Intermittent Esotropia Research Articles

Intermittent esotropia and ataxia in a child with late diagnosis of empyema in the sphenoid sinus - a case report

Background: Acute bacterial rhinosinusitis is a common condition often affecting children with inflammation of the mucous membrane in one or more nasal sinuses. Isolated sphenoid sinus infections can exhibit atypical or no symptoms before potentially severe suppurative complications develop. Awareness of early signs of complications is crucial to avoid delays in referral, diagnosis, and treatment. We present the first detailed report of a child with sphenoid sinus empyema with the symptoms intermittent unilateral esotropia and limb and gait ataxia. This case emphasizes the need to recognise atypical presentations, aiding early diagnosis and treatment to prevent severe, possibly life-threatening complications. Case presentation: A 7-year-old girl, previously healthy, presented with a months-long decline in health marked by general malaise, significant weight loss, and recurrent upper respiratory infections. Despite multiple primary care visits no antibiotics were prescribed because infection parameters were found to be normal. Subsequently, the emergence of intermittent double vision prompted referral to the pediatric emergency department. Examination revealed a wide-based gait, ataxic finger-nose-finger and knee-heel tests, and intermittent esotropia of the left eye. Neurological examination was otherwise unremarkable. Imaging of the cerebrum was performed on the suspicion of intracranial pathology and found isolated empyema within the left sphenoid sinus. Endoscopic sinus surgery and antibiotic treatment led to a full recovery within a month. The accommodative esotropia, likely triggered by the infection, was identified, and successfully treated with spectacles. Conclusion: This case recognises isolated empyema in the sphenoid sinus as a potential cause of intermittent esotropia and limb and gait ataxia. It serves as a reminder for clinicians to be vigilant for early signs of suppurative complications to commence prompt diagnosis and treatment to prevent delayed recognition and severe complications. It advocates the inclusion of images of the sphenoid sinus to accompany the conventional scans of the cerebrum, as patients risk referral on the suspicion of intracranial pathology on the basis of neurological symptoms.

Prism adaptation response and surgical outcomes of acquired nonaccommodative comitant esotropia

ABSTRACT Purpose To investigate the clinical factors influencing the prism adaptation response of acquired non-accommodative comitant esotropia (ANAET) and evaluate the surgical outcomes. Study design Retrospective observational study. Methods This study assessed patients with ANAET who underwent strabismus surgery based on the results of a short prism adaptation test (PAT). Patients wore Fresnel trial prisms based on alternate prism cover tests in outpatient clinics. The cover test was then performed after 15–20 minutes; if the deviation increased, the power of the prism was increased to neutralize the angle. The test was repeated until the angle was stable. Patients were classified as either prism builders (angle increased by ≥ 10 prism diopters [PD] compared with the entry angle) or prism non-builders (angle increased by < 10 PD). The following clinical characteristics were noted: age at onset, age at surgery, duration of esotropia, refractive error, angle of deviation, presence or absence of intermittent esotropia at near, and pre- and postoperative sensory status. Results A total of 41 patients (median age, 15.4 years) were evaluated. The mean (standard deviation) spherical equivalent refractions were −3.03 (3.33) diopters (D) and −3.05 (3.23) D in the right and left eyes, respectively. Twenty-seven (66%) patients were prism builders. The prism builders had greater myopia (builders vs. non- builders, right eye: −3.97 [2.97] vs. −1.22 [3.33] D, P = .01; left eye: −4.08 [2.78] vs. −1.07 [3.20] D; P = .003), lower angle of deviation at near (median [interquartile range] 30.0 [20.0, 35.0] vs. 42.5 [35.0, 49.4] PD; P = .009), much more preoperative intermittent esotropia or esophoria at near (44% vs. 7%, P = .03) and diplopia (96% vs. 64%, P = .01), and better postoperative stereoacuity (50 [40, 110] vs. 100 [60, 400] arcsec, P = .02) than the prism non-builders. The overall success rate was 83%, without a significant difference between the two groups (builders vs. non-builders, 89% vs. 71%, P = .21). Conclusion In cases of myopic refractive error, a small entry angle with intermittency at near, and good binocularity, it is recommended that surgery is performed based on prism-adapted angle to prevent under-correction.

