Infantile Esotropia Research Articles

Ocular findings in syndromic gingival fibromatosis: a case study and electronic microscopic investigation of lens.

We report a case of syndromic gingival fibromatosis with notable ocular lesions, bilateral congenital cataracts, esotropia, and high myopia of a 21-year-old male patient from China. The patient was diagnosed with gingival fibromatosis based on his massive gingival overgrowth and histological findings that were consistent with gingival fibromatosis through a gingival biopsy. Lens opacity features were presented and phacoemulsificaion with intraocular lens(IOL) implantation was performed to manage the cataracts in both eyes. Transmission electronic microscopy was used to investigate the ultrastructure of the removed lens tissue. We also review the literature on gingival fibromatosis and briefly summarize the ocular manifestations of this rare disease.

The relationship of age when motor alignment is achieved and the subsequent development of stereopsis in infantile esotropia

To determine the oldest age beyond which the chance of developing stereopsis is not possible even with excellent motor alignment in patients with infantile esotropia. The medical records of children with infantile esotropia who underwent a single operation and had alignment within 10(Δ) of orthotropia at all follow-up examinations were retrospectively reviewed. Patients were assessed for stereopsis after the age of 48 months. A total of 38 children were included. There was a statistically significant inverse correlation between age at surgery and final stereopsis (r = 0.494, P = 0.002). There was a significant difference at mean age at surgery between patients having stereopsis better than 1000 arcsec and those having no stereopsis (P = 0.002). Post hoc power analysis revealed a value of 85%. Receiver operating characteristic curve analysis revealed that the optimum cut-off value of the age at surgery for predicting stereopsis was 16 months (Youden index = 0.474; area under ROC curve, 0.784; 95% CI: 0.62-0.90; P = 0.0002). Surgery for infantile esotropia is most likely to result in measureable stereopsis if patient age at alignment is not more than 16 months.

Comparative study of Y-split recession versus bilateral medial rectus recession for surgical management of infantile esotropia.

AimThis prospective study compares the results of bilateral medial rectus recession versus (vs) Y-split recession of medial recti techniques for surgical management of essential infantile esotropia.Patients and methodsThirty patients were included in this study and had preoperative infantile esotropia with large angles (ie, >30 prism diopters [PD]). Patients were divided into Group A, which underwent bilateral medial rectus (BMR) recession and Group B, which underwent bilateral Y-split recession of medial recti muscles. All patients were subjected to complete ophthalmologic examination and met the criteria for inclusion in this study. The degrees of BMR recessions performed ranged from 6.0–7.5 mm. All operations were performed under general anesthesia. Follow-up visits were conducted at 1 and 2 weeks, and 1, 3, and 6 months postoperatively. Rates of reoperation for residual esotropia and consecutive exotropia were determined.ResultsThe patients’ preoperative angles of deviation ranged from 30–80 PD. Group A consumed 57% less operative time than Group B. Immediately postoperatively, the Y-splitting technique showed satisfactory results (ie, orthotropic or residual angles ≤15 PD) in 73% of patients vs 67% only for the BMR recession patients. By the end of six months of follow up; 13% of the BMR technique patients vs 27% of the Y-splitting technique patients showed negative change of PD but without reoperation.ConclusionOur results suggest that, although the Y-splitting technique is more difficult and time consuming, both procedures are effective and have shown comparable results for the correction of horizontal deviation ≤70 PD.

Heidelberg Spectralis infrared video imaging: a clinical tool for diagnosing ocular torsional instability

Heidelberg Spectralis infrared video imaging provides a diagnostic modality for the assessment of dynamic torsional instability of the eyes. It accurately detects monocular changes in both vertical and torsional eye position as fixation is switched from one eye to the other without the need for illuminating either eye. Heidelberg Spectralis infrared video imaging is useful for depicting the subtle torsional components of dissociated vertical divergence, latent nystagmus in patients with infantile esotropia.

