Infantile Esotropia Research Articles

Botulinum toxin; indications, success rates and complications in the management of horizontal strabismus in Saudi Arabia.

Introduction: This study aims to analyze the indications, effectiveness and side effects of Botulinum toxin in the management of different horizontal strabismus entities. Methods: A retrospective analysis of cases underwent botulinum toxin injection for strabismus in Dhahran Eye Hospital from November 2013 till September 2016 where no previous surgery or intervention have been performed or a previous facial or ocular trauma. Main success indicator was a remaining angle of less than 10 prism diopter. Results: A total of 74 cases were included. 52.7% males and 47.3% females. Age ranged from two months to forty-five years. The most prevalent diagnosis was partially accommodative esotropia (PAET). The mean angle of deviation was 37.3 prism diopters (PD) with a range of 10 to 90 PD. Overall success rate was 54% with PAET scoring the highest (70.6%). No clinical significance was found regarding age, angle of deviation or the presence of amblyopia. However, the absence of inferior oblique overaction was statistically significant on the success rate of infantile esotropia. No serious peri-operative complications were documented. Conclusion: Botulinum toxin represents a cost effective, safe, repeatable alternative to surgery in the management of different entities of horizontal strabismus. Success rate differs in different diagnoses with PAET scoring the highest. Presence of inferior oblique overaction leads to a significant lower rate of success.

Cortical Visual Connections via the Corpus Callosum are Asymmetrical in Human Infantile Esotropia

ABSTRACTPurpose: Besides chiasmal hemidecussation, interhemispheric connections are likely important in human binocularity. The corpus callosum (CC) is the major fiber bundle in the mammalian brain which mostly connects homologous cortical areas in the two hemispheres. Visual interhemispheric connections were found abnormal in strabismic cats. No studies have investigated these pathways in humans with infantile strabismus.Methods: Diffusion tensor imaging was used in four subjects with infantile esotropia (IE) and nine control subjects with normal binocularity, in order to study interhemispheric fibers in the CC connecting the right and left primary visual cortical areas.Results: The number of callosal fibers linking both visual cortical areas between the hemispheres was found to be higher in subjects with IE. Also in IE, the amount of visual callosal fibers found after analysis from the primary visual cortical areas on one side appeared significantly different from the amount starting from the contralateral primary visual areas. The distribution area on one side is wider.Conclusion: We show callosal visual fibers to be abnormal in human IE. Subjects with IE showed abnormal numbers of transcallosal fibers connecting the visual cortical areas on both sides which likely results from an abnormal elimination process during development. Pruning of these fibers in IE favors the side of the visual cortex ipsilateral to the dominant eye. This study underlines the likely role of the CC in the development of human binocularity.

Esotropia and Exotropia Preferred Practice Pattern®

Esotropia and Exotropia Preferred Practice Pattern®

The Use of Botulinum Toxin to Treat Infantile Esotropia: A Systematic Review With Meta-Analysis.

The purpose of this review was to examine the efficacy of botulinum toxin in the treatment of infantile esotropia and to evaluate the average response of BT and its complication rates. A research was performed in the Latin American and Caribbean Literature on Health Sciences (LILACS), MEDLINE, and Cochrane Central Register of Controlled Trial (CENTRAL). The database was searched between December 28, 2016 and January 30, 2017. The selection was restricted to articles published in English, Spanish, or Portuguese. There were no date restrictions in the search. Nine studies were eligible for inclusion. The grouped success rate of BT treatment in infantile esotropia was 76% (95% confidence interval [CI]: 61%-89%). For the success rate, I2 of 94.25% was observed, indicating a high heterogeneity (P < 0.001). The complication rates were also analyzed. The grouped consecutive exotropia (XT) rate was 1% (95% CI: 0%-2%). The grouped ptosis rate was 27% (95% CI: 21%-33%). The grouped vertical deviation rate was 12% (95% CI: 4%-22%). The mean change of the deviation after BT injection was -30.7 (95% CI: -37.7, -23.8), demonstrating a significant improvement in alignment. Botulinum toxin injection into medial recti muscles reveals to be a safe procedure and a valuable alternative to strabismus surgery in congenital esotropia, especially in moderate deviations.