Clinical Characteristics of Intermittent Esotropia

Purpose: To evaluate clinical findings and surgical outcomes of intermittent esotropia.Methods: We retrospectively reviewed the medical records of 23 patients (aged 9-42 years) who presented with intermittent esotropia between January 2007 and December 2020. We analyzed the age at onset, angle of deviation, presence of symptomatic diplopia, fusional state, near stereoacuity, and surgical results.Results: The mean age at onset was 19.9 ± 8.0 years and mean duration of esodeviation was 23.4 ± 27.1 months. Mean follow-up time was 13.0 ± 15.6 months. All patients except three had symptomatic diplopia, and 78.3% showed intermittent diplopia. Mean angles of deviation were 21.6 ± 10.3 prism diopters (PD) at distance and 20.2 ± 10.4 PD at near. Twenty-one patients (91.3%) were myopia. No patients had amblyopia and one had dissociated vertical deviation. On Worth’s four-dot test, five patients (21.7%) showed diplopia and four showed suppression at both distance and near. The other patients showed fusion at near or distance. Eleven patients underwent surgical correction. At the final examination, all patients achieved successful motor alignment and fusion with resolution of diplopia. Only two patients (18.2%) achieved normal 60 arcsec stereopsis, and six attained subnormal stereopsis.Conclusions: The main symptom of intermittent esotropia was diplopia. Surgical treatment was effective in achieving good postoperative motor alignment and fusion. However, successful motor alignment did not guarantee recovery of fine stereopsis.

Contributions to the study of spinocerebellar ataxia type 38 (SCA38).

To report clinical and ancillary findings in a kindred with spinocerebellar ataxia 38 (SCA38). Five family members spanning two generations developed gait ataxia and intermittent diplopia. On examination, a cerebellar syndrome accompanied by downbeat nystagmus and a saccadic head impulse test (HIT) were found. Whole-exome sequencing demonstrated a heterozygous variant in ELOVL5, c.779A > G (p.Tyr260Cys), in four tested patients. Intermittent concomitant esotropia and hypertropia caused transient diplopia in one individual each. Saccadic HIT responses were found in four subjects. Sensorineural hypoacusis was present in every case. Electrophysiological studies demonstrated a sensory neuronopathy in patients from the first generation, with prolonged disease duration. Baseline serum docosahexaenoic acid (DHA) percent was diminished in four individuals. Oral 26-week dietary DHA supplementation, 650mg/day, raised serum DHA percent and induced a statistically significant reduction in Scale for the Assessment and Rating of Ataxia (SARA) total scores, and in stance and heel-shin slide item scores. The mentioned ELOVL5 variant segregated with disease in this kindred. Downbeat nystagmus, intermittent heterotropia causing transient diplopia, vestibular impairment demonstrated by abnormal HIT, and sensory neuronopathy were part of the clinical picture in this series. DHA supplementation raised serum DHA percent in cases with diminished levels, and induced a clinical amelioration and a statistically significant reduction in SARA scores in the study group. Further studies are needed to investigate the role of these findings in SCA38, and to determine the response to prolonged DHA supplementation.

