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A. J. Hamilton
HISTORY OF AV PATTERN
STRABISMUS
• Originally described as “an abnormal variation in the angle of horizontal strabismus in
vertical gaze” by Alexander Duane in 1897.
• Later labelled as “Horizontal strabismus with associated vertical elements” from 1896-1956.
• First official series of papers with emphasis on the measurement of horizontal deviation in
vertical gaze was penned by Uretts-Zavalia in 1948, in his papers “Abducción en la elevación”
and “Paralisis bilateral congenita del musculo oblicuo inferior”. Attention was also made to
the point that overaction and subsequently underaction of the oblique muscles were in fact
associated with increased and decreased convergence or divergence.
• By the late 1950’s, the syndrome was officially given the title of ‘A’ or ‘V’ Pattern strabismus,
by Dr. D. G. Albert and F. D. Costenbader in 1955 and 1957 respectively, owing to both ‘A’ and
‘V’ patterns being the most commonly noticed forms. The name was then shortened to ‘A-V
Pattern Strabismus’ as it stands today.
• The syndrome as a whole falls under the Strabismus sub-group of ‘Complex strabismus’ or
‘comitant horizontal/vertical deviations in Strabismus’
INCIDENCE OF AV PATTERN STRABISMUS
• 15-25% of cases of pediatric strabismus occur with A/V Pattern Strabismus as a subsidiary symptom
associated with most common forms of Strabismus: Brown’s Syndrome, Duane’s retraction Syndrome, or
any association with any form of over/underaction of the Superior/Inferior obliques
• A/V Pattern Strabismus is the most common form of Infantile Strabismus.
• While ‘A’ Pattern is perhaps the most common, ‘V’ Pattern in either esotropia or exotropia is quite
prevalent in both pediatric and adult strabismus categories.
• Other rarer forms such as ‘X’ pattern, Lambda pattern, and ‘Y’ pattern strabismus have also been
documented and seen; Lambda pattern being a sub-group of ‘A’ pattern, while ‘Y’ pattern is more closely
associated with ‘V’ pattern. ‘X’ pattern to date remains a group of its own, since so little is still unknown
of this sub-type.
• These special forms of incomitance in vertical gaze consist of nothing more than modifications of the
classic A or V patterns; therefore,they should not be regarded as separate entities.
COMMON FORMS OF AV PATTERN
STRABISMUS
‘A’ PATTERN STRABISMUS
‘A’ PATTERN ESOTROPIA
• An A pattern is present when a horizontal deviation shows a more convergent (less divergent)
alignment in upgaze compared with downgaze.
• An ‘A’ pattern is considered significant if the difference between upgaze and downgaze is ≥10 Δ.
• Patients with ‘A’ pattern esotropia will show on clinical presentation:
• An increase of the esotropia in midline upgazes, and a decrease of the esotropia on
midline downgazes
• The eyes will be mostly straight in Primary gaze and direct downgaze
• Patients will adopt a chin-up head posture to compensate for single binocular vision.
• In cases of an ‘A’ pattern exotropia, the deviation of the eyes is more pronounced as the
eyes move more towards midline downgaze rather than midline upgaze.
• There is an evident divergence of the eyes in direct downgaze, with the eyes ‘splaying
outwards’.
• Like in ‘A’ pattern esotropia, a patient’s eyes in primary and upgaze will often look
straight, and work together closely to normal. ‘A’ pattern exotropia is much more
prevalent in midline downgazes, rather than upgaze. This misalignment is often not
noticed by parent’s whose children have this form of strabismus.
• Similar again to an ‘A’ pattern esotropia, patients will often assume an abnormal head
posture, except that it will be a chin-down, head turn, again allowing the patient to
achieve single binocular vision in primary gaze.
“A” PATTERN EXOTROPIA:
Mongoloid feature
- On upgaze, the eyes
converge inward
- On downgaze, the
eyes diverge outward
‘A’ PATTERN EXOTROPIA
Anti-mongoloid
feature
- Upgaze eyes
diverge outwards
- Primary position
eyes are evidently
esotropic
-Downgaze eyes
converge inwards
‘V’ PATTERN ESOTROPIA
• Patients with ‘X’ pattern often present with a visible exotropia that is only present
or evident in direct upward and downward gaze.
• They often have little to no horizontal deviation on either adduction, or abduction,
with only minimal deviation in primary position.
• Most patients will not adopt an abnormal head posture, but will ‘raise’ or ‘dip’ their
head, depending on which direction they are needing to visualize, be it upgaze or
downgaze, in order to bring both eyes into single binocular vision.
‘X’ PATTERN STRABISMUS
This boy presents with an ‘X’
pattern strabismus, made evident
by that there is a definite
divergence of both eyes, shown by
the hallmark ‘outward splaying’ of
both eyes on both upgaze and
downgaze. This is heightened by
the fact that he ‘dips’ his head
down to bring his eyes “up” on
upgaze, and ‘raises’ his head to
bring his eyes ‘Downwards” on
downgaze. What makes this
pattern difficult to distinguish is
that there is little horizontal
deviation on either adduction or
abduction, and that he doesn’t
adopt any abnormal head posture
in primary.
‘Y’ PATTERN STRABISMUS
• Like ‘X’ pattern, patients with this form of AV pattern strabismus will only display
the deviation of the eye in all gazes above midline gaze.
• There is little to no deviation in either primary position or direct downgaze.
• This pattern is often hard to distinguish from a bilateral Inferior oblique overaction,
but has been documented in the form of ‘Pseudo Y pattern associated with Inferior
Oblique overaction’.
• The most adopted theory as to the cause for a ‘Y’ pattern is an abberant innervation
of the Lateral Rectus in up gaze.