A Model Explaining Infantile Esotropia: Dissociated Strabismus as a Result of Sensory Interhemispheric Dissociation and Crossed Dominance in the Brainstem

Over 150 million years, modern reptiles, birds and mammals evolved. Predatory birds and mammals have eyes on the front of their heads. In these animals, binocular correspondence, voluntary eye movements, eye-hand coordination, partial decussation at the optic chiasm and cortical interhemispheric pathways could develop at the cost of a smaller visual field. The subsequent enlargement of the cerebral neocortex and the hemispheric pathways are of central importance in binocular vision, sensory fusion and infantile strabismus. To investigate visual interhemispheric fibers, tractography was used in subjects with infantile esotropia (IE), callosal agenesis and control subjects with normal binocularity. In human callosal agenesis, normal binocularity could be explained by a different interhemispheric connection. In subjects with infantile esotropia, the analyses starting from the primary visual area on one side appeared different from the analysis from the other side. The distribution areas are asymmetrical between sides. Binocularity and alignment not only rely on correspondence between crossed and uncrossed hemi-representations but, in addition the corpus callosum, the most important interhemispheric pathway in placental mammals, seems important in the development of human binocularity. When correspondence is possible between the hemi-representations of the crossed and the uncrossed pathway on both sides of the cortex, the uncrossed pathway finds its way via the corpus callosum toward the contralateral hemi-representation of the same eye. A vertical midline must come out of this process. Meanwhile, however, the other uncrossed pathway strives to find the vertical midline of the other eye. Likely, the corpus callosum is important during the tuning of the pathways involved in sensory fusion. The anterior commissure might be an alternative in callosal agenesis. A failure in the offset will result in strabismus and crossed dominance after V1. Consequently, the normal binocular development of the brainstem (i.e., the superior colliculus), will not take place and latent nystagmus, as well as dissociated divergence, may ensue.

The Motor Development of Children with Infantile Esotropia

Background Until now, many studies have investigated the link between motor development and visual-spatial abilities in infancy and childhood. Most of these studies found evidence that there is such a link in typically developing children or children with locomotor delay. Only a few studies have tested the consequences of this link in children with abnormal visual development because of infantile esotropia. Moreover, little is known about the effects of late surgery on motor development. Patients and Methods We assessed the motor abilities of 3- to 7-year old children with severe deficits in stereopsis due to infantile esotropia (angle ≥ 12°) and typically developing children prior to and 12 to 16 months after surgery. We used the Movement Assessment Battery for Children (Movement ABC-2). Results Prior to and one year after surgery, the strabismic children showed significantly lower global motor scores than normal children. Moreover, in the strabismic children, we found significant differences relative to the healthy children in the subscales assessing manual dexterity and balance prior to and significant differences in the subscales assessing manual dexterity and ball skills after surgery. Overall, the strabismic group did not demonstrate improvements in motor development after surgery. However, the children with a positive Bagolini striated glass test following surgery performed better in the subscale assessing balance than children with a negative Bagolini striated glass test. Conclusions Motor skills were poorer in children with infantile esotropia, both prior to and following surgery. Moreover, the children with improved binocular vision after surgery demonstrated better balance skills. Possible explanations and practical implications are discussed.

Bimedial rectus muscle elongation versus bimedial rectus muscle recession for the surgical treatment of large-angle infantile esotropia.

PurposeTo compare bimedial rectus muscle recession (BMRR; 7–8 mm) and bimedial rectus muscle elongation (BMRE; 6.5–9 mm) for the surgical treatment of large-angle infantile esotropia (ET; ≥70 prism diopters [PD]).Patients and methodsTwenty-four patients with large-angle infantile ET were divided into 2 groups; group A (n=12) underwent BMRR and group B (n=12) underwent BMRE. All patients received surgery under general anesthesia and were followed for at least 24 months after surgery. The mean dose-response effect at 24 months was calculated for each patient.ResultsThe mean preoperative angle of deviation was 79.16±7.64 PD (range, 70–90) in group A and 85.83±9.25 PD (range, 70–100) in group B. The duration of surgery was 55% shorter in group A compared with group B. There were no cases of over-correction, but there were 6 cases of under-correction in group A (50%) and 2 cases of under-correction in group B (16.7%). The mean dose-response effect was 4.42±0.19 PD/mm in group A and 5.45±0.39 PD/mm in group B.ConclusionBMRE is more effective than BMRR for the surgical treatment of large-angle infantile ET despite a higher level of technical difficulty.