Medium-Term Outcomes of Three Horizontal Muscle Surgery in Large-Angle Infantile Esotropia

To evaluate the medium-term motor outcomes of three horizontal muscle surgery in patients with large-angle infantile esotropia. The charts of 18 patients with large-angle (> 55 prism diopters [PD]) infantile esotropia who underwent bilateral medial rectus muscle recession and one lateral rectus muscle resection were retrospectively reviewed. Preoperative and postoperative deviations at last examination, overcorrections and undercorrections, necessity of additional horizontal surgery, and follow-up durations were recorded. The median age of patients at surgery was 22 months (range: 10 to 168 months). Orthotropia to within 10 PD or less was achieved in 14 of 18 patients (78%) in a median follow-up of 32 months (range: 5 to 63 months). The mean preoperative deviation of 68.8 ± 9.54 PD decreased to a median of 1 PD (range: esotropia 30 to exophoria 4 PD) postoperatively (P < .005). Marked residual esotropia necessitating additional surgery occurred in 4 patients, but significant overcorrection was not observed. The success rate of the three horizontal muscle surgeries appears to be high enough in medium-term follow-up in patients with large-angle infantile esotropia. Overcorrection that necessitates additional horizontal muscle surgery does not seem to be significant in the medium term, according to this study.

Essential infantile esotropia: postoperative motor outcomes and inferential analysis of strabismus surgery

BackgroundThe aim of this retrospective study is a long-term evaluation of postoperative motor outcomes and the inferential analysis of strabismus surgery in infant eyes with essential infantile esotropia.Methods576 patients were compatible with the criteria: confirmed EIE diagnosis, angle ≥ 30 pD, absence of associated ocular anomalies, onset by 6 months of age, absence of hyperopia > 3 Diopters, operation before age 4. Preoperative deviation classes (30–40 pD, 41–59 pD, ≥ 60 pD) were established, different types of surgery were performed. Follow-up was conducted for 5 years after surgery. Longitudinal data were analyzed using general linear mixed models stratified according to the class of pre-operative deviation. A random intercept and a random slope with time (in months) was assumed with an unstructured within subject correlation structure for repeated measurements.ResultsIn patients with preoperative angle ≤ 40 pD, a significant interaction effect for intervention by time (F5,155.9 = 3.56, p = 0.004) and a significant intervention effect (F5,226.1 = 6.41, p < 0.001) on residual deviation were observed; only the intervention 5 showed a residual deviation inside the limits of a partial success. In Class 41-59, a significant interaction effect for intervention by time (F4,166.7 = 5.16, p = 0.001), intervention (F4,178.1 = 2.48, p = 0.046) and time (F1,174.6 = 9.99, p = 0.002) on residual deviation were observed; intervention 7 had the highest degree of stability showing an outcome within the range of a partial success. In Class ≥ 60 pD no significant effect for intervention (F4,213.9 = 0.74, p = 0.567), time (F1,169.5 = 0.33, p = 0.569) or intervention by time (F4,160.9 = 1.08, p = 0.368) on residual deviation was observed; intervention 3,6 and 7 resulted in a residual deviation within the range of a partial success.ConclusionsWe suggest, where possible, a two-horizontal muscles approach in small angle EIE, while a multiple muscles surgery in large angle EIE.

Modified Inferior Oblique Transposition Considering the Equator for Primary Inferior Oblique Overaction (IOOA) Associated with Dissociated Vertical Deviation (DVD)

