Nonaccommodative Esotropia Research Articles

Bimedial hang-back recession— outcomes and surgical response

To report outcomes and identify factors affecting surgical response for constant esotropia using 'hang-back' bimedial rectus recession. Retrospective case series analysis. Patients managed by a single surgeon over a 4-year study period were categorized into esotropia types: infantile, partially accommodative, nonaccommodative and secondary esotropia. Postoperative alignment was compared between types, and regression modelling used to examine factors predicting surgical response. In all, 95% (18/19) of children with partially accommodative esotropia achieved postoperative deviation <15 prism dioptres from orthotropia, compared to 56% (15/27) of children with infantile esotropia, 69% (11/16) of children with non-accommodative esotropia and all (2/2) of those with secondary esotropia. Surgical response (Delta/mm recession performed) increased with the magnitude of both preoperative deviation (P<0.001) and anisometropia (P<0.001); the effect of deviation on surgical response was reduced by amblyopia (P=0.02). Age at surgery was statistically associated (P=0.002) but had negligible clinical effect on response. Surgical response to hang-back recession may be partially predicted by preoperative factors.

Short-Term Motor and Sensory Outcomes in Acquired Nonaccommodative Esotropia of Childhood

Information on the management of acquired nonaccommodative esotropia (ANAET) of childhood is incomplete. Most prior reports combine the results of patients with both accommodative and nonaccommodative esodeviations. The primary objective of this study was to describe the early postoperative motor and sensory results of children with acquired nonaccommodative esotropia.The medical records of 72 consecutive children with ANAET who underwent surgical correction at East Tennessee State University College of Medicine from August 1, 1995 through October 1, 2001 were retrospectively reviewed.The median age at surgery for the 72 study patients was 43.8 months with a median angle of deviation of 30 prism diopters (PD) at both distance and near. Ten patients (13.9%) required a second surgical procedure while one patient (1.4%) required a third. The cumulative probability of a second surgery within two years of the first procedure was 24% (95% CI 4–43%). During a median postoperative follow-up period of 7.1 months, 64 (88.9%) patients were within 8 PD of orthotropia on the last postoperative examination. Normal postoperative stereoacuity was achieved in several children whose deviation began after 30 months of age, as well as in one child who was misaligned for at least two years prior to surgery.Although the postoperative follow-up on these patients with acquired nonaccommodative esotropia managed without prism adaptation is short, the motor results are similar to other studies on patients with acquired esotropia, with sensory outcomes superior to those obtained in children with congenital esotropia.

Photorefractive keratectomy followed by strabismus surgery for the treatment of partly accommodative esotropia

To evaluate photorefractive keratectomy (PRK) followed by bilateral medial rectus muscle recessions (BMR) to treat adults with partly accommodative esotropia. We reviewed medical records of 10 consecutive patients with partly accommodative esotropia who underwent PRK to correct hyperopia followed 6 months later by BMR to treat the accommodative and nonaccommodative components of their esotropia, respectively. Visual acuity, spherical equivalent of refractive error, alignment, and sensory data were collected and analyzed. Twenty eyes of 10 patients were treated and followed for 1 year. PRK was successful in treating the hyperopia (mean post-PRK spherical equivalent was 0.14 D (SD = 0.22)) and the accommodative portion of the esotropia (the mean percentage of the distance accommodative component eliminated by PRK was 101.67% and the mean percentage of the near accommodative component eliminated by PRK was 115%). However, subsequent BMR using standard surgical tables based on the distance deviation to treat the post-PRK residual (nonaccommodative) esotropia resulted in uniform undercorrection. PRK may be useful to treat the accommodative portion of partly accommodative esotropia. Bilateral medial rectus muscle recession can be used to treat the residual, nonaccommodative component; however, it may be necessary to base the surgical dosage on the near deviation.

Progressive increase in the angle of deviation in acquired nonaccommodative esotropia of childhood

Purpose Although the angle of deviation in patients with congenital esotropia has been shown to increase during the early preoperative period, few data exist regarding this change in other forms of childhood esotropia. The primary objective of this study was to investigate whether the angle of deviation increases with time in patients with acquired nonaccommodative esotropia (ANAET). Methods The medical records of all children whose ANAET was diagnosed at East Tennessee State University College of Medicine from August 1, 1995, through October 1, 2001, were retrospectively reviewed. All patients were assessed for any change in the amount of their strabismic angle and associated risk factors. Results Eighty-two patients with ANAET were identified, and all except 3 underwent more than one examination. Of the 79 children who underwent more than one examination, 26 (32.9%) displayed an angle increase of ≥10 prism diopters (PD) during a median follow-up period of 2.9 months. The ANAET of those patients whose angle increased by ≥10 PD was diagnosed (28.4 months of age vs 45.5 months of age, P = .003), and they underwent surgery (35.9 months of age vs 53.3 months of age, P = .003) at a significantly younger median age than those whose angle increased <10 PD. Conclusions The angle of deviation of approximately one third of patients with ANAET in this study increased at least 10 PD in the early preoperative period. This increase occurs more often in younger patients and underscores the importance of performing serial measurements of the deviating angle before surgical intervention is undertaken.