The medial rectus is the bad actor in intermittent esotropia

The medial rectus is the bad actor in intermittent esotropia

Functional anatomy of extraocular muscles during human vergence compensation of horizontal heterophoria

We employed magnetic resonance imaging to quantify human extraocular muscle (EOM) contractility during intermittent convergent and divergent strabismus with each eye viewing monocularly at 20 cm compared with centered target fusion. Contractility, indicated by posterior partial volume change, was analyzed in transverse rectus and in medial and lateral superior oblique (SO) muscle compartments. In five subjects with intermittent esotropia, abduction of the deviated eye to monocular target fixation was associated with significant whole lateral rectus (LR) contraction, but with medial rectus (MR) relaxation that was significantly greater in the superior than inferior compartment. Esotropic eye abduction to binocular fusion was associated with similar relaxation in the two MR compartments, but with greater contraction in the LR's superior than inferior compartment. The whole diverging eye SO muscle relaxed. In three subjects with intermittent exotropia, converging eye fusional adduction was associated with significant whole LR relaxation and with MR contraction attributable to significantly greater contraction in the superior than inferior compartment. In adduction of the exotropic eye to monocular target fixation but not fusional adduction, the whole SO exhibited significant relaxation. Rectus pulley positions were not significantly altered by fusion of either form of intermittent strabismus. Globe rotational axis was eccentric in intermittent strabismus, rolling the eye so that rectus EOM lever arms facilitated vergence. These results confirm, and extend to fusion of intermittent horizontal strabismus, differential compartmental function in horizontal rectus EOMs and suggest a novel role for the SO in compensation of both intermittent esotropia and exotropia. NEW & NOTEWORTHY Disjunctive eye movements normally permit binocular fixation in near visual space but also compensate for mechanical imbalances in binocular alignment developing over the life span. Magnetic resonance imaging of the extraocular muscles demonstrates important differential function in muscle compartments during compensation of large-angle intermittent convergent and divergent strabismus in humans. Eye translation during rotation also enhances vergence compensation of intermittent strabismus.

Congenital Ocular Neuromyotonia with Partial Third Nerve Palsy

ABSTRACTPurpose: We report the first case of congenital ocular neuromyotonia (ONM) and the results of strabismus surgery for this patient’s co-existing cranial nerve (CN) III palsy.Patients and method: The patient presented at 18 months with strabismus that had reportedly been present since the time of birth. On exam, she had persistent exotropia (RXT) and hypertropia (RHT) with episodes of esotropia in the right eye that could be evoked by sustained left gaze. A diagnosis of ONM with partial CN III palsy was made. T1-weighted, T2-weighted, and fluid-attenuated inversion recovery magnetic resonance imaging failed to reveal intracranial pathology.Results: Gaze induced intermittent esotropia resolved with carbamazepine. Surgery was performed to improve the patient’s RXT and RHT. Post-operatively, the patient’s RXT had improved from 12 to 15 prism diopters (∆) at near and 20∆ at a distance to 10∆ RXT at near with no horizontal deviation at distance. Her deviation has remained stable for 13 years, as has her neurological exam and good state of health.Conclusion: This case demonstrates that ONM may present congenitally and adds to the body of knowledge regarding surgical outcomes on concurrent CN palsies in these patients.

The Value of Fusional Convergence Amplitudes in Esodeviation Surgery Without Adjustable Sutures.

To explore the application of preoperative fusional convergence amplitudes in the selection of a target angle for non-adjustable suture strabismus surgery with deteriorated intermittent esotropia and diplopia. Thirty-one consecutive cases of presumed acquired non-accommodative, deteriorated intermittent esotropia managed surgically between 2005 and 2016 were reviewed retrospectively. For each individual, a target angle (deviation angle for which surgery was based) was selected preoperatively after analysis of fusional convergence amplitudes. Outcomes in patients selected for overcorrection at 6 meters (target angle > angle in primary position at 6 meters) were compared to those who had planned surgery based on a target angle that did not exceed their measured angle (target angle ≤ angle in primary position) at 6 meters. All 31 patients achieved binocular single vision in primary position at both near and 6 meters without prisms, orthoptic therapy, or additional surgery at 4 to 6 months postoperatively. Greater mean correction in the target angle > angle in primary position group compared to the target angle ≤ angle in primary position group was observed, but this difference was not statistically significant (P = .57). Among this diagnostically specific cohort with intermittent esotropia with symptomatic diplopia and measurable binocular single vision preoperatively, targeted surgery based on an analysis of preexisting fusional convergence amplitudes had an outcome that compared favorably to that of documented adjustable suture strabismus surgery. [J Pediatr Ophthalmol Strabismus. 2018;55(6):375-381.].