‘Y’ PATTERN ANTI ELEVATION SYNDROME
B
A) This teenage girl shows a pseudo-inferior
oblique overaction with ‘Y’ pattern exotropia. When
viewed in the field of the inferior obliques, it is
indistinguishable from a true inferior oblique
overaction. In primary and midline gazes there is
no overaction of the inferior oblique. B) It is only by
breaking down the frame rate to 0.1 second
intervals from direct adduction to upgaze in
adduction, can one see that there is no ‘outward
splaying” of the eyes until she has reached
maximum elevation in adduction.
GRADING OF OBLIQUE
MUSCLE OVERACTION
• Grading of oblique muscle overaction in practice is more of measuring the amount
by visual interpretation rather than exact science. Most surgeons use a grading
scale of 1+ to 4+ overaction. For inferior oblique grading, 1+ overaction means only
slight overaction or over elevation in adduction. Grade 4+ means the most
overelevation possible. Grades 2+ and 3+ overaction are the two gradations between
those extremes.
GRADING SEVERITY OF OBLIQUE
OVERACTIONS
CAUSES OF AV PATTERN
STRABISMUS
In Strabismic documentation and presentation, there are three main groups of causes
of AV Pattern Strabismus. These are:
This young boy has Crouzon’s disease with an evident ‘V’ pattern associated with a craniofacial
abnormality. Note the ‘upshoot’ and ‘downshoot’ of both eyes as he looks to both his left, in
abduction, and right, in adduction. The arrow mark above his left eye is the surgeon’s mark
indicating a left ‘V’ pattern exotropia.
MANAGEMENT
• Transposition of the inferior recti will expand the closed end of the V pattern by
weakening the adduction vector of the inferior recti in downgaze. Transposing the
SRs nasally will help close the open end of the V pattern in an exotropic patient and
transposing the IRs nasally will help close an A-pattern exotropia.
Male
TRANSPOSITION OF THE RECTI TO CORRECT
AV PATTERN STRABISMUS
•
This boy initially presented with a ‘V’ pattern exotropia which is evident by the exotropia of his left eye in
primary, and the ‘outward splaying’ of both eyes in direct upgaze. In the second 9-nine gaze diagnostic
versions, we see him again following a bilateral lateral rectus recession. Now his eyes are straight in
primary position, and there is no evidence of any horizontal deviation in upgaze.
IN SUMMARY
• Treatment of AV Patterns is relatively summed up in this crucial treatment goal:
Weaken the Overacting oblique muscles to alleviate the horizontal deviation!!!
• IF, there is no oblique dysfunction, treatment can consist of bilateral or unilateral
surgery on transpositioning of the horizontal recti muscles.
• Regarded as the most recognizable form of Infantile strabismus.
• Evidence of any type of horizontal deviation is particularly demonstrated in either direct
upgaze, or direct downgaze.
• ‘A’ & ‘V’ pattern strabismus accounts for 15-25% of most horizontal strabismus anomalies
to date.
REFERENCES
Online references:
• The Strabismus Minute: http://www.cybersight.org
• Strabismus Summary series: http://www.geocities.ws/sapatney/webavst.htm
• McGill University Pediatric & Adult Strabismus:
http://www2.medicine.mcgill.ca/strabismus/atlas/patients/atlasNav/atlas.php
• A Pattern Esotropia & Exotropia/V pattern Esotropia & Exotropia:
https://emedicine.medscape.com/article/1199714-overview
& https://emedicine.medscape.com/article/1199825-overview
• Pattern Strabismus - Grand Round lectures by Dr. Robert O. Hoffman, John A. Moran Eye
care centre, Utah: https://www.youtube.com/watch?v=APjGJ_soPG4
REFERENCES CON’T
Paper references:
• Duane A. Isolated paralysis of the ocular muscles. Arch Ophthalmol,1897; 26: 317–34.
• Albert DG. Personal Communication. In Parks MM. Annual review: Strabismus. Arch
Ophthalmol 1957; 58: 136–60.
• Costenbader FD. The “A” and “V” patterns in strabismus. Trans Am Acad Ophthalmol
Otolaryngol, 1964; 68: 354–86.
• Sharat, S. Parija, S. A-V Pattern Strabismus- A Simplified Approach. Orissa Journal of
Ophthalmol 2010; 40-43.
• Kushner BJ. Pseudo inferior oblique overaction associated with ‘Y’ and ‘V’ patterns.
Ophthalmology 1991; 98: 1500–5.
REFERENCES CON’T
Textbook references:
• Rosenbaum, Arthur L., Santiago, Alvina P. Clinical Strabismus management. Principles and Surgical techniques.,
The Curtis Centre, Philadelphia, Philadelphia, Pennsylvania. W.B. Saunders ,1999.
• von Noorden, Gunter K. MD, Campos, Emilio C. Binocular Vision and Motility – Theory and management of
Strabismus, 6th edition. Baylor College of Medicine, Houston, Texas, Mosby 2002
• Ellis, George S. At the Crossings – Pediatric Ophthalmology and Strabismus, New Orleans Academy of
Ophthalmology, 2004.
• Taylor, David MD, Hoyt, Creig S. Pediatric Ophthalmology and Strabismus 4th edition. Elsevier Saunders 2005
• Coats, David K., Olitsky, Scott E. Strabismus Surgery and it’s complications, Springer 2007
• Kanski, Jack J., Bowling, Brad. Clinical Ophthalmology – A Systematic approach, 7th edition. ExpertConsult,
Elsevier Saunders, 2011
• Kushner, Burton J. Strabismus – Practical pearls you won’t find in Textbooks. Springer 2017.