Accommodative esotropia following surgical treatment of infantile esotropia: frequency and risk factors

Purpose: We aimed to examine the frequency of and risk factors for the development of accommodative esotropia following surgical treatment for infantile esotropia. Methods: A total of 29 children were recruited. Potential risk factors for the development of accommodative esotropia included: sex; angle of deviation at initial and final visits; cycloplegic refractive error at initial and final visits; increase in hyperopia; amblyopia; amblyopia treatment; age at surgical treatment; pre‐ and postoperative latent nystagmus; dissociated vertical deviation or inferior oblique muscle overaction; additional surgical procedures; unstable alignment, and binocular sensory status. Results: Overall, 14 (48.2%) of 29 children developed accommodative esotropia during the 36‐ to 132‐month postoperative follow‐up period. Twelve (85.7%) of the 14 patients developed refractive accommodative esotropia and two developed non‐refractive accommodative esotropia. The onset of accommodative esotropia occurred at a mean of 8.8 months (range 6–24 months) after the initial surgical alignment. This corresponded to a mean age of onset for accommodative esotropia of 43.2 months. We determined that, among children with infantile esotropia, those who had hyperopia of ≥ 3.0 D and increasing hyperopia after surgery and those who did not develop dissociated vertical deviation during the follow‐up period were more likely to develop accommodative esotropia. Conclusions: Children who have the established risk factors should be followed closely for the development of accommodative esotropia. The treatment of these children with appropriate glasses may prevent the development of adverse effects of accommodative esotropia on sensory and motor functions.     

Acute acquired comitant esotropia simulating late onset accommodative esotropia

Acute acquired comitant esotropia in the older child, adolescent, and young adult may represent uncorrected accommodative esotropia. Three young patients developed spontaneous diplopia associated with acute comitant esotropia. In all cases, cycloplegic refraction revealed high uncorrected hyperopia suggesting late onset accommodative esotropia. However, for one patient an intracranial neoplasm precipitated the strabismus and for the other patients the hyperopic correction did not alter the deviation. Clinicians confronted with older children or adolescent patients with acute comitant esotropia associated with large uncorrected hyperopia should not hastily classify the deviation as being accommodative in etiology. Although the latter is possible, the hyperopia may be coincidental and masking an underlying mechanism.     

Follow-up monitoring of accommodative esotropia.

PURPOSE: To ascertain an examination interval that will not increase the risk of untimely detection of decompensation of accommodative esotropia whether or not initial nonoperative treatment must be supplemented. METHODS: The records of 63 patients with accommodative esotropia examined at 3- to 6-month intervals were reviewed for the occurrence of decompensation, changes in refraction, and the need for increased correction of hyperopia or the addition of bifocals. RESULTS: Decompensation, which was not associated with substantial refractive changes toward or away from emmetropia, occurred in 11 patients. No instance of decompensation occurred in the first 12 months of observation. Although 7 of these decompensated patients were among the 18 (28.6%) requiring supplemental nonoperative treatment, their mean annual refractive change did not differ significantly from the 11 patients who did not decompensate. Eight (18.6%) of 43 patients first controlled earlier than age 48 months later decompensated; 3 (15.0%) of 20 patients with later onset reached this outcome. CONCLUSIONS: The monitoring of controlled accommodative esotropia at intervals of 9 to 12 months is adequate for most patients, at least over the first 2 years, with the exception of those requiring treatment for associated conditions such as amblyopia. Refractive error changes and the need for supplemental treatment after initial control are not prominently associated with decompensation. Age of onset of accommodative esotropia earlier or later than 48 months did not influence rapidity of decompensation.     

Clinical features predictive of successfully weaning from spectacles those children with accommodative esotropia.