Purpose: Inferior oblique anterior transposition (IOAT) should be done only in patients with inferior oblique overaction (IOOA) and dissociated vertical deviation (DVD) without fusional potential because the procedure can cause anti-elevation syndrome. This study reports the results of modified inferior oblique transposition onto the equator in 7 patients diagnosed with infantile exotropia or esotropia associated with IOOA and DVD.Methods: We performed modified inferior oblique (IO) transposition onto or considering the equator on 7 patients who had infantile exotropia or esotropia associated with IOOA and DVD. Five patients had infantile exotropia, and the other two patients had infantile esotropia. Six patients had undergone bilateral rectus -- Bilateral Lateral Rectus (BLR) or Bilateral Medial Rectus (BMR) -- recession previously and one patient underwent BLR recession and IO transposition simultaneously. They had more than +1.5 IOOA with DVD in both eyes. IO was transposed vertically onto the equator in this study. The mean distance between the lateral border of the inferior rectus insertion and the equator was 5.6 mm (range: 4.5 to 6.5 mm). Three months after the operation, degree of IOOA and DVD in each eye was evaluated.Results: IOOA and DVD were markedly reduced in all patients (+0.5 ∼+1 for IOOA postoperatively). Mild contralateral IOOA was noted but the motility disturbance was successfully corrected in all cases postoperatively.Conclusion: Bilateral IO transposition onto the equator could minimize antielevation and corrected IOOA and DVD successfully in patients with infantile exotropia or esotropia.

Prevalence and pattern of strabismus in primary school pupils in benin city, Nigeria

Background: Strabismus is the most common amblyogenic factor and approximately 40% of children with manifest strabismus have amblyopia. In Nigeria, it is generally believed that strabismus is not common. However, few studies have been done to determine the prevalence of strabismus in Benin City, Edo State. Objective: This study aims to determine the prevalence and pattern of tropias and phorias in primary school children in Benin City. Methods: This was a cross-sectional study carried out on primary school pupils in government schools located within Egor Local Government Council Area, Edo State. Results: Two thousand one hundred and thirty-nine students (2139) were examined. There were 1024 males (47.87%) and 1115 females (52.13%). The overall prevalence of tropias in this study was 0.89%. Esotropia was seen in 0.56% (12 pupils, SE 0.03%) and exotropia in 0.33% (7 pupils, SE 0.02%) of the pupils. Infantile esotropia was the most common form of esotropia while alternating exotropia was the most common pattern of exotropia. 57.04% of the pupils had heterophoria. Conclusion: The prevalence of manifest strabismus in Benin City was low however there should be training of non-ophthalmic staff such as teachers to detect and refer cases of strabismus.

Persistent Binocular Diplopia in Childhood Following Successful Treatment for Esotropia: A Case Series

IntroductionDiplopia is rare in children with nonpathological esotropia because facultative suppression develops prior to visual maturation. Our aim is to present five cases of children with binocular diplopia following treatment of childhood esotropia, exploring possible mechanisms for the development of diplopia based upon the patient's history and findings, and discussing treatment for diplopia in this setting.MethodsA retrospective chart review of five sequential patients presenting with binocular diplopia following treatment of esotropia was performed. Treatment of esotropia included correction of hyperopic error, correction of anisometropic amblyopia to 20/30 or better, and strabismus surgery as indicated.ResultsDiplopia developed in two children with accommodative esotropia, one child with infantile esotropia and partially accommodative esotropia, and two children with a history of infantile esotropia and consecutive exotropia following surgical correction. Diplopia onset occurred between ages 7 and 11. Four of the five children experienced resolution of diplopia with prism glasses.ConclusionChildren with esotropia before visual maturation may develop persistent diplopia. Clinical features of the children with diplopia in our case series include poor fusion, poor stereopsis, consecutive exotropia, refractive changes, onset of diplopia after 7 years of age, and occlusion therapy for amblyopia. Prisms may be beneficial in controlling the diplopia.

What to Predict Favorable Long-Term Sensory Outcome after Surgery for Infantile Esotropia?

What to Predict Favorable Long-Term Sensory Outcome after Surgery for Infantile Esotropia?

Does dominance of crossing retinal ganglion cells make the eyes cross? The temporal retina in the origin of infantile esotropia – a neuroanatomical and evolutionary analysis.

