The Role of Dynamic Retinoscopy in Predicting Infantile Accommodative Esotropia and Influencing Emmetropization.

INTRODUCTION AND PURPOSE: To investigate the role that dynamic retinoscopy can play in reducing the occurrence of infantile accommodative esotropia and facilitating emmetropization in infants with high hyperopia. PATIENTS AND METHODS: 211 orthotropic infants under 1 year of age (3.5 to 12 months) identified as having ≥5 diopters of hyperopia in their more hyperopic eye on a routine eye exam. On enrollment, infants underwent an assessment of accommodation using dynamic retinoscopy as well as a cycloplegic refraction. Infants who showed normal accommodation were followed without spectacles. If dynamic retinoscopy showed subnormal accommodation, partial hyperopic correction that allowed for full binocular accommodative responses at near were prescribed. Main outcome measures were the occurrence of esotropia, changes in refractive error, and visual acuity. RESULTS: Of the 211 infants enrolled, 146 showed normal accommodation and were followed without glasses (Group 1). None of these patients developed strabismus. Sixty-five patients showed subnormal accommodation and received partial hyperopic correction (Group 2). Thirty-four of the 65 (52%) in Group 2 did not develop strabismus (Group 2A) and 31 of the 65 (48%) developed strabismus (Group 2B). All 3 groups showed a reduction of hyperopia of 0.37D ± 0.25/year, 0.50D ± 0.28/year, and 0.60D ± 0.20/year in groups 1, 2A, and 2B, respectively. None of the differences between groups were statistically significant. CONCLUSIONS: Normal accommodation on dynamic retinoscopy in orthotropic hyperopic infants is a predictor of continued good alignment and such infants can be followed without spectacles. Partial spectacle correction based on dynamic retinoscopy may have a beneficial effect on reducing the development of strabismus without impeding emmetropization. Early binocular accommodative behavior seems to be predictive of infants at risk of developing strabismus.

Combined recession and resection surgery in the management of convergence excess esotropia with different levels of AC/A ratio.

PURPOSE: To study prospectively the effect of extirpating the proprioceptive impulse at the myotendinous junction combined with recession of the medial rectus muscles in patients with convergence excess esotropia. METHODS: A total of 21 patients with different sizes of AC/A ratios (high, 8; normal, 12; low, 1) underwent a surgical procedure consisting of combining resection of 2.5 mm of the insertional end of the medial rectus muscles with recession from the original insertion, based on the patient's angle of esotropia at 1/3 m while wearing full cycloplegic refraction, with an additional recession of 1 mm for each rectus muscle based on current surgical tables. A satisfactory outcome was defined as orthotropia or esotropia of <10Δ at near and distance fixations with available correction and reduction of the distance--near disparity to <10Δ. RESULTS: All patients, regardless of the size of AC/A ratio and the amount of near-distance disparity, had satisfactory alignments at near and distance fixations, with residual near-distance disparity of <10Δ. Consecutive distance exotropia did not develop even when there was preoperative distance orthotropia. Outcome measures remained stable for a mean of 4.3 years. None of the 8 patients with high AC/A ratios required bifocal wear or overcorrection prescriptions to maintain alignment postoperatively. CONCLUSIONS: This technique of combined resection and recession of the medial rectus muscle shows promise in the treatment of convergence excess esotropia. The main advantage is improvement in distance alignment while selectively reducing the near angle in patients with different levels of AC/A ratios.

Late Presentation of Ataxia, Areflexia, and Electrophysiological Abnormalities as Part of Miller Fisher Syndrome: Case Report.

Miller Fisher syndrome (MFS) is characterised by the triad of ophthalmoplegia, ataxia, and areflexia. A case with external ophthalmoplegia and absence of ataxia and areflexia until the end of second week is presented. Electrophysiological findings became apparent after the third week and showed reduced amplitudes of sensory nerve action potentials and prolonged latencies of F with no evidence of conduction blocks. There was no response to intravenous immunoglobulin, but there was response to corticosteroids. This case may represent an atypical MFS with late presenting electrophysiological abnormalities. Corticosteroids can be a therapeutic option when intravenous immunoglobulin fails to control clinical symptoms.

Surgical planning and innervation in pontine gaze palsy with ipsilateral esotropia.

PURPOSE: To discuss surgical intervention strategies among patients with horizontal gaze palsy with concurrent esotropia. METHODS: Five consecutive patients with dorsal pontine lesions are presented. Each patient had horizontal gaze palsy with symptomatic diplopia as a consequence of esotropia in primary gaze and an anomalous head turn to attain single binocular vision. RESULTS: Clinical findings in the first 2 patients led us to presume there was complete loss of rectus muscle function from rectus muscle palsy. Based on this assumption, medial rectus recessions with simultaneous partial vertical muscle transposition (VRT) on the ipsilateral eye of the gaze palsy and recession-resection surgery on the contralateral eye were performed, resulting in significant motility limitation. Sequential recession-resection surgery without simultaneous VRT on the 3rd patient created an unexpected motility improvement to the side of gaze palsy, an observation differentiating rectus muscle palsy from paresis. Recession combined with VRT approach in the esotropic eye was abandoned on subsequent patients. Simultaneous recession-resection surgery without VRT in the next 2 patients resulted in alleviation of head postures, resolution of esotropia, and also substantial motility improvements to the ipsilateral hemifield of gaze palsy without limitations in adduction and vertical deviations. CONCLUSIONS: Ocular misalignment and abnormal head posture as a result of conjugate gaze palsy can be successfully treated by basic recession-resection surgery, with the advantage of increasing versions to the ipsilateral side of the gaze palsy. Improved motility after surgery presumably represents paresis, not "paralysis," with residual innervation in rectus muscles.

The accommodative element in accommodative esotropia.

PURPOSE: To evaluate the effect of reducing the hyperopic correction on the state of binocular accommodative response in fully accommodative esotropia and to determine the "comfortable" amount of reduction in hyperopic correction. DESIGN: A cohort study. METHODS: Hyperopic corrections of children with a baseline refractive error of +1.50 to +5.0 diopters were gradually reduced in 0.50-diopter increments. Binocular accommodative ability was assessed by dynamic retinoscopy (monocular estimate method). Similar binocular accommodative responses were ascertained among patients with a baseline hyperopic correction of < or =3.0 of hyperopia and >3.0 of hyperopia, and patients were divided into two groups, group 1 (13 patients) and group 2 (18 patients), accordingly. RESULTS: After a reduction of 2.0 diopters in group 1 and 1.0 diopter in group 2, there was a decrease in accommodative response initially in the nondominant eye, accompanied by the dominant eye with a further reduction of 0.50 diopter. To overcome the bilateral accommodative lag, a reinstatement of a 0.50-diopter stronger hyperopic correction was required. Patients in group 1 tolerated a mean undercorrection of 2.37 diopters, and 77% were weaned from their spectacles. All of the children in group 2 were dependent upon spectacles at the completion of the study period. The final spectacle worn was a median of -1.67 diopters less than their full cycloplegic refraction. CONCLUSIONS: A complete binocular accommodative ability seems to be a prerequisite for the establishment of "comfortable" hyperopic undercorrections. It does not seem to be a reasonable approach to consider further reductions in hyperopic correction in the presence of a bilateral decreased accommodative performance.