Management of strabismus in nanophthalmic patients: A long-term follow-up report

Purpose The purpose of this study is to identify the characteristics of strabismus that coexist with nanophthalmos and to report the results of strabismus surgery performed on these small eyes. Design Retrospective, consecutive, noncomparative interventional case series. Participants Fifteen bilateral nanophthalmic patients, of whom five underwent horizontal muscle surgery, were included in this study. Methods Chart review. The clinical examination included visual acuity assessments using the linear Snellen and the Lea charts, slit-lamp and fundus examinations, intraocular pressure, and axial length measurements. The orthoptic examination consisted of measurements of ocular deviations using the prism cover test with an accommodative target at both near and distance with and without refractive correction, assessment of ocular motility with ductions and versions, binocularity with Worth’s four-dot test, and the Titmus test. Amblyopia was treated with part-time occlusion. Surgery for the correction of esotropia included bilateral medial rectus recessions or recess–resect procedures. Main outcome measures Magnitude of strabismic deviation, best-corrected visual acuity, and the level of binocular vision achieved were monitored. Results The average age of enrollment in the study was 4.7 (range, 1–12) years. The patients were followed for an average of 7.0 (range, 4–14) years. The mean axial length was determined as 18.4 mm (range, 15.5–20.7). The mean refractive error in spherical equivalents was measured as +9.9 and ranged between +4.0 and +15.0 diopters. Five patients (33%) had nonaccommodative esotropia, four (27%) had partially refractive esotropia, four (27%) had microesotropia, and two (13%) had exotropia. Five patients, all having nonaccommodative esotropia, underwent surgery for the correction of ocular misalignment. Diminishing the surgical dose in these small eyes resulted in undercorrections. Despite patching, 3 patients (20%) had unilateral and 12 patients (80%) had bilateral amblyopia at the conclusion of the study. Conclusions Strabismus in nanophthalmos usually manifests as nonaccommodative and partially refractive esotropia. Medial rectus recession should be applied with care to prevent adduction deficit and convergence insufficiency. Otherwise, there seems to be no need for decreasing the surgical dose with regard to the smaller axial length. Amblyopia tends to be persistent in these patients.

Nonaccommodative esotropia after cataract extraction in a patient with previous accommodative esotropia

We report a case of nonaccommodative esotropia developing after bilateral cataract surgery that corrected the preexisting hyperopia in a patient with accommodative esotropia since childhood. The esotropia required surgical correction despite the good visual acuity after the cataract surgery. In patients with preexisting strabismus, there is a possibility of decompensation of adaptive binocular mechanisms after cataract surgery and refractive procedures.

Re-recession of the Medial Rectus Muscles in patients with recurrent esotropia

Purpose: Retrospective evaluation of changes in ocular motility after surgical re-recession of the medial rectus (MR) muscles as treatment of recurrent esotropia (ET). Methods: We describe 115 patients (age, 11 months—77 years; median, 11.1 years; 83 children and 32 adults) with an average amount of non-accommodative ET before surgery of 18.7 PD (SD = 8.8 PD). Preoperative alignment, amount of re-recession, distance from insertion to the limbus, and postoperative alignment and versions were collected. Results: In most cases, MR muscles were re-recessed to a fixed distance of 12 mm from the limbus, with unilateral re-recessions in cases with relatively small ET (typically < 20 PD) and bilateral re-recessions in cases with larger amounts of ET (typically > 20 PD). No clear relation was found between the amount of re-recession and the change in alignment in prism diopters. The success rate (esotropia [ET] ≤ 10 PD or exotropia [XT] ≤ 8 PD) 4 weeks to 8 months after surgery was 85%, with 4 patients still showing ET and 13 patients showing XT. Incidence of XT was higher for bilateral than for unilateral re- recessions. Significant underaction of the MR muscles was noted in 7% of the patients. None of the undercorrected patients and only 1 of the overcorrected patients were adults. Among adults, incidence of MR underaction was 4%. Long-term follow-up (8-120 months; median, 25 months) data from 59 patients indicated that good stability in alignment can be expected. Conclusion: The results support the notion that MR re-recession to 12 mm from the limbus successfully corrects recurrent ET up to 35 PD and that it is particularly effective in adults. (J AAPOS 2001;5:381-7)

Common forms of childhood esotropia.