PURPOSE: It has been reported that most children with accommodative esotropia are not able to discontinue spectacle wear as they become older. We conducted a prospective study to determine which factors are predictive of successfully weaning children from spectacles. METHODS: Beginning in 1995, children with fully accommodative esotropia with a baseline refractive error of + 1.50 to + 5.00 diopters (D) were gradually weaned from their hyperopic correction. Patients with amblyopia or who had previously undergone strabismus surgery were excluded. Children were weaned in 0.50 D increments until spectacles were discontinued or they developed esotropia, asthenopia, or decreased vision. A multivariate analysis was performed to assess the association between successful weaning and various clinical characteristics. RESULTS: Twelve of 20 children (60%) were successfully weaned from spectacles. Spectacles were prescribed at a mean age of 4.2 +/- 1.5 years, and weaning was initiated at a mean age of 8.0 +/- 1.1 years. The spherical equivalent of the least hyperopic eye when spectacles were prescribed was 2.99 +/- 1.06 D. The clinical characteristic most clearly associated with successful weaning was the refractive error at the time glasses were prescribed. Whereas 10 of 11 (91%) patients with < 3 D of hyperopia were weaned from spectacles, only 2 of 9 (22%) patients with 3 to 5 D of hyperopia were successfully weaned from their spectacles (P =.005). CONCLUSIONS: Many children with fully accommodative esotropia can be weaned out of spectacles during the grade school years. The degree of baseline hyperopia appears to be one of the best predictors of success.     

Update on accommodative esotropia

PURPOSE: The aim of this study was to present an update on accommodative esotropia. METHODS: The diagnosis, clinical features, etiology, treatment, prognosis, and clinical course for the 3 types of accommodative esotropia are presented. RESULTS: Accommodative esotropia is the most common pediatric strabismus and must be differentiated from other pediatric esotropias. Although its average age of onset is 2.5 years, it can begin during the first year of life and is seen rarely in older children and teenagers. Refractive accommodative esotropia and nonrefractive accommodative esotropia have a better prognosis for achieving normal binocular vision and high-grade stereopsis with appropriate and timely treatment than partly accommodative esotropia. Children with successfully treated accommodative esotropia need to be followed up with to prevent possible deterioration and development of a superimposed nonaccommodative esotropia, which in some cases may require extraocular muscle surgery. Emmetropization and spontaneous resolution of the esotropia occur rarely and may take many years. CONCLUSION: Approximately 50% of all pediatric esotropias are either entirely or partly accommodative. Proper care is long term and includes monitoring the refractive error and binocular vision status over the years.     

Risk factors for accommodative esotropia among hypermetropic children

PURPOSE: Identification of risk factors for accommodative esotropia may help to determine which children with hyperopia may benefit from early spectacle correction or preventive therapy. METHODS: Participants in the family history study were 95 consecutive patients, aged 18 to 60 months, with accommodative esotropia. Participants in the binocular sensory function study were a subgroup of 41 children enrolled in the family history study within 1 month of onset, while the esodeviation was still intermittent. Participants in the hypermetropia study were 345 consecutive patients, ages 12 months to 8 years, with refractive error of +2.00 D or greater and no esodeviation before age 12 months. RESULTS: In the family history study, 23% of children with accommodative esotropia had an affected first-degree relative, and 91% had at least one affected relative. In the binocular sensory function study, random-dot stereoacuity was abnormal in 41% of children, whereas an abnormal motion VEP, Worth 4-dot, or positive 4-PD base-out prism responses were present in 4% or less of the children. In the hypermetropia study, patients with a mean spherical equivalent of < +3.00 D and significant anisometropia had a 7.8-fold increased risk for accommodative esotropia over nonanisometropic patients. CONCLUSIONS: A positive family history, subnormal random-dot stereopsis, and hypermetropic anisometropia each pose a significant risk for the development of accommodative esotropia. Assessment of these risk factors in conjunction with refractive screening should help to identify those children who are most likely to benefit from early spectacle correction or preventive treatment.     

