DESARROLLO MOTOR

Su funcin es
mantener
cada ojo
derecho al
frente para
que la imagen
del objeto
visto caiga
sobre la fvea

Juega papel importante

mielinizacin de fibras
motoras y sensoriales.

DESARROLLO DE VISIN
BINOCULAR
El recin nacido posee un potencial
gentico de binocularidad desde el
nacimiento que evoluciona los 6
primeros meses con la separacin de
las columnas de dominancia y la
aparicin de clulas corticales
binoculares.
Para que exista VB se requiere:
Dos imgenes ntidas de tamao y
forma simtrica para cada ojo, aparato

EVOLUCIN V.B.
Nistagmo fisiolgico hasta
tercera semana
Luego aparece reflejo de fijacin
Primeros tres meses
superposicin de imgenes.
Tercer mes: fusin gruesa
(Sheiman,1994, citado por Camacho 2009)

Movimientos cabeza ojos

OTROS PARMETROS
Sensibilidad al contraste:
Mejora a medida que la AV
progresa, nivel adulto edad
escolar
Visin cromtica: 2 mes
(incompleta)
Estereopsis: 3. 5 a 6 meses de
edad, 8o. mes nivel adulto (Daw,
2006)

PERIODO CRTICO
Periodo de tiempo
durante el cual la
integridad del sistema
visual es susceptible
de modificacin por
experiencia.

PERIODO CRTICO
De cero a seis meses
Sensibilidad mxima
Primordial recibir estimulo
visual claro
Deprivacin produce
disminucin visual
irreversible

CATEGORIAS DE RIESGO
Deprivacin de patrones
Desenfoque ptico
Estrabismo
(Adler, 1994)

ESTRABISMO
La ambliopa por
estrabismo
ocurre
aproximadament
e en el 50% de
pacientes con
endotropia
congnita, pero
es poco comn
en pacientes con

 Neutralizacin
foveolar en ojo
desviado
(escotoma) para
eliminar
interferencia
sensorial. La
fvea pierde
funcin como sitio
ptimo de
resolucin y como
punto de
referencia de

PRONSTICO
Edad del paciente
Severidad de la ambliopa
Tipo de ambliopa
Edad de aparicin del factor

ambliopizante
Instauracin del tratamiento
(Wright, et al 2006)

ET DEL LACTANTE PRECOZ, INFANTIL

(CONGNITA) AAO, 2008
Ha sido descrito como sndrome, por
ejemplo Sndrome de Ciancia,
Sndrome Congnito o Sndrome de
Lang.
Algunas endotropas de comienzo
temprano no son necesariamente
congnitas, xej refractivas precoces y
las asociadas a desrdenes
neurolgicos

 en quienes se identificaron y analizaron los

cuatro elementos clnicos ms caractersticos
para determinar el origen congnito de una
endotropa: Limitacin de la abduccin (LABD)
en 95.4%, incomitancia horizontal (IH) en
67.7%, desviacin vertical disociada (DVD) en
66.15% y nistagmo latente (NL) en 60%.

CARACTERISTICAS
Presencia demostrada a los 6 meses
Antecedentes familiares
Se presenta en 30% de los nios con
problemas neurolgicos y de desarrollo
(parlisis cerebral-hidrocefalia)

AV similar en los dos ojos y alternancia en fijacin

(Ferrer Ruiz, 1991) (Wright, 2000)

Fijacin cruzada (Ferrer Ruiz, 1991) (Wright, 2000)

 Posible ambliopa

(40-50%

Wright, 2000)

Hiperfuncin Oblicuo Inferior,

DVD (50%) (Wright, 2000)
Asimetra seguimiento nasal
y temporal

Calcutt C; Murray AD. Untreated essential infantile

esotropia: factors affecting the development of
amblyopia. Eye 1998;12 ( Pt 2):167-72.

PURPOSE: A concomitant esotropia, presenting within the

first 6 months of life, associated with a high incidence of
dissociated vertical deviation, manifest latent nystagmus and
asymmetric optokinetic nystagmus is termed essential infantile
esotropia. Most studies concern patients diagnosed in infancy
and treated throughout childhood. This paper addresses the
factors that may influence the development of amblyopia in
patients who remain untreated until visual adulthood. The
correlation between anisometropia and amblyopia was
statistically significant.

ET DEL LACTANTE
Hipermetropa

Fuente

+ 1.00, +2.00

(AAO, 2008)

+ 2.25 a + 5.00

(Wright, 2000)

+1.50, +2.00

(Ferrer R, 1991)

< 2.00

(Ticho, 2003)

ngulo

Fuente

Mayor 30 ^

(AAO, 2008)
(Ticho, 2003)

Entre 30 y 70^

(Wright, 2000)

45-50 ^ mnimo (Ferrer R, 1991)

PATOGENIA (AAO, 2008)

Sensorial (Worth): Deficiencia centro
enceflico de fusin
Mecnico (Chavasse)
Costenbader, Taylor e Ing reportaron
resultados favorables en bebes operados entre 6
meses y dos aos.
Importante intervenciones tempranas

MANEJO (AAO, 2008)

La ciruga se puede hacer en nios sanos entre
4 y 6 meses para lograr la mxima VB
(estereopsis)
Congenital Esotropia Observational Study
(CEOS)
Clinical reports have demonstrated that surgical correction
of the esotropia between 6 and 12 months of age provides
for enhanced development of stereoacuity compared with
later surgery.