Esotropia and Exotropia Preferred Practice Pattern®

Esotropia and Exotropia Preferred Practice Pattern®

Medial rectus muscle violates Sherrington's law during fusional divergence in artificial esophoria and intermittent esotropia

Medial rectus muscle violates Sherrington's law during fusional divergence in artificial esophoria and intermittent esotropia

Stepwise increase of hypermetropic correction using contact lenses in intermittent partially accommodative esotropia

BackgroundThe aim was to present a series of patients with intermittent partially accommodative esotropia (pAcc‐ET) in evaluating the effect of over‐plus correcting the hypermetropia relative to the non‐cycloplegic refraction using contact lenses.MethodsTwenty‐three patients (23.8 ± 8.9-years) with intermittent pAcc‐ET were fitted with soft daily single‐vision contact lenses and the hypermetropia was over‐plus corrected relative to the original subjective non‐cycloplegic refraction, reducing distance visual acuity to 0.8 (decimal acuity). Hypermetropia correction was increased at follow‐ups (every second week) until visual acuity stabilised or symptoms ceased. The contact lenses were worn for the entire study period.ResultsAfter eight weeks of treatment (two to four follow‐ups) the intermittent esotropia stabilised into esophoria and the magnitude of the deviation at distance was reduced in 70 per cent (16/23) of patients and at near in 91 per cent (21/23) of patients. As a result calculated accommodative‐convergence and the level of accommodation (stimulus AC/A ratio) was reduced in 83 per cent (19/23) of patients but still classified as high (less than 5:1).ConclusionsCompared to correction based on original non‐cycloplegic subjective refraction, increasing correction of hypermetropia with contact lenses in partially accommodative esotropia reduced the magnitude of the eso‐deviation at distance and near. In addition to reducing accommodative demand and stimulus AC/A with increasing hyperopic correction, contact lenses may provide additional benefit given the increased hyperopic correction and the decreased stimulus for accommodation required at the corneal plane.

Malignant Hypertensive Retinopathy in an Infant with Mid-Aortic Occlusion

Purpose. Case report describing an eight-month-old infant presenting with intermittent esotropia and irritability who was found to have malignant (grade 4) hypertensive retinopathy and mid-aortic syndrome. Methods. Visual acuity was 6/140 in the right eye and not recordable in the left eye. Blood pressure was as high as 230/120 mmHg. Fundoscopy revealed bilateral optic disc swelling, macular stars, and serous retinal detachment in the left eye, findings that are consistent with malignant (grade 4) hypertensive retinopathy. CT abdominal angiogram revealed a severe mid-aortic syndrome with occlusion of the abdominal aorta at T12. Results. The patient was treated with medical management of his hypertension, improving the subretinal exudate. Binocular visual acuity improved to 6/9.5 over 9 months. There was a persistent left relative afferent pupillary defect and moderate left esotropia. Conclusion. This is the first reported case of malignant hypertensive retinopathy in an infant with concomitant mid-aortic occlusion. The authors emphasize the need for an ophthalmological and pediatric examination in a child presenting with intermittent squint and irritability. The esotropia was found to be a false localizing sign of raised intracranial pressure secondary to the severe mid-aortic syndrome.

Stereoacuity in children with accommodative esotropia versus partially accommodative esotropia

• Accommodative esotropia was defined as > 10 PD of intermittent or constant esotropia. • Fully accommodative esotropia (FAET) was diagnosed in those children having 4 weeks and maintaining such alignment for > one year. • Partially accommodative esotropia (PAET) was diagnosed in those children with 10 PD or more residual ET after wearing their full hyperopic spectacle correction for > 4 weeks. • Stereoacuity was tested with the fly and circles on the Stereo Fly Test (Stereo Optical Co., Inc.) at 40 cm.