Outcome in refractive accommodative esotropia

AIM: To examine outcome among children with refractive accommodative esotropia. METHODS: Children with accommodative esotropia associated with hyperopia were included in the study. The features studied were ocular alignment, amblyopia, and the response to treatment, binocular single vision, requirement for surgery, and the change in refraction with age. RESULTS: 103 children with refractive accommodative esotropia were identified. Mean follow up was 4.5 years (range 2-9.5 years). 41 children (39.8%) were fully accommodative (no manifest deviation with full hyperopic correction). The remaining 62 children (60.2%) were partially accommodative. At presentation 61.2% of children were amblyopic in one eye decreasing to 15.5% at the most recent examination. Stereopsis was demonstrated in 89.3% of children at the most recent examination. Mean cycloplegic refraction (dioptres, spherical equivalent) remained stable throughout the follow up period. The mean change in refraction per year was 0.005 dioptres (D) in right eyes (95% CL -0. 0098 to 0.02) and 0.001 D in left eyes (95% CL -0.018 to 0.021). No patients were able to discard their glasses and maintain alignment. CONCLUSIONS: Most children with refractive accommodative esotropia have an excellent outcome in terms of visual acuity and binocular single vision. Current management strategies for this condition result in a marked reduction in the prevalence of amblyopia compared with the prevalence at presentation. The degree of hyperopia, however, remains unchanged with poor prospects for discontinuing glasses wear. The possibility that long term full time glasses wear impedes emmetropisation must be considered. It is also conceivable, however, that these children may behave differently with normal and be predestined to remain hyperopic.     

Risk factors for the development of accommodative esotropia following treatment for infantile esotropia.

PURPOSE: One aim of the study was to determine whether accommodative esotropia after surgical alignment in infantile esotropia occurs because a pre-existing accommodative component is unmasked at the time of surgery or whether it occurs as a sequela of infantile esotropia. A second aim of the present study was to examine risk factors for accommodative esotropia after surgery for infantile esotropia. METHODS: A total of 80 consecutive patients who were enrolled in a prospective study of infantile esotropia had been followed for more than 4 years and had achieved orthoposition were included. Twelve potential risk factors were examined: age at onset, initial esodeviation, initial refractive error, age at alignment, delay in alignment, presurgical glasses, amblyopia, additional surgical procedures, unstable alignment, increase in hypermetropia, peripheral fusion, and stereopsis. Mantel-Haenszel odds ratios were computed for each factor and were corrected to relative risks. RESULTS: Overall, 48 of 80 children (60%) developed accommodative esotropia at a mean age of 33 months. Increasing hypermetropia, delay in alignment, and poor stereopsis posed significant risks for accommodative esotropia. The remaining 9 factors were not associated with increased risk for accommodative esotropia. CONCLUSIONS: Accommodative esotropia is unlikely to be a pre-existing condition in most cases because the mean age of onset was 23 months postoperative and the prevalence of preoperative hypermetropia greater than +3.00 D was low. Both delay in alignment and stereopsis risk factors may reflect compromised binocular sensory status that allows accommodative esotropia to occur at low to moderate levels of hypermetropia. Identification of children treated for infantile esotropia who are at risk for accommodative esotropia may allow for prevention or early treatment.     

Treatment outcomes in refractive accommodative esotropia.