To determine the most common forms of childhood esotropia. Prospective, consecutive, observational case series. All esotropic children younger than 11 years of age from a predominantly rural Appalachian region evaluated from August 1, 1995 through July 31, 1998. Demographic and clinical data were collected for all patients. The percentage ratio of the various forms of childhood esotropia. 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%). 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.

Acquired nonaccommodative esotropia in childhood

Purpose: Acquired nonaccommodative esotropia (ANAET) in childhood is reported to occur infrequently and is often associated with an underlying neurologic or neoplastic disorder. The primary objective of this study was to ascertain the prevalence and clinical characteristics of this form of childhood esotropia. Methods: A cohort of all children younger than 11 years with esotropia from a predominantly rural Appalachian region was prospectively identified from August 1, 1995, through July 31, 1998. The age at onset, family history of strabismus, perinatal and medical history, ophthalmologic findings, and surgical results were reviewed for all patients with ANAET. Results: Twenty-three (10.4%) of 221 consecutive children with esotropia were diagnosed with ANAET compared with 12 (5.4%) diagnosed with congenital esotropia. The median age at esotropia onset for the 23 children with ANAET was 31.4 months (range, 8-63 months) with a mean initial angle of esotropia of 24 PD. Although at least 2 children presented with diplopia, none of the 23 patients were known to have harbored intracranial tumors or other lesions of the central nervous system during the follow-up period. Fourteen of the 19 patients who underwent surgery attended follow-up visits for at least 6 months after their last surgical procedure: 13 were within 8 PD or less of orthotropia, whereas the final patient had persistent esotropia. Twelve of the 13 patients within 8 PD of orthotropia demonstrated some level of stereopsis, including 2 children with bifoveal fixation. Two (10.5 %) of the 19 operated patients later required a low hyperopic spectacle correction to control their deviation. Conclusions: ANAET was more prevalent than congenital esotropia in this cohort of children with esotropia. This clinically distinct form of strabismus typically begins between 1 and 5 years of age and appears to be infrequently associated with underlying disease. The angle of deviation is relatively small and early surgical correction is more likely to achieve bifoveal fixation for these patients than for those with congenital esotropia. (J AAPOS 2001;5:85-9)

Measurements for horizontal extraocular muscle surgery from the suture site: outcome and influencing factors.

Measurement of recession in strabismus surgery is performed either from the limbus or from the muscle insertion. These measurement methods may result in inaccuracies that may influence the outcome of the procedure. We prospectively evaluated the outcome of recessions measured from the extraocular muscle suture site to its insertion in an incidence cohort. Thirty-six consecutive surgical procedures for infantile esotropia and 23 for constant exotropia were performed in which measurements were performed from the suture site. A successful surgery for esotropia was defined as an orthophoria of up to +10 prism dioptres of deviation for non-accommodative targets at a distance of 20 feet, measured by cover and prism test. A successful surgery for exotropia was defined as a residual deviation between -10 and +10 prism dioptres. The statistical significance of the outcome influencing factors was assessed by chi-square test. Six weeks following surgery, 28 procedures (78%) for infantile and non-accommodative esotropia and 19 procedures (83%) for exotropia were successful. At the end of the follow-up period (mean 13.7 months +/- 9.4 for esotropia and 11.6 months +/- 12.8 for exotropia), the success rate was 77% for esotropia and 75% for exotropia. Prematurity and mental retardation in esotropia, exotropia with pre-operative deviations larger than -45 prism dioptres and amblyopia in exotropia were related to unfavourable outcome (p < 0.05). Measurement for muscle recession can be performed from the suture site. The outcome is comparable to the outcome when measurements are performed from the limbus or the insertion, probably due to the incidence cohort. Refinement of the technique and defining other factors influencing the outcome of strabismus surgery may improve the outcome.