Strabismus Incidence in a Danish Population-Based Cohort of Children

To our knowledge, there have been few population-based studies of strabismus incidence conducted. Our population-based study provides valuable data for health services planning and identifying research needs. To determine the incidence and age distribution of strabismus, overall and by subtype, among children 7 years or younger. This population-based cohort study was conducted with data from 96 842 children enrolled in the Danish National Birth Cohort. Age-specific incidence and cumulative incidence and median age at the detection of strabismus, overall and by subtype. The study cohort included 96 842 children born between 1996 and 2008 who are predominantly Caucasian and is composed of approximately 30% of births in Denmark, with a boy-girl ratio of 51:49. Overall, 1309 cases of strabismus were identified in the cohort. We found an overall cumulative strabismus incidence of 2.56% (95% CI, 2.42-2.69) at 7 years. The overall incidence was similar among boys and girls. Two hundred sixteen participants (16.5%) (95% CI, 14.5-18.6) had congenital esotropia, 177 (13.5%) (95% CI, 11.7-15.5) had fully accommodative esotropia, 252 (19.3%) (95% CI, 17.1-21.5) had partially accommodative esotropia, and 181 (13.8%) (95% CI, 12.0-15.8) had exotropia. The esotropia:exotropia ratio was 5.4:1 (95% CI, 3.4:1 to 7.5:1). Age-specific incidence curves for congenital esotropia, fully accommodative esotropia, partially accommodative esotropia, and all exotropia revealed interactions between strabismus subtype and age, suggesting that the different subtypes had different age-specific patterns of incidence (P < .001 for all comparisons between pairs of curves). The median age at detection for the 4 subtypes was 0, 32.0, 26.1, and 16.6 months, respectively. In a national, population-based cohort study, we found a cumulative incidence of strabismus consistent with those reported in smaller European and American cohorts, but a somewhat higher esotropia:exotropia ratio than those that, to our knowledge, are typically reported by English and American studies. Patterns of incidence by age differed for different strabismus subtypes, indicating differences in age at onset and thereby implying differences in the underlying etiology.

Callosal and commissural interhemispheric connections between primary visual areas in infantile esotropia

Images in the median plane of the head either fall on both nasal hemi-retinae or on both temporal hemi-retinae. Interhemispheric connections, in humans the corpus callosum, allow cortical cells to have receptive fields on opposite sides. These connections were shown to be abnormal in infantile esotropia while individuals with agenesis of the corpus callosum may show normal stereopsis and disparity vergence. We have investigated here whether interhemispheric connections through the anterior commissure, a phylogenetic earlier interhemispheric pathway, might explain this inconsistency.

Infantile esotropia: where have they gone? an international survey of the incidence, presentation, and treatment of infantile esotropia

The incidence of infantile esotropia from population studies in the US suggests an incidence of 1 in 403 live births(1). This does not mirror the clinical experience in the UK. This study sought to analyse the possibility of this decreasing incidence as well as the choice of management.

Postoperative full abduction in a patient of Duane retraction syndrome without an abducens nerve: a case report

BackgroundDuane retraction syndrome (DRS) consists of abduction deficit, globe retraction and upshoots or downshoots with adduction. The abducens nerve on the affected side is absent in type 1 DRS. After bilateral medial rectus muscle recession in unilateral type 1 DRS may improve the abduction limitation, but still more than −3 limitation remains.Case presentationA 6-month-old boy presented with esotropia which had been noticed in early infancy. He showed limited abduction, fissure narrowing on attempted adduction and a small upshoot OS. Left abducens nerve was not identified on magnetic resonance imaging compatible with Duane retraction syndrome type 1. He showed full abduction after bilateral medial rectus recession of 6.0 mm at the age of 9 months, and remained orthotropia with full abduction OU 2 years postoperatively. He is my only patient with Duane retraction syndrome who showed full abduction after bilateral medial rectus recession.ConclusionsA patient with the type 1 Duane retraction syndrome rarely may show full abduction after bilateral medial rectus recession mimicking infantile esotropia.

Clinical characteristics of sibling patients with comitant strabismus.

To investigate the clinical characteristics of sibling patients with comitant strabismus. Sibling patients who were diagnosed with comitant strabismus from January 2005 to December 2014 were retrospectively reviewed. Factors including age, sex, types of strabismus, refractive errors, angle of deviation, and coexistence of other strabismus were analyzed. A total of 62 patients (31 pairs of siblings) were included. Of these, 26 pairs had intermittent exotropia, 3 had accommodative esotropia, and 2 had infantile esotropia. There were no pairs with different subtypes of strabismus. The age at first visit was 3.7±2.6y and the mean follow-up period was 30.5±24.1mo. In siblings with intermittent exotropia, there was no difference in age of onset, age at operation, or refractive errors between the first and second-born children. The 20 (77%) pairs of siblings with exotropia showed more than 80% concordance of maximum angle of deviation during follow-up. In the 9 pairs in which both siblings had an operation, the final angle of deviation after the operation was 8.2±8.1 prism diopters (PD) in first-born children and 8.6±6.5 PD in second-born children. The subtypes of strabismus are the same in all pairs of siblings and clinical characteristics of strabismus are similar between the first and second-born children. This similarity could be an indicator for the diagnosis of second-born children. Further prospective study including a larger number of sibling patients is needed.

