基于Base-out恢复点为目标手术量的急性共同性内斜视手术效果

目的:探讨以Base-out恢复点为目标手术量的急性共同性内斜视(acute acquired comitant esotropia,AACE)的治疗效果。方法:随诊以Base-out恢复点为目标手术量、且术后随访时间超过4个月的AACE患者,分析术前及末次随诊时斜视度、双眼视功能参数及术后立体视恢复的影响因素。结果:将43例患者纳入研究,其中男27例(63%),女16例(37%),手术年龄9~53(23.7±11.4)岁,术前斜视持续时间3个月~11年(24.8±24.5个月),术后随访4~62(15.8±14.5)个月。术前Base-out恢复点比斜视度更大[远距差值(9.3±6.9)PD,P<0.001;近距差值(11.4±6.7)PD,P<0.001];术前视远和视近斜视度分别为(38.4±13.2)PD和(37.6±13.7)PD,末次随诊时视远和视近斜视度分别为(0.74±2.4)PD和(0.70±2.4)PD(均P<0.001),38例(88%)患者无眼位偏斜,5例(12%)有轻微内隐斜视。末次随诊时视远和视近立体视锐度显著改善(P<0.001),末次立体视功能与术前近距立体视水平和术前斜视持续时间相关。结论:以Base-out恢复点为目标手术量的AACE手术能取得较好的矫正效果,未见眼位过矫者;术后立体视恢复与术前近距立体视和术前斜视持续时间相关,提示适当早期手术可能有助于术后立体视功能的恢复。     

Age-related distance esotropia.

PURPOSE: To describe a form of acquired esotropia occurring in older adults, which here is termed age-related distance esotropia. METHODS: A retrospective consecutive case series of 26 patients with this condition was reviewed. RESULTS: The patients ranged in age from 62 to 91 years old with a median age of 77 years. The distance deviation varied from 4 prism diopters (PD) ET (esotropia) to 20 PD ET, with a median angle of 9 PD ET. At near fixation, the measurements ranged from 9 PD ET' to 10 PD X' (exophoria), with a median deviation of 3 PD ET'. Ductions and versions were full, with no evidence of lateral rectus paresis. None of these patients had an obvious underlying neurologic disorder, such as tumor or stroke. Treatment consisted of prescribing the minimum prismatic correction that eliminated distance diplopia, which was then incorporated into the patients' current spectacles. This treatment successfully eliminated the symptoms in all patients. No patient in this study required surgery. CONCLUSION: A distinctive form of strabismus occurs in older adults that is characterized by esotropia greater at distance than near fixation. The etiology of this disorder is unknown, but it is likely secondary to anatomical changes in the orbit and/or muscles associated with aging. Most patients are readily corrected by prisms but, surgical correction might be required in some cases.     

Preoperative prism adaptation for acquired esotropia: long-term results.

PURPOSE: The efficacy of preoperative prism adaptation in subjects with acquired esotropia has been established at 6 and 12 months postoperatively. We evaluated the outcomes of subjects with acquired esotropia who had preoperative prism adaptation and were followed longer than 12 months. METHODS: A retrospective analysis was undertaken of 2 groups of subjects with acquired esotropia who underwent bilateral medial rectus recessions based on the distance angle of deviation and were followed more than 12 months postoperatively. Group A subjects had preoperative prism adaptation to determine the target angle for corrective surgery. In Group B subjects, surgery was based on the maximum angle of strabismus at distance, determined by alternate prism cover test without preoperative prism adaptation. RESULTS: We compared 17 subjects in Group A and 19 subjects in Group B. The postoperative follow-up period was 3 +/- 1.7 years in Group A and 4.8 +/- 1.8 years in Group B. The age at the last visit was 9.1 +/- 2 years in Group A and 10 +/- 2 years in Group B. Postoperative residual esotropia was 2.6 +/- 2.5 PD at distance in Group A patients and 6.6 +/- 5.9 PD in group B patients (P =.002). Residual esotropia at near was 3 +/- 3.8 PD in Group A and 11.5 +/- 8.12 PD in Group B (P <.01). More Group B subjects required bifocal spectacles to achieve optimal alignment at near (P =.001). CONCLUSION: Acquired esotropia subjects operated on for their distance prism-adapted angle maintained better motor alignment over a long-term follow-up period when compared with nonprism-adapted subjects operated on for their distance angle.     

Botulinum treatment of childhood strabismus

Four hundred thirteen children ranging in age from 2 months to 12 years were treated for strabismus by botulinum injection of extraocular muscles. An average of 1.7 injections per patient was given. Follow-up at an average of 26 months after the last injection (minimum, 6 months) was available on 362 children (88%). The frequency of correction of 10 prism diopters (PD) or less in various groups of strabismus cases was: all 362 cases, 61%; all esotropia, 66%; infantile esotropia, 65%; and exotropia, 45%. Smaller deviations (10-20 PD) were more frequently corrected (73%) than were larger deviations (20-110 PD, 54%). The frequency of correction to 10 PD or less of previously operated cases was not different from that of unoperated cases. There was no globe perforation, amblyopia, or visual loss produced by the injection treatment in this series.     

