doses – erectile failure
Women: reports of both increased and decreased subjective arousal
Delayed or absent orgasm

Opioids: HeroinStimulate opiate receptors (enkephalins (body) and endorphins (brain)) – results in reduction in circulating testosterone
Produce relaxation/sense of well being
Analgesic affect – opiate receptors in female genital tract
Few reports of acute use: lowers drive, delays orgasm
Male Heroin addicts:
loss of drive, erectile dysfunction, orgasmic dysfunction
Withdrawal: increased morning erections, spontaneous ejaculation, slow return of sex drive, erectile and orgasmic dysfunction
Female Heroin addicts:
Decreased drive, increased drive, anorgasmia
Withdrawal: loss of libido

Hallucinogens (LSD, PCP)Purported to be “ultimate sex drug.”
Affects dopamine, serotonin, and with PCP, glutamate.
Sexual pleasure enhanced (all pleasure enhanced – e.g., watching paint dry is equally pleasurable)
Sexual Performance (animal studies):
low doses:
Males: premature ejaculation
Females: normal receptivity
Moderate to high doses – lack of physical coordination precludes any sexual activity.

Psychotropic Drug Use and Sexual Functioning

AntidepressantsMAO inhibitors, SSRIs
Impair all aspects of the sexual response cycle in men and women
Serotonin 5-HT2 receptor implicated
Nephazadone (serzone) SSRI and 5-HT2 antagonist – fewer sexual side effects
Stimulation of the 5-HT2 receptor (peripherally) causes vasoconstriction

AntipsychoticsDecreases dopamine activity
Males
Enhances erection
Several reported cases of priapism
Females
Enhances vaginal lubrication?
Delayed and inhibited orgasm

Anti-Parkinsonian drugsIncreases dopamine activity
Sexual drive:
Increases sex drive
Several cases of hypersexuality in men (<1%)
One reported case of hypersexuality in a woman (levodopa/carbidopa)
Sexual arousal: L-dopa increases erection in men with erectile failure

Recreational Drug Use and Sexual Functioning.ppt

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