Spasm of the near reflex. Treatment with botulinum toxin

Clinical caseA 38-year-old female with diplopia and esotropia, with limitation of ocular abduction in both eyes, with full abduction after doll's head rotation also being observed. She was diagnosed with spasm of the near reflex. Treatment with injections of botulinum toxin in both medial rectus has temporally resolved the convergence spasm. DiscussionNear reflex spasm is characterized as miosis, pseudomyopia, and convergent strabismus that lead to diplopia, blurred vision, headache, and variable, progressive, and intermittent esotropia. As the spasm worsens there will be limited ocular versions and ductions simulating a sixth nerve palsy. Botulinum toxin may be effective in some cases.

Long-Term Binocularity in Accommodative Esotropia

Purpose: To find clinical factors related to the long-term outcome of binocularity in accommodative esotropia. Methods: Forty-nine patients with accommodative esotropia who were followed over 5 years after successful optical alignment within 8 prism diopters of orthophoria at near and distance with glasses including bifocals were included. The patients who had stereo acuity better than 50 seconds/arc and central fusion without suppression scotoma at the final visit were divided into the bifoveal fusion group and the others were divided into the peripheral fusion group. Clinical factors were analyzed between the two groups (Chi-square test, student t-test). Results: Of the 49 patients, 15 patients were included in the bifoveal fusion group and 34 patients were included in peripheral fusion group. Mean follow-up was 88.9 ± 25.4 months. Clinical factors that were significantly related to the bifoveal fusion group were older age of onset, shorter duration of misalignment, intermittent esotropia at the initial visit and after initial optical correction, smaller residual deviations at distance after initial optical correction and at the final visit, and lesser amblyopia. Conclusions: To obtain better levels of long-term binocularity, optical correction should be done as early as possible, before the presence of constant eye misalignment or amblyopia, and the residual esodeviations after optical correction should be kept as small as possible. J Korean Ophthalmol Soc 2015;56(5):759-763

Espasmo del reflejo de cerca. Tratamiento con toxina botulínica

Clinical caseA 38-year old female with diplopia and esotropia, with limitation of ocular abduction in both eyes, with full abduction after doll's head rotation also being observed. She was diagnosed with spasm of the near reflex. Treatment with injections of botulinum toxin in both medial rectus has temporally resolved the convergence spasm. DiscussionNear reflex spasm is characterized as miosis, pseudomyopia, and convergent strabismus that lead to diplopia, blurred vision, headache, and variable, progressive, and intermittent esotropia. As the spasm worsens there will be limited ocular versions and ductions simulating a sixth nerve palsy. Botulinum toxin may be effective in some cases.

Sustained improvement of reading symptoms following botulinum toxin A injection for convergence insufficiency

AbstractIntroduction: We evaluated the use of botulinum toxin A in adults with convergence insufficiency in whom prior treatment had failed.Methods: We studied 8 patients (median age 36 years, range 17 to 77 years) with reading symptoms due to convergence insufficiency defined as an exodeviation greater at near, not exceeding 10 PD in the distance measured by prism and alternate cover test, and either convergence near point >6 cm or reduced fusional amplitudes. All patients were still symptomatic after prior treatment by convergence exercises (n = 8), base-in prism glasses (n = 5) or strabismus surgery (n = 2). Five patients received injection of 5 IU botulinum toxin in 0.1 ml saline to one lateral rectus muscle, two received 2.5 IU, and one received 2.5 IU to both lateral rectus muscles.Results: At 1 month post injection, all patients had an initial reduction of exodeviation from baseline (median 9 PD, p = 0.008) at near, although 2 patients had a temporary intermittent esotropia in the distance with dip...