Resultados da correção cirúrgica de esotropias de grande ângulo, em portadores de baixa de acuidade visual unilateral

Objetivo: Avaliar os resultados cirúrgicos de esotropias de grande ângulo (no mínimo 60 dioptrias prismáticas - dp), associadas à baixa de acuidade visual (BAV) unilateral, cuja cirurgia foi planejada com o intuito de não se operar o olho de melhor visão. Casuística e Métodos: Foram selecionados 17 casos de esotropias não-acomodativas, associadas à BAV (AV <= 0,4 no olho não-fixador, com a melhor correção) e sem tratamento cirúrgico prévio. Foi considerado bom resultado desvio pós-operatório de no máximo 10 dp, com rotações binoculares de até -2 de reto medial e +2 de reto lateral, regular XT / ET entre 10 e 15 dp, inclusive, ou rotações de ± 3 e ruim se tinha XT / ET > 15 dp ou rotações de ± 4. Resultados: 13 (76,4%) tinham AV de conta-dedos no olho não-fixador, 2 (11,7%) atingiam 0,1 e outros 2 (11,7%) 0,4. Em 3 havia alta miopia (equivalente esférico > ou = -6,00 dioptrias esféricas) em ambos os olhos. Entre os 17 pacientes, 12 (70,5%) obtiveram bom resultado cirúrgico, 3 (17,6%) foram regulares e 2 (11,7%) ruins. Conclusão: A cirurgia de estrabismo sob anestesia tópica mostrou ser eficaz e segura nestes casos especiais de BAV em um dos olhos, sendo que na maioria das vezes consegue-se não operar o olho de melhor visão; o que a nosso ver, só se tornou possível pelo uso da anestesia tópica.

Bilateral posterior fixation sutures on the medial rectus muscles for correction of nonaccommodative esotropia with infantile onset criteria.

Bilateral posterior fixation sutures on the medial rectus muscles can be used in the management of nonaccommodative esotropia with criteria indicative of infantile onset. The postoperative results of posterior scleral fixation of bilateral medial rectus muscles on ocular motility and the angle of esotropia in different directions of gaze, as well as on the near point of convergence, have been studied. Twenty-six patients suffering nonaccommodative esotropia of the infantile onset type, showing variable angles, adduction overshooting, and esodeviation, which had started within the first year of life, were examined. The angle of esotropia was measured at near, distance, and in the different directions of gaze. All patients underwent post-equatorial scleral fixation of both medial rectus muscles at 12 mm to 14 mm from the insertion, depending on the preoperative angle of esotropia. With the alternate prism cover test, 20 patients (76.9%) showed an angle <10 prism diopters (delta) in the primary position, as well as in the different directions of gaze. Fifteen of the 20 patients (57.7%) even showed simultaneous perception at near and at distance with Bagolini's striated glasses. Six patients were under-corrected. Bilateral posterior fixation of the medial rectus muscles is a good procedure to correct the angle of esotropia in patients who meet the following criteria: essential infantile esotropia, showing overacting medial rectus muscles, variable angles, and nonaccommodative convergence excess.

Posterior fixation suture and convergence excess esotropia

The present study investigates the results of Cüppers' `Fadenoperation' in patients with non-accommodative convergence excess esotropia. Particular attention is given to postoperative eye alignment at distance fixation. Group 1 (n=96) included patients with a `normal' convergence excess. The manifest near angles (mean ET 16.73° ± 6.33°, range 4°-33°) were roughly twice the size of the distance angles (mean ET 6.50° ± 3.62°, range 0°-14°). These patients were treated with a bilateral fadenoperation of the medial recti without additional eye muscle surgery. Three months after surgery, the mean postoperative angles were XT 0.5° ± 3.3° (range XT 11°-ET 5°) for distance fixation, and ET 2.7° ± 3.6° (range XT 5°-ET 14°) for near fixation, respectively. Postoperative convergent angles at near fixation >ET 10° were present in two patients (1.9%). Group 2 (n=21) included patients with a mean preoperative distance angle of ET 9.2° ± 3.7° (range 6°-16 °) and a mean preoperative near angle of ET 23.4° ± 3.1° (range 16°-31°). These patients were operated on with a bilateral fadenoperation of the medial recti and a simultaneous recession of one or both medial rectus muscles. Mean postoperative angles were XT 0.5° ± 4.6° (range XT 12°-ET 7°) for distance fixation and ET 1.4° ± 4.5° (range XT 8°-ET 13°) for near fixation, respectively. In this group, 2 patients (10.6%) had a postoperative exotropia >XT 5° at distance fixation, and two patients had residual esotropia >ET 10° at near fixation. Group 3 (n=17) included patients with a pronounced non-accommodative convergence excess. Near angle values (mean of 17.8° ± 5.3°, range ET 7°-26°) were several times higher than the distance angle values (mean ET 1.9° ± 4.2°, range XT 3° -ET 6°). These patients were treated with a bilateral fadenoperation of the medial recti and a simultaneous resection of one or both medial rectus muscles. Mean postoperative angles were ET 0.2° ± 4.7° (range XT 8°-ET 6°) for distance fixation and 5.3° ± 6.1° (range XT 3°-ET 12°) for near fixation, respectively. One patient had a postoperative distance angle >XT 5°, whereas two patients displayed postoperative convergent angles >ET 5° at near fixation.