A closer look at the evolution of the eye and the brain provides a possible explanation for both the origin of infantile esotropia and its motor characteristics. In the course of evolution, the eyes have moved from a lateral to a frontal position. Consequently, the monocular visual fields started to overlap resulting in a binocular visual field. In lateral-eyed animals, the retinae project to the contralateral visual cortices only. These projections are also found in binocular mammals and birds with binocular visual fields but in addition there are uncrossed projections from the temporal retinae to the visual cortex. The partial chiasmal decussation and the corpus callosum provide the necessary structure that allows binocular vision to develop. Disruption of normal binocular development causes a loss of binocularity in the primary visual cortex and beyond. Beyond the primary visual cortex, the contralateral eye dominates while the temporal retinal signal appears to lose influence. Loss or absence of binocular vision in infantile esotropia may be caused by inadequate retinotopic matching between the nasal and temporal retinal signals like in albinism with an abnormal or asymmetric chiasmal decussation or agenesis of the corpus callosum. Dominance of the crossing retinal signal might also explain the motor characteristics of infantile esotropia (asymmetric OKN, latent nystagmus, DVD). A normal binocular cortical signal will predominate over the evolutionary older, originally non-binocular, retinal projections to the superior colliculi (CS) and the accessory optic system (AOS). A suppressed temporal retinal signal paves the way for the re-emergence of eye movements driven by one eye, as in lateral-eyed non-binocular animals.

Applicability of scanning laser ophthalmoscopy microperimetry on the fixation patterns of monofixation syndrome

ObjectiveTo investigate the monocular fixation pattern and characteristics in patients with monofixation syndrome using scanning laser ophthalmoscopy (SLO) microperimetry (MP). MethodsTwenty-four patients older than 5 years who had 8 prism diopters (PD) or less of deviation after surgery were analyzed. The A group included 14 patients with infantile esotropia (ET), and 10 patients with acquired ET were assigned to B group. The monocular fixation pattern and characteristics of all patients were investigated using SLO MP. Central or mild eccentric fixation was defined as eyes with more than 50% of the fixation points located within the 2° diameter circle centred on the fovea. ResultsMean ages at the time of surgery were 27 (range, 11–48) months in A group and 75 (range, 27–166) months in B group. Mean ages at the time of MP examination were 117 (range, 64–210) months in A group and 106 (range, 64–167) months in B group. Mean distant and near angles of esodeviation were −1.7 PD (–8 to 8) and −2.7 PD (–8 to 6) in A group and 0.6 PD (–2 to 8) and –0.4 PD (–2 to 0) in B group. Central or mild eccentric fixation was present in 8 patients (57%) and moderate or severe eccentric fixation in 6 patients (43%) in A group. In contrast, all patients in B group had central or mild eccentric fixation (p = 0.022). ConclusionsPostoperative moderate eccentric or severe eccentric fixations were observed in 43% of patients with infantile ET in either eye; however, all patients with acquired ET showed central or mild eccentric fixation in both eyes.

Assessment of Cortical Dysfunction in Infantile Esotropia Using fMRI

Functional magnetic resonance imaging (fMRI) is popular in the field of neuroimaging. The aim of this study was to explore the neural basis of infantile esotropia and locate the cortical region of fusion function defects using blood oxygen level-dependent fMRI (BOLD-fMRI). Subjects (5 with infantile esotropia and 8 normal) were presented with a visual stimulus (letter E). The BOLD-fMRI was used to measure the visual cortex response as the distance between the E and the eyes changing from 20 to 100 cm using a block experimental design. Data were processed offline using statistical parametric mapping and compared between the 2 groups. Areas activated in the visual cortex of normal subjects were located in the bilateral frontal gyrus and left lingual visual cortex (p<0.001). The BOLD signal in the left cingulate gyrus, bilateral precuneus, and left angular gyrus was higher in the infantile esotropia group than in the controls (p<0.001). None of the visual cortical areas showed higher signal in the control individuals than in those with infantile esotropia (p<0.001). The bilateral frontal gyrus and left lingual visual cortex regulate normal fusion function in human eyes. In infantile esotropia, the left cingulate gyrus, bilateral precuneus, and left angular gyrus visual cortex may compensate for the fusion dysfunction. These insights may help improve the diagnosis and treatment of strabismus.