Botulinum Toxin as an Alternative to Treat the Spasm of the Near Reflex

We describe the case of an eight-year-old girl with complaints of headaches and blurred vision (uncorrected visual acuity: 0.1 decimal) that showed on examination miotic pupils, pseudomyopia, no ocular motility restrictions, and no associated neurological disease. After initial treatment with cyclopentolate for two months, pseudomyopia persisted with an intermittent and variable esotropia. Spectacles of +1 both eyes and atropine 1% one drop daily were then prescribed. The situation improved and remained stable for several weeks, with pseudomyopia and esotropia reappearing later. Finally, botulinum toxin (2.5 iu Botox®) was injected in the medial rectus muscle on two occasions and a visual therapy program based on the stimulation of fusional divergence, diplopia, and stereopsis consciousness was recommended. This prescription was combined with the use of atropine during the first few weeks. Orthotropia and corrected distance visual acuity of 1.0 were found three months after treatment. The evolution and clinical results of this case report suggest that botulinum toxin in combination with other therapeutic alternatives may be useful in the treatment of spasm of the near reflex.

Sustained improvement of reading symptoms following botulinum toxin A injection for convergence insufficiency

Introduction: We evaluated the use of botulinum toxin A in adults with convergence insufficiency in whom prior treatment had failed.Methods: We studied 8 patients (median age 36 years, range 17 to 77 years) with reading symptoms due to convergence insufficiency defined as an exodeviation greater at near, not exceeding 10 PD in the distance measured by prism and alternate cover test, and either convergence near point >6 cm or reduced fusional amplitudes. All patients were still symptomatic after prior treatment by convergence exercises (n = 8), base-in prism glasses (n = 5) or strabismus surgery (n = 2). Five patients received injection of 5 IU botulinum toxin in 0.1 ml saline to one lateral rectus muscle, two received 2.5 IU, and one received 2.5 IU to both lateral rectus muscles.Results: At 1 month post injection, all patients had an initial reduction of exodeviation from baseline (median 9 PD, p = 0.008) at near, although 2 patients had a temporary intermittent esotropia in the distance with diplopia associated with difficulty driving. At 6 months, when the pharmacological effect of botulinum toxin had completely worn off, patients still maintained a small reduction of exodeviation (median 4 PD, p = 0.3) at near. Reading symptoms improved in 7 of 8 patients at 1-month post injection, and in all patients at 6 months. Two patients had health-related quality of life assessed with the Adult Strabismus 20 Questionnaire, showing improved Reading Function scores at 6 months. Interestingly, 3 patients reported improved reading despite returning to the baseline angle at 6 months, and 2 of 4 with 12-month follow-up still reported improvement.Conclusions: In adult convergence insufficiency, botulinum toxin injection to a lateral rectus muscle improves reading symptoms beyond the duration of the pure pharmacological effect. Botulinum toxin injection may be useful in management of adult convergence insufficiency, although repeat injections may be needed.

Acute Adult Onset Comitant Esotropia Associated with Accommodative Spasm

Acute onset comitant esotropia associated with spasm of accommodation in children and adults is a rare clinical condition. When occurring with pupillary miosis and restricted ocular motility, it is referred to as "spasm of near reflex" (SNR) and may require neurological investigation. The natural history of SNR depends on its etiology. There is little information in the literature regarding the long-term follow-up of SNR and the stability of visual signs and symptoms following cessation of treatment. We report a case of SNR in an otherwise healthy young male, and discuss the presentation, clinical investigations, management, response to treatment, and 1-year follow-up. A 23-year-old male patient reported to the clinic with sudden onset of blurred vision, inward deviation of the eyes, and binocular diplopia. On examination, he was diagnosed to have acute onset esotropia resulting from SNR. He was treated with cycloplegic medications and vision therapy. The condition resolved following 1 year and there has been no recurrence. Acute adult onset esotropia occurring with accommodative spasm responds favorably to cycloplegic medications but may need a longer course of treatment for successful resolution and stability.