PURPOSE: To document and compare the clinical features and functional outcomes in patients with accommodative esotropia. To assess the efficacy of conventional management of accommodative esotropia, to determine functional outcomes of amblyopia and binocular vision, and to analyze possible risk factors involving the development of amblyopia. METHODS: We retrospectively reviewed the charts of 147 patients whose esotropia was corrected to within 10 prism diopters of orthotropia at both distance and near with use of full cycloplegic hyperopic correction. Multiple parameters were reviewed, including initial and final cycloplegic refraction, distance, and near deviation with and without glasses, stereoacuity, age of onset, and initiation of treatment, presence of anisometropia, and change in hyperopia. RESULTS: At presentation, 87 (59.2%) of the 147 patients were amblyopic, and anisometropia was found to be the only statistically significant risk factor for this (P = .001). Only 24.2% of these patients have stereo acuity between 40 and 100 sec/arc, 20.96% of patients have 200 to 800 sec/arc, and 22.58% of patients have 1980 to 3000 sec/arc; the remaining 32.26% had no stereo acuity. Fusion was achieved in 73.5% of the patients and later presentation (> 24 months) of esodeviation significantly determined their fusional ability (P = .031). Consecutive exotropia developed in 5.4 % of the patients an average of 5.5 years after institution of full optical correction. For clinical and functional outcomes we did not find any statistically significant difference between early onset (before 1 year old) and typical onset (2 to 3 years) age groups. The trend towards decreasing hyperopia was apparent, averaging -0.16 +/- 0.20 diopters annually in 80.5% of the patients with at least 5 years follow-up, although 23% of patients still had 20/40 or worse visual acuity in the amblyopic eye. CONCLUSIONS: Amblyopia is a commonly associated finding at presentation for patients with accommodative esotropia. Most of the patients developed good fusion but poor stereopsis at the end of treatment.     

Photorefractive keratectomy for the treatment of purely refractive accommodative esotropia

PURPOSE: To evaluate the results of photorefractive keratectomy (PRK) for the treatment of young adult patients with purely refractive accommodative esotropia. SETTING: Private practice and university hospital, Milan, Italy. METHODS: The medical records of consecutive patients who had PRK for hyperopia associated with purely refractive esotropia were reviewed retrospectively. Preoperative and postoperative visual acuity, alignment, and sensory data were recorded and analyzed. Surgical methods and complications were reviewed. RESULTS: Sixteen eyes of 8 patients were treated. The mean patient age at the time of treatment was 24.6 years (range 17 to 38 years). All patients were followed for 1 year. At the 1-year follow-up evaluation, the uncorrected visual acuity was 20/40 or better in all eyes. No patient lost a line of best spectacle-corrected visual acuity. The mean spherical equivalent was -3.7 diopters (D) preoperatively and -0.7 D postoperatively. All patients were within +/-0.37 D of emmetropia at the 1-year evaluation. Preoperatively, the mean esotropic deviation was 10.75 prism diopters. Postoperatively, all patients were orthophoric without correction. Stereopsis was unaffected by PRK in all patients. There were no intraoperative or postoperative complications. CONCLUSION: Photorefractive keratectomy was an effective treatment for esotropia associated with mild to moderate hyperopia in young adults with purely refractive accommodative esotropia. These findings should not be widely applied to children with accommodative esotropia.     

儿童部分调节性内斜视的手术矫正与立体视觉

为探讨儿童部分调节性内斜视的手术时机，观察了７８例儿童部分调节性内斜视矫正术后的立体视恢复情况；分析各种因素对其立体视恢复的影响。结果：７８例中，５５例术后获得立体视，功能治愈率为７０．５％，且术后立体视的恢复率与术前相比，差异非常显著（ｐ＜０．０１）；早期手术组及具有融合功能组的立体视的恢复率显著高于较晚手术组及无融合功能组（ｐ＜０．０１）；发病越早，术后建立立体视的预后越差。结论：儿童部分调节性内斜视与部分调节因素有关，其由于解剖因素所引起的斜视需手术矫治。从立体视恢复上考虑，当患儿全矫配镜半年眼位仍不能正位时，应尽早手术矫正其残存的内斜度。术中应根据戴全矫眼镜后的眼位决定手术量。术后由于调节因素所致的内斜视仍需配镜矫正。     

间歇性外斜视合并调节性内斜视：附8例报告

本文对我院3年2158例初诊斜视者中遇到的8例间歇性外斜视合并调节性内斜视进行分析讨论.归纳本型斜视病人的临床特征为:(1)发病年龄较早.(2)先发现内斜视.(3)患者常有中或高度远视(6/8).(4)AC/A 比率正常或偏低.(5)其斜视度变化大,外科30～15°(?)正位(?)内科15～30°.(6)内斜视可戴镜矫正.3例患者做了视觉电生理的眼球运动检查,但没获规律性的结果.最后讨论了本病的发病情况(0.4%,8/2158)和治疗问题.     