The advancement of the medial rectus muscle for consecutive exotropia

ObjectiveTo characterize the dose effect of the advancement of the medial rectus muscle (MR) for consecutive exotropia (XT) after corrective surgery for infantile esotropia (ET) and provide a guide for achieving orthotropia. DesignRetrospective cohort study. ParticipantsSeventy-seven patients with consecutive XT that developed after surgery for infantile ET. MethodsAll patients underwent advancement of the unilateral or bilateral MR and were followed up for at least 1 year. The angle of deviation and stereopsis were retrospectively reviewed from patient records. ResultsAt the time of surgery for infantile ET, the mean eso-angle was 52.2 ± 13.10 prism diopters (PD; mean age, 28.5 ± 16.97 months). The exo-angle of consecutive XT was 25.6 ± 8.47 PD (mean age at surgery, 132.7 ± 82.32 months). The mean deviation was 1.8 ± 10.40 PD XT at the final follow-up (47.0 ± 43.57 months). The corrective effect of the exo-angle for a 1-mm advancement of the MR was 3.1 PD at 1 year after surgery and 2.9 PD at the last follow-up. There was a significant positive relationship between the preoperative exo-angle and the corrective effect of the 1-mm advancement of the MR at the last follow-up (r = 0.367, p < 0.05). Postoperatively, orthotropia was present in 79.2% of patients, re-exodrift in 16.9%, and ET in 3.9%. Favourable stereopsis was achieved in 73.2%. ConclusionsMR advancement was effective for treating consecutive XT, followed by recession of the MR for infantile ET, achieving favourable stereopsis. The corrective value was 3 PD per 1-mm advancement of the MR.

Three Horizontal Muscle Surgery for Large-Angle Infantile or Presumed Infantile Esotropia

Bilateral medial rectus muscle recession and one lateral rectus muscle resection surgery for the correction of large-angle infantile esotropia may be associated with a favorable long-term motor outcome. A consecutive exotropic drift was encountered more commonly than a recurrent esotropic drift in the long run, especially in the smaller (50-69 prism diopters [Δ]) range of preoperative esodeviation. To outline the short- and long-term motor outcomes of graded bilateral medial rectus muscle recession and one lateral rectus muscle resection for the correction of large-angle esotropia (≥50Δ). Retrospective analysis. Strabismus service, tertiary care university referral center. A total of 194 consecutive patients with infantile or presumed infantile esotropia. All patients underwent bilateral medial rectus recession and a lateral rectus resection in the nondominant eye by the same surgeon. Short-term (8 weeks) and long-term rates of postoperative successful alignment (±10Δ), undercorrection, and overcorrection. The median age of patients at surgery was 2.7 years (range, 20 months-36 years). The median follow-up time was 4.5 years (range, 6 weeks-25 years). The mean preoperative deviation was 68.2Δ. Of the 194 patients, 121 (62.4%) were successfully aligned at the last follow-up visit or prior to reoperation, and 154 (79.4%) were successfully aligned at the 8-week postoperative evaluation. A comparison of early vs late outcomes revealed a higher rate of late overcorrections (5.15% vs 24.1%, respectively; P = .001) but the same rate of undercorrections (15.4% vs 15.1%; P = .85). The outcome of surgery was not associated with the presence of amblyopia, high hyperopia, or the total amount of millimeters of surgery but was adversely influenced by the presence of inferior oblique overaction and the magnitude of the preoperative esodeviation. Delayed consecutive exotropia was more prevalent in the 50Δ to 69Δ range of preoperative esodeviation. Three horizontal muscle surgery for the correction of large-angle esotropia is associated with a high success rate. Long-term follow-up indicated that an exotropic drift may be expected 3 times more often than an esotropic drift.

Interventions for infantile esotropia.