Unilateral Recession-Resection Surgery for Infantile Esotropia: Survival of Motor Outcomes and Postoperative Drifts

ABSTRACTPurpose: To outline the short- and long-term motor outcomes of unilateral medial rectus muscle recession and lateral rectus muscle resection for the correction of moderate angle infantile esotropia. Methods: A retrospective study of 109 consecutive patients with moderate angle infantile esotropia treated with graded unilateral recession-resection surgery. Criteria for successful motor outcome included alignment ±10Δ from orthophoria. Outcome evaluation was a comparison of successful alignment versus an overcorrection or undercorrection at eight weeks postoperatively as well as on the final follow-up examination. Results: The mean preoperative deviation was 35.5 prism diopters (Δ) and mean follow-up time was 4.9 years. At the eight-week postoperative examination, 99 patients (89.9%) were successfully aligned, as opposed to 75 of 95 patients (78.9%) at the final postoperative visit (P=0.041). There was no statistically significant difference between the rate of early versus late undercorrections (7.3% versus 12.5%, P=0.267) or overcorrections (2.7% versus 8.3%, P=0.125). Ten patients had an esotropic drift over time and 10 patients had an exotropic drift. Recurrent esotropia was associated with high hyperopia and presumed infantile esotropia diagnostic entity. The Kaplan-Meier estimate of survivorship of a successful motor outcome was 75.5% at five years and 71% at 15 years postoperatively. The mean response to surgery was 2.9Δ per mm of muscle recessed and resected and was positively related to the preoperative angle of deviation (R=0.615). Conclusions: The unilateral recession-resection procedure for the correction of infantile esotropia is shown to be associated with a favorable survival of motor outcomes and a relatively balanced rate of undercorrections versus overcorrections tending to be maintained through the follow-up period.

To what extent may Botulinum toxin type A injections be an alternative choice to surgery in infantile esotropia?

Evaluation of a single injection of botulinum toxin A in infantile esotropia as an alternative choice to surgery in a retrospective cases serie. Patients (65 consecutive children aged 9 to 26 months with infantile strabismus) underwent botulinum toxin A injection in both medial recti Botulinum toxin A injection. Clinical datas including measurement of angle of deviation before and after injection. visual acuity, stereoscopy and side effects were observed in a 24 months period of follow-up. Stable satisfactory result (angle equal to or less than 8 dioptres) was obtained in 33 cases (50.7%). Excellent result (-2 to + 4 dioptres) were obtained in 17 children (26%). Additional surgery was required in 32 cases for a residual (albeit smaller angle than the initial deviation) or recurrent deviation and/or DVD (49,2%). Botulinum toxin A reduces the tonic spastic motor component of strabismus and, should additional surgery be required (49% in our series), allows the procedure to be carried out on a smaller angle. A reduction in the maximum angle of deviation is thus achieved sooner, and allows the development of anomalous binocularity in a stable microtropia.

Botulinum toxin for the treatment of strabismus.

Botulinum toxin for the treatment of strabismus.

Esotropia with an accommodative component after surgery for infantile esotropia compared to primary accommodative esotropia

To compare the clinical outcomes of patients with an esotropia with an accommodative component after infantile esotropia surgery and patients with primary refractive accommodative esotropia. The medical records of patients with postoperative (secondary group) and primary refractive accommodative esotropia (primary group) were reviewed retrospectively. Changes in ocular alignment, refractive error, weaning rate, decompensation rate over time, and sensory outcomes were compared. The overall change in ocular deviation with glasses correction was -0.5Δ/year in the secondary group and -0.2Δ/year in the primary group (P=0.010). The overall change in spherical equivalent refractive error was -0.2 D/year in the secondary group and -0.3 D/year in the primary group (P<0.001). The latest stereoacuity result was poorer in the secondary group than in the primary group (P=0.027). No significant differences in the decompensation or weaning rates were detected between groups. The changes in refractive error and the amount of esotropia over time were different between the secondary group and the primary group. Although refractive error was significantly lower and stereoacuity was poorer in the secondary group compared to the primary group, the majority of patients in the secondary group maintained good control of ocular alignment after hyperopic correction.