Comparison of clinical characteristics of familial and sporadic acquired accommodative esotropia.

PURPOSE: To compare the clinical characteristics of patients with familial and nonfamilial acquired accommodative esotropia. METHODS: We recruited 48 patients from 33 families with acquired accommodative esotropia (an inward deviation of the eyes of 10 PD or more, a hypermetropia greater than or equal to +1.50 D, and an onset of esotropia at, or later than, 1 year of age). Our control group consisted of 20 patients with no known family history. Spherical error of refraction, stereoacuity, and need for strabismus surgery were determined and the 2 groups were compared. RESULTS: No statistically significant difference was found between the spherical equivalent error of refraction in familial cases (mean = +4.50 OD, +4.63 OS; range = +1.50 to +10.30 OD, +2.00 to +9.38 OS) versus those with nonfamilial disease (mean = +4.93 OD, +5.02 OS; range = +2.50 to +11.00 OD, +2.50 to +10.90 OS) (P =.47 OD; P =.47 OS). There also was no difference between the percentage of patients with familial disease who had some degree of stereoacuity (58%) and those without a family history (59%) (P > .99). Patients with familial acquired accommodative esotropia did not require more surgical interventions (26%) than those with nonfamilial acquired accommodative esotropia (30%) (P = .79). CONCLUSIONS: The general clinical characteristics of familial and nonfamilial acquired accommodative esotropia are very similar.     

Superior and Lateral Rectus Myopexy for Acquired Adult Distance Esotropia: A “One Size Fits All” Surgery

ABSTRACT

Aim: To evaluate the results of bilateral lateral rectus to superior rectus myopexy for the treatment of acquired adult distance esotropia.

Methods: The charts of all adult patients who were operated for esotropia by the first author at the Department of Ophthalmology, Assaf Harofeh Medical Center, Tel Aviv University, Zrifin, Israel, between the years 2010-2015 were analyzed. Patients with the following inclusion criteria were included: acquired esotropia (not present during childhood); deviation greater for distance than near by at least 4 prism diopters (PD); slight abduction deficit in one or both eyes and/or displacement of the lateral rectus downwards as evident by CT/MRI with or without superior rectus nasal shift and no neurologic abnormalities such as cranial nerve palsies or other.

Results: Eighteen patients were identified (age 31–80 years, mean 49.6 years, 77.7% females). Pre-operative esodeviation averaged 24.3 PD (range 14–35 PD) for distance and 15.7 PD (range 8-25 PD) for near. Thirteen patients (72%) had diplopia. All patients were myopic (average -5.54 diopters, range -2.00 to -13.00). All patients underwent bilateral superior rectus–lateral rectus myopexy. Seven patients needed additional single medial rectus recession of between 2–6 mm, and two had additional inferior rectus recession. After a follow-up period of 3–52 months (average 16 months), 16/18 patients (88%) had a deviation less than 5 PD. No overcorrections were noted.

Conclusion: Lateral to superior rectus myopexy is a safe and effective treatment for patients with distance esotropia in which displacement of these muscles is identified. Additional single medial rectus and/or inferior rectus recession may be needed in some patients.     

Retroequatorial myopexy combined with bimedial recession for near-distance disparity esotropia

Purpose: In cases of esotropia combined with a high AC/A ratio, partly accommodative convergence excess or with nonaccommodative convergence excess, two methods of surgical therapy are possible: recession of the medial recti (Parks) and retroequatorial myopexy (Cüppers). Our aim was to answer the question whether retroequatorial myopexy alone and in combination with bimedial recession are appropriate methods of reducing the strabismic angle at near and distant fixation to values under 10 PD and near-distance disparity to less than 10 PD to form the basis for single binocular vision without bifocals. Patients and methods: Eighty-three patients, aged 2–14 years (39 boys and 44 girls), were included in the study: 37 children (group A) with early-onset near-distance esotropia of 14–48 PD for distance and 26–65 PD for near objects and 46 children (group B) with acquired near-distance esotropia of 8–45 PD for distance and 26–70 PD for near objects. Inclusion criteria were a near-distanced disparity of at least 10 PD (range 10–33 PD), a follow-up of at least 3 months (median 5 months, range 3–69 months), retinoscopy in cycloplegia and full refractive correction. The amount of conventional surgery was chiefly based on the distance angle of esotropia. The myopexy was placed 12, 13 and 14 mm behind the insertion of the medial rectus. Results: In 73 of 83 patients (88 %) we were able to reduce the strabismic angle for distance and near fixation to less than 10 PD and in 73 cases even under 5 PD. In 77 of 83 patients (93 %) the near-distance disparity was reduced to less than 10 PD and in 72 patients (87 %) even under 5 PD. Postoperatively, 9 children had bifocals, but 3 of them have meanwhile discarded them. Two cases were slightly ocvercorrected and 1 case undercorrected. Seventy children (84 %) attained grade of binocularity. Conclusion: Retroequatorial myopexy (fadenoperation) alone and combined with bimedial recession is an effective procedure in treating esotropia with abnormal near-distance disparity.      