Beware: Armed and Dangerous—Acquired Non-Accommodative Esotropia

Beware: Armed and Dangerous—Acquired Non-Accommodative Esotropia

The Stigma of Strabismus: An Ophthalmologist's Perspective

I would like to congratulate Satterfield et al 1 for their article in the August 1993 issue of theArchives. This is an excellent article that addresses many problems that the patient with strabismus experiences. I do not believe many ophthalmologists are sensitive to their problems or needs. As an ophthalmologist who grew up with a nonaccommodative esotropia that followed poliomyelitis with onset at age 5 years, partial surgical correction at age 14 years, and slight overcorrection at age 24 years, I can attest to the multiple problems that the child or adult with strabismus encounters. The cruel insensitivity of other children and adults cannot be overstated. As a result, I developed multiple defense mechanisms that still allowed me to reach my goals in life. The most profound effects on my activities as a child were with regard to sports and social interactions. Fortunately, I learned alternative methods of achieving

Asymmetric Inferior Oblique Overaction and Its Association with Amblyopia in Esotropia

To evaluate the frequency of asymmetric inferior oblique overaction and its relationship to amblyopia, the authors reviewed the records of all patients who presented to Children's Hospital of Dallas with esotropia over a 2-year period. A total of 368 patients were identified and classified as infantile esotropia, acquired accommodative or partially accommodative esotropia, or acquired nonaccommodative esotropia. Two hundred forty-two patients (66%) had no amblyopia, of which 90% had symmetric inferior oblique activity. One hundred twenty-six patients (34%) had amblyopia; of these patients, 93 (74%) had symmetric inferior oblique action. Amblyopia was strongly associated with increased inferior oblique overaction in the amblyopic eye (P less than 0.001). This finding was consistent for all subgroups. The relative risk for having amblyopia as opposed to normal vision in an eye with increased inferior oblique activity relative to the contralateral eye was 5.6 to 8.6 depending on the eye. Amblyopia should be strongly suspected in patients with esotropia and asymmetric inferior oblique activity, specifically in the eye with more inferior oblique overaction.

Acute acquired comitant esotropia.

Acute acquired comitant esotropia has been used to describe a dramatic onset of a relatively large angle of esotropia with diplopia and minimal refractive error. We describe six children aged 5 to 11 years who developed an acute non-accommodative esotropia with diplopia. Neurological examination, including CT scan, in each of these children gave negative results. We suggest that this is an unusual presentation of esotropia of undetermined aetiology. The diagnosis, clinical characteristics, and management are discussed.

Length-tension diagrams of medial rectus muscles after Cüppers' fadenoperation. Surgical assessment of the reversibility of posterior fixation sutures.

Length-tension diagrams of 6 medial rectus muscles, previously submitted to a posterior fixation suture (fadenoperation), were compared to 6 unoperated medial rectus muscles. Both sets of patients presented a nonaccommodative convergence excess esotropia, uncontrolled by conservative treatments (full refraction and progressive addition lenses or bifocals). No changes were found in primary length or spring constant in the muscles operated on with a bridge suture technique (Castiella), in contrast with a marked stiffening appearing in the muscles operated on following Cüppers' original technique.

Consecutive accommodative esotropia.

This paper reports nine patients who developed accommodative esotropia following correction of intermittent exotropia. Eight cases originally were esotropic; one was esotropic secondary to previous surgery for nonaccommodative esotropia. All had the pattern of "divergence excess." In seven patients recession of both lateral recti had been performed in conventional amounts; one case had a recession/resection procedure, and one case recession of the lateral recti followed by resection of the medial recti. In all cases the consecutive accommodative esotropia included an abnormally high distance/near relationship. All were controlled by appropriate optical or drug treatment, and six cases deteriorated later. Surgical overcorrection was not a prominent contributing factor. Preoperative occlusion and/or the +3.00 D test would not have predicted the persistence of the high distance/near relationship. There were no other obvious indicators of this complication.

Changes in the Binocular Fixation Patterns and the Visually Evoked Potential in the Treatment of Esotropia with Amblyopia

Using the binocular fixation pattern (BFP) and the visually evoked potential (VEP), thirteen amblyopic patients with comitant, non-accommodative esotropia with an angle range up to 30Δ were studied before and during occlusion therapy. A graded BFP with a stronger preferred fixation could be used to diagnose amblyopia. The BFP, however, showed no significant change with therapy despite improvement in acuity. In contrast, the VEP amplitudes, initially reduced in amblyopia, increased significantly as the vision responded to patching. The VEP was useful in diagnosing strabismic amblyopia and giving a predictive range of acuities.