Outcome of early surgery in infantile esotropia: Our experience in tertiary care hospital

BackgroundInfantile esotropia is a convergent strabismus presenting before 6 months of age and is the most common strabismus disorder presenting in the ophthalmology OPD. The dilemma of whether to go for early surgery and how early has been a matter of research for the last 50 years. We describe our results of surgery in infantile esotropia at variable age groups, as well as with different reoperation rates and compare with the results in western literature. MethodsA prospective study was carried out through a review of 113 cases operated for infantile esotropia between February 2013 and August 2014. The variables studied were: age at surgery, type of fixation, refractive error, associated nystagmus, inferior oblique overaction or dissociated vertical deviation (DVD), type of surgery performed and pre- and postoperative deviation angles. ResultsThere were 67 male and 46 female cases of infantile esotropia. The age group of patients varied from 6 months to 12 years. Latent nystagmus was seen in 22 cases, inferior oblique overaction in 49 cases and DVD (mild) in 14 cases. Bimedial rectus recession was done in 78 cases and recession–resection in non-dominant eye in remaining 35 cases. The postoperative residual deviation was <10 PD in 102 cases, between 10 and 16 PD in 5 cases and more than 16 PD in 6 cases. Only 6 cases (5.3%) required reoperation for correction of residual deviation. ConclusionThe authors recommend surgery before 12 months in all cases of infantile esotropia. The reoperation rates in the current study were considerably low.

Refractive error changes after bilateral medial rectus muscle recession surgery in congenital esotropia

Purpose The aim of this study was to evaluate the changes in refractive errors after bilateral medial rectus muscle recession surgery in children with congenital esotropia. Patients and methods Medical reports of 75 children with congenital esotropia were retrospectively reviewed. All included patients attended the Ain Shams University hospitals for undergoing bilateral medial rectus muscle recession surgery from January 2013 till January 2016. Cycloplegic refraction was done preoperatively and 3 months and 1 year postoperatively. Spherical equivalent (SE) was calculated to determine the amount of change in refractive error especially astigmatism and its axis. Patients were excluded if neurological abnormalities or developmental delays were documented and if structural eye abnormalities were present. Results Significant myopic shift and astigmatic change were determined in the SE refraction in the early postoperative period (3 months); however, these changes disappeared in the long term (at the postoperative first year). Conclusion Only the early postoperative period showed significant change in the SE value with myopic shift that necessitates early postoperative visual rehabilitation for fear of recurrence of the deviation or development of amblyopia.

Epidemiology of strabismus surgery in a public hospital of the Brazilian Federal District

Abstract Purpose: to determine the prevalence of different types of strabismus submitted to a surgical procedure in a public hospital in the Brazilian Federal District. Methods: Retrospective cross-sectional review of medical records of patients who underwent strabismus surgery performed by the same surgeon from 2004 to 2014. Incomplete records were excluded from the study. Variables included sex, age, type of strabismus, type of surgery, and re-surgeries. Strabismus was classified into three main types (esotropia, exotropia, and pure vertical deviation), and their subtypes. The type of surgery was determined by the number of muscles operated on (up to two, or more than two), the involvement of oblique and vertical rectus muscles, and muscle displacement. Results: 563 patients were reviewed and 531 were included in the study. The average age was 12.7 years, and females accounted for 54.4% of total patients. Esotropia was the most frequent type of strabismus (74%), followed by exotropia (23.7%) and pure vertical deviation (2.3%). The most frequent subtype of esotropia was infantile (49.1%), with 16.1% of these surgeries performed before the age of 2. Constant exotropia was the most frequent subtype of exotropia (27.8%). The prevalence of esotropia decreased with age, whereas that of exotropia increased. 52.3% of surgeries involved more than two muscles. An association between different types of deviation was found in 58.9% of patients. In cases of paralytic strabismus, the sixth nerve was the most affected (46%). Re-surgeries accounted for 10.7% of total surgeries. Conclusion s: Esotropias were the most common types of strabismus, especially infantile esotropia. Most cases were associated with other types of deviation, and needed more complex surgeries, involving more than two muscles. This study expects to contribute to the planning of health measures that may effectively improve the assistance provided to the population.

Results of early surgery performed patients and late surgery performed patients with infantile esotropia

Results of early surgery performed patients and late surgery performed patients with infantile esotropia