Drover JR, Stager DR Sr, Morale SE, Leffler JN, Birch EE.
Improvement in motor development following
surgery for infantile esotropia. J AAPOS. 2008
Apr;12(2):136-40. Epub 2007 Dec 21.
Prior to surgery, patients with infantile esotropia were
delayed in their achievement of developmental milestones.
However, following surgery, a comparison group of
patients showed rapid development and possessed motor
skills comparable to those of normal children, suggesting
that early surgery is beneficial to both visual and motor
development

Von Noorden GK. Bowman lecture. Current concepts of

infantile esotropia. Eye (Lond). 1988;2 ( Pt 4):343-57
Several forms of esotropia with a different pathophysiology that meet the criterion of an
onset early in life must be distinguished from essential infantile esotropia. A hypothesis is
presented, according to which a delayed development or a congenital defect of retinal
disparity sensitivity (motor fusion) in an otherwise normal infant with immature sensory
functions causes esotropia under the influence of various strabismogenic factors. Some of
these factors are genetically determined, hence the familial occurrence of essential infantile
esotropia. The absence or marked decrease of stereopsis and the asymmetry of optokinetic
nystagmus are interpreted as the consequence of ocular misalignment early in life rather
than of structural anomalies in the afferent visual pathways of esotropic patients. The
therapeutic results after surgery are classified into four groups: subnormal binocular
vision, microtropia, small angle eso- or exotropia and large angle residual or consecutive
eso- or exodeviations. Analysis of data from 358 operated patients with a documented
onset of esotropia prior to the sixth month of life has shown that the probability of
obtaining an optimal functional result is increased when surgical alignment is completed
before completion of the second year of life. However, surgery after the age of two or even
four years of life does not preclude the development of binocular vision on a subnormal or
anomalous basis

Birch EE, Fawcett S, Stager DR. Why does early surgical

alignment improve stereoacuity outcomes in
infantile esotropia? J AAPOS. 2000 Feb;4(1):10-4.

CONCLUSIONS: The results suggest that early

surgical alignment is associated with better
stereopsis in those patients with infantile esotropia
who were treated during the first 24 months of life,
because early surgery minimizes the duration of
misalignment

Ruiz MF, Alvarez MT, Snchez-Garrido CM, Hernez JM,

Rodrguez JM. Surgery and botulinum toxin in
congenital esotropia. Can J Ophthalmol. 2004 :639-49.

Initial treatment with botulinum toxin, injected into

both medial recti, is effective, reducing the amount
of further horizontal surgery and favouring
postoperative stability, except in children under 18
months, in whom injection of 5 units induces
unbalanced dissociated vertical deviation.

Baggesen K, Arnljot HM. Treatment of

congenital esotropia with botulinum
toxin type A. Acta Ophthalmol. 2009 Oct 30.
Conclusion: Botulinum toxin type A injections into
the medial recti muscles are a valuable alternative
to conventional strabismus surgery.

Rowe F, Noonan C. Complications of botulinum toxin a

and their adverse effects. Strabismus. 2009 OcDc;17(4):139-42
A low incidence of complications per injection (12.4%) was
found particularly for induced vertical deviations (2%) and
hemorrhages (1%). Incidence for ptosis was the highest
(8.4%). Notably, 10 additional cases of ptosis had resolved
before follow-up. Two children were given occlusion
therapy to prevent the possibility of stimulus deprivation
occlusion until ptosis resolution.

Martn Gallegos-Duarte. Estigma y origen de la endotropa

congnita. Rev Mex Oftalmol; En-Feb 2005; 79(1): 10-16
Objetivo: Determinar los elementos nosolgicos bsicos que permiten
conocer, de manera precisa, que una endotropa es de origen congnito
independientemente de la edad en que se presente o se diagnostique, y
cmo es que interactan estoselementos para comprender mejor la
gnesis de la endotropa congnita (EC).
Material y mtodos: Estudio prospectivo, longitudinal, observacional y
descriptivo de pacientes con EC, a quienes se les realiz historia
estrabolgica completa. Se analiz el estado sensorial, refractivo y motor:
versin horizontal y vertical, hiper e hipofunciones, refraccin,
movimientos disociados, tipo de nistagmo, tortcolis, capacidad visual,
pruebas de fusin, deteccin y medicin del grado de ambliopa.

Resultados: Se analizaron 65 pacientes con EC, en

quienes se identificaron y analizaron los cuatro
elementos clnicos ms caractersticos para determinar
el origen congnito de una endotropa: Limitacin de la
abduccin (LABD) en 95.4%, incomitancia horizontal
(IH) en 67.7%, desviacin vertical disociada (DVD) en
66.15% y nistagmo latente (NL) en 60%.
Conclusiones: Se demuestra la certitud diagnstica de
EC a partir de la correlacin de cuatro elementos
clnicos bsicos que determinan el estigma congnito
independientemente de la edad del paciente.