儿童部分调节性内斜视的手术探讨

目的探讨儿童部分调节性内斜视的手术时机，手术量。方法对35例部分词节性内斜视的患儿戴全矫眼镜半年以后，手术矫治与调节因素无关的非调节因素所致的内斜视。手术量按裸眼和戴镜后斜视度的平均值设计。结果35例中．眼位矫正满意32例占91．43％，良好3例占8．57％；功能治愈有立体视19例占54．29％。结论儿童部分调节性内斜视，其由解剖因素所致的斜视需手术矫正。当患儿戴全矫眼镜半年眼位仍不能恢复正位时，可尽早手术矫治其残存的内斜度，手术量按裸眼与戴镜平均斜视度设计，术后由于调节因素所致内斜仍需配镜矫正。     

Childhood esotropia

PURPOSE: To review the most recent studies on childhood esotropia, and to summarize recent changes in treatment approach. RECENT FINDINGS: Constant, large-angle esotropia present in the first few months of life may be suitable for early surgery. Earlier surgical intervention, within the first several months of onset, is associated with better sensory outcomes. Similar findings are true for accommodative esotropia; children treated within the first 4 months of constant esotropia have better outcomes. Refractive surgery has been used successfully in adult patients to treat accommodative esotropia. SUMMARY: New developments pertaining to infantile esotropia have helped clarify the pathophysiology of the condition and the best treatment approaches. Abnormal binocular visual input early in life contributes to poor outcomes in both infantile and accommodative esotropia.     

Spasm of the near reflex mimicking deteriorating accommodative esotropia.

PURPOSE: To describe a patient with accommodative esotropia who developed spasm of the near reflex. CASE REPORT: A 6-year-old girl with a history of successfully treated refractive, accommodative esotropia suddenly developed spasm of the near reflex after the death of a relative. The condition resolved after 2 months. CONCLUSION: Spasm of the near reflex should be considered in children with accommodative esotropia who seem to deteriorate and become esotropic once again while wearing their hyperopic glasses.     

Early-onset refractive accommodative esotropia.

INTRODUCTION: We studied the natural history of pure refractive accommodative esotropia after spectacle correction in patients with onset before 1 year old to determine whether their outcomes and characteristics were different from those of patients with more typical age at onset of refractive accommodative esotropia. METHODS: We retrospectively reviewed the charts of 17 children with onset of refractive accommodative esotropia before 1 year old. Records of 26 children with onset after 2 years old were reviewed as controls. RESULTS: The mean ages at diagnosis were 9 months and 48 months for the study and control groups, respectively. All 17 study patients and all 26 control patients were initially well aligned with spectacles at distance and near. Follow-up averaged 34 months for study patients and 41 months for control patients. Three study patients (17.6%) and 1 control patient (3.8%) had eventual deterioration and required strabismus surgery (P = .28). None of the study patients developed amblyopia, whereas 42% of control patients did (P = .001). Seven of 15 (47%) of the study patients with known birth history were born prematurely, whereas only 3 of 24 (12%) control patients were born prematurely (P = .03). CONCLUSIONS: Refractive accommodative esotropia was diagnosed at as early as and age 4 months. Prematurity appeared to be a risk factor. Amblyopia was not detected in any patient with early-onset refractive accommodative esotropia. Treatment with full hyperopic spectacle correction led to long-term stable alignment, with relatively few patients requiring 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.     

Factors influencing stereoacuity in accommodative esotropia.