Infantile esotropia (IE) is the inward deviation of the eye. Various aspects of the clinical management of IE are unclear; mainly, the most effective type of intervention and the age at intervention. The objective of this review was to assess the effectiveness of various surgical and non-surgical interventions for IE and to determine the significance of age at treatment with respect to outcome. We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 5), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to June 2013), EMBASE (January 1980 to June 2013), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to June 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 10 June 2013. We manually searched the conference proceedings of the European Strabismological Association (ESA) (1975 to 1997, 1999 to 2002), International Strabismological Association (ISA) (1994) and American Academy of Paediatric Ophthalmology and Strabismus meeting (AAPOS) (1995 to 2003). Efforts were made to contact researchers who are active in the field for information about further published or unpublished studies. We included randomised trials comparing any surgical or non-surgical intervention for infantile esotropia. Each review author independently assessed study abstracts identified from the electronic and manual searches. No studies were found that met our selection criteria and therefore none were included for analysis. The main body of literature on interventions for IE are either retrospective studies or prospective cohort studies. It has not been possible through this review to resolve the controversies regarding type of surgery, non-surgical intervention and age of intervention. There is clearly a need for good quality trials to be conducted in these areas to improve the evidence base for the management of IE.

The Optokinetic Uncover Test

We devised the optokinetic uncover test to examine the role of peripheral retinal motion input in generating horizontal optokinetic responses in patients with infantile strabismus. To ascertain whether subcortical visual input contributes to the asymmetrical monocular optokinetic responses that characterize infantile esotropia. Observational study in an academic research setting. Ten patients with infantile esotropia. Optokinetic uncover test. Optokinetic testing was performed in 7 patients with isolated infantile esotropia (5 untreated and 2 previously treated) and in 3 patients with infantile esotropia syndrome associated with mild neurological disease. RESULTS All patients showed poor temporally directed optokinetic responses that instantaneously improved when the occluded esodeviated eye was uncovered, exposing it to nasally directed optokinetic motion. This improvement in optokinetic responses did not necessitate a fixation shift to the contralateral eye. Nasally directed optokinetic input to the esodeviated eye can supplement temporal monocular optokinetic responses in the fixating eye under binocular conditions. This nonfoveal optokinetic contribution suggests that monocular nasotemporal optokinetic asymmetry is partly attributable to subcortical visuovestibular responses mediated by nonfoveal retina.

Surgery for Infantile Esotropia: Is Timing Everything?

Infantile esotropia affects binocular alignment and development of binocular vision. Delayed correction may lead to loss of stereopsis. Waiting for the angle of deviation to stabilise prior to surgery does not impact overall postoperative outcomes greatly. Early surgical intervention produces better outcomes in terms of sensory and motor development, binocular vision and stereoacuity. The period of misalignment has the greatest effect on postoperative outcome therefore early surgery is recommended.

DVD—a conceptual, clinical and surgical overview

Dissociated vertical deviation is recognized by clinicians as a slow, dissociated hypertropic deviation of a nonfixating eye. It is usually bilateral, asymmetrical, and often associated with congenital esotropia. The deviating eye elevates, abducts, and excyclotorts. There is no unanimous agreement on the mechanism and pathophysiology of DVD.

Timing of surgery for congenital esotropia

Congenital esotropia is defined as an esotropia before the age of 6 months, because of its early onset and often constant angle, it cause heavier binocular visual function damage compared with other types of strabismus. Early surgery can improve binocular visual function, but demand reliable, accurate measurements which is difficult to achieve in children, and it may increase the risk of second surgery, amblyopia and anesthesia. Late surgery can gain reliable strabismus angle, but it reduced the likelihood of recovery binocular visual function, and the contracture of medial rectus after a long time esotropia increased mechanical limitation of adduction. Therefore, the choice of timing to do surgery has been controversy over the years. In this paper, we will combine the research status and clinical practice to discuss this issue, and present some point of view for the peer reference.