Preoperative prism adaptation in acquired esotropia with convergence excess.

PURPOSE: The prism adaptation test (PAT) is used preoperatively to determine the surgical target angle for acquired esotropia. We assessed the surgical outcomes for children with convergence-excess esotropia (near esotropia greater than distance esotropia by 10 prism diopters [PD] or more) whose target angle was based on the results of the PAT geared to the near deviation. METHODS: We reviewed the charts for all of one surgeon's patients who underwent the PAT for near convergence-excess esotropia and who were followed-up for at least 6 months after surgery. Patients who wore prisms were classified as PAT responders (esotropia <= 8 PD at distance and near with four-dot fusion at near) or nonresponders (exotropia at distance or lack of four 4-dot fusion at near). Responders underwent surgery for the adapted angle at near. The nonresponders who had exotropia at distance had surgery for an angle between the near and distance angles. Nonresponders with esotropia angles <= 8 PD at distance and near underwent surgery for the total near deviation. RESULTS: Fifty-four (83%) of the 65 children were PAT responders. Thirty-nine (72%) of the 54 responders and 6 (55%) of 11 nonresponders had excellent results (heterotropia <= 8 PD at distance and near with four-dot fusion at near). All 13 responders whose angles built with prism had excellent results. Among 61 patients who had an esotropia <= 8 PD at near with prisms preoperatively, only 4 (6.6%) developed overcorrections at distance by the latest follow-up examination; 3 were responders and 1 a nonresponder. CONCLUSIONS: PAT for the near deviation in children who have convergence-excess esotropia is a useful test in estimating the target angle for surgery. Responders whose angles built with prism had a particularly high success rate. Surgery geared to the near-adapted angle has a low risk of creating an overcorrection in the distance regardless of the response to PAT.     

Resolution in partially accomodative esotropia during occlusion treatment for amblyopia

PURPOSE: To evaluate alignment changes in partially accommodative esotropia during occlusion treatment for amblyopia. METHOD: Changes at the deviation angles of 63 partially accommodative esotropia patients, who had occlusion treatment for amblyopia, were evaluated retrospectively. RESULTS: Mean deviation angle at the start of therapy without glasses was 45 PD (10-90 PD) and became 27 PD (5-70 PD) after at least 2 months with glasses. During 12 (2-36) months of occlusion period, mean manifest deviation angle with glasses decreased to 11 PD (0-50) (P < 0.001) and amblyopia resolved in 71.5% of the cases. After termination of amblyopia treatment 24 (38%) cases had surgery for the residual deviation but if we had planned surgery before amblyopia treatment, 81% of the patients would have had surgery. DISCUSSION: Should amblyopia be treated initially or should we operate first in patients with strabismus and amblyopia together? Our research suggests that we should not hurry to operate in high hypermetropic partially accommodative cases, which have amblyopia and a long-term history of strabismus. Initial amblyopia treatment in these cases allows time for resolution of the nonaccomodative component in strabismus and can significantly decrease the necessity for surgery.     

Common forms of childhood esotropia

OBJECTIVE: To determine the most common forms of childhood esotropia. DESIGN: Prospective, consecutive, observational case series. PARTICIPANTS: All esotropic children younger than 11 years of age from a predominantly rural Appalachian region evaluated from August 1, 1995 through July 31, 1998. METHODS: Demographic and clinical data were collected for all patients. MAIN OUTCOME MEASURES: The percentage ratio of the various forms of childhood esotropia. RESULTS: Two hundred twenty-one consecutive children without prior surgical treatment were evaluated for esotropia. One hundred seventeen (52.9%) of the 221 children had some form of accommodative esotropia, 38 (17.2%) were associated with congenital or acquired abnormalities of the central nervous system, 23 (10.4%) displayed acquired nonaccommodative esotropia, 15 (6.8%) resulted from ocular sensory defects, 12 (5.4%) had confirmed congenital esotropia, seven (3.2%) had paralytic esotropia, and an unverified age at onset prevented an accurate categorization in the remaining nine (4.1%). CONCLUSIONS: Children with accommodative esotropia accounted for more than half of the study patients and were diagnosed nearly 10 times more frequently than children with congenital esotropia. Esotropic patients with central nervous system defects or with an acquired nonaccommodative deviation were also more common than children with congenital esotropia. Children with congenital esotropia or with a paralytic or sensory cause of their deviation were relatively uncommon.