PURPOSE: Despite successful optical realignment, many children with accommodative esotropia (ET) have abnormal stereoacuity. In a prospective study, we examined the influence of age of onset, age at alignment, duration of constant misalignment, and accommodative convergence/accommodation ratio on random dot stereoacuity outcomes in accommodative ET. METHODS: Participants were 111 consecutive children with accommodative ET. Random dot stereoacuity was measured using the Randot preschool stereoacuity test, the Randot stereoacuity test, the infant random dot stereoacuity cards, and the Lang 1. RESULTS: Age of onset has only a minor influence on stereoacuity (P <.02); children with onset >/=age 25 months have better stereoacuity compared with children with an onset between ages 7 and 17 months. Age at alignment has a minor influence on stereoacuity (P <.001); children with intermittent ET who have been treated have better stereoacuity than children with a constant ET aligned between ages 6 and 24 months and after age 24 months. Duration of constant misalignment has the strongest influence on stereoacuity (P <.001); children who had intermittent misalignment or who had a constant misalignment of less than 4 months' duration have better stereoacuity than patients who had a constant misalignment greater than 4 months' duration. The accommodative convergence/accommodation ratio does not influence stereoacuity outcomes (P >.10). CONCLUSIONS: Fine random dot stereoacuity is associated with a constant misalignment of less than 4 months' duration. These findings promote prompt and aggressive treatment of accommodative ET at the onset of intermittent or constant misalignment.     

Clinical evaluation of cessation of hyperopia in 123 children with accommodative esotropia treated with glasses for best corrected vision

Purpose: This study aimed to determine age at successful cessation of hyperopic glasses, the influence of hyperopia on the esotropic angle and age at discontinuation of glasses in accommodative esotropia (AE) patients. Methods: We performed a retrospective study in 123 AE patients who achieved complete emmetropization and maintained orthophoria without hyperopic glasses between March 1999 and February 2005. All patients had been prescribed the weakest possible glasses to provide best corrected vision and maintain fusion in hyperopia. Results: Pure AE was found in 64 patients and partial AE in 59. At the initial visit, 56.1% of patients had refractive errors of 3.00?5.00 D (mean cycloplegic spherical equivalent [SE]). The angle of esotropia without correction was 30.90 ± 14.80 prism dioptres (PD) (mean ± standard deviation) in pure AE, and 42.70 ± 15.19 PD in partial AE (p = 0.000). The non‐accommodative component in partial AE was 24.07 ± 14.90 PD. The mean age at cessation of glasses use was 13.50 ± 3.81 years. Stereopsis was noted in 70.2% of patients at the initial visit and 96.4% at the last visit. Pearson’s correlation coefficients (r) were 0.480 between the degree of hyperopia and amount of optically corrected esotropia (p = 0.000), and 0.434 between the degree of hyperopia and age at successful cessation of corrective glasses use (p = 0.000). Conclusions: The mean age at resolution of hyperopia with good stereopsis was 13.5 years. The degree of hyperopia seemed to correlate with the angle of esotropia and the age of successful cessation of corrective glasses.     

Unusual Presentation of Spasm of Near Reflex Mimicking Large-Angle Acute Acquired Comitant Esotropia

We report the case of an 11-year-old boy who presented with sudden esotropia, binocular diplopia, and blurred vision. The patient was neurologically normal. He had a large, constant, comitant, alternating esotropia associated with minimal accommodative spasm. Ocular motility and pupillary reactions were normal. He was diagnosed to have spasm of the near reflex presenting as acute onset of esotropia. The esotropia was persistent despite treatment and eventually resolved with prolonged cycloplegic therapy. This unusual case illustrates that spasm of the near reflex can have unique and variable presentations. Spasm of the near reflex needs to be considered in the differential diagnosis of every case of acute, acquired, comitant esotropia. This is the first case of spasm of the near reflex where persistent esotropia is reported in the absence of any neurological disorder.