The incidence, clinical features, and management of essential infantile esotropia in the United Kingdom. A British Ophthalmology Surveillance Unit (BOSU) study.

BACKGROUND/OBJECTIVES: A national study was undertaken through the British ophthalmology surveillance unit (BOSU) to determine the incidence, presenting features and management of essential infantile esotropia (EIE) in the UK. METHODS: Data from a prospective national observational study of newly diagnosed EIE presenting to clinicians in the United Kingdom over a 12-month period were collected. Cases with a confirmed diagnosis by a clinician of a constant, non-accommodative esotropia ≥20 prism dioptres (PD), presenting at ≤12 months, with no neurological or ocular abnormalities were identified through BOSU. Follow-up data were collected at 12 months. RESULTS: A total of 57 cases were reported giving an incidence of EIE of 1 in 12,828 live births. The mean age of diagnosis and intervention were 7.05 ± 2.6 months (range 2-12) and 14.7 ± 4.9 months (range 6.5-28.1), respectively. Management was surgical in 59.6%, botulinum toxin alone in 22.8%, and 17.5% were observed. The preoperative angle of esotropia was smaller in the observation group (P = 0.04). The postoperative angle of esotropia was not statistically significant between botulinum toxin or surgery (P = 0.3), although the age of intervention was earlier in the botulinum group (P = 0.007). Early intervention (before 12 months of age) did not influence the post-intervention motor outcomes between 0 and 10 prism dioptres of esotropia (P = 0.78). CONCLUSIONS: The incidence of EIE in the UK is considerably lower than reported in other population-based studies. The preferred method of treatment was surgical with earlier intervention in those treated with botulinum toxin. An early age of intervention (<12 months) did not influence motor outcomes.

Nonsurgical Consecutive Exotropia Following Childhood Esotropia: A Multicentered Study.

PURPOSE: Nonsurgical consecutive exotropia (NCX) occurs when an esotropia (ET) spontaneously converts to exotropia (XT) without surgical intervention. Although NCX is considered to occur in early-onset accommodative ET with high hyperopia, consensus on causation is lacking. We report the clinical characteristics of NCX and assess the response to conservative management. DESIGN: Retrospective, multicenter, observational case series. METHODS: Patients aged 6 months and older with an initial diagnosis of ET who converted to XT without surgical intervention. Sensory strabismus was excluded. Age, visual acuity, cycloplegic refraction, glasses prescriptions, deviation, and binocular vision were collected. RESULTS: Forty-nine children were included with a mean age of 3.5 ± 1.6 years and 8.4 ± 3.6 years at the time of ET and NCX, respectively. Mean refractive error was +4.40 ± 2.13 diopters (D) and +4.05 ± 2.74 D at the time of ET and NCX, respectively. Accommodative ET occurred in 60% of cases, and only 35.7% were high hyperopes. All but 1 patient presented with XT at distance. In response to the XT, a mean decrease in hyperopic prescription of 1.55 ± 0.48 D was given (N = 17); only 1 case reverted to ET. Eventually, 43% underwent XT surgery, with similar rates between those who had refractive management and those who did not. CONCLUSIONS: NCX occurs in both accommodative and nonaccommodative ET; high hyperopia is present in only one-third of cases. On average, drift to XT occurs within 5 years. Refractive management has a modest result. No predictive risk factors were identified. Our findings challenge hyperopia-linked theories of causation. Nonrefractive explanations, such as the role of the vergence system, deserve further study.

Demographic and clinical characteristics of age-related distance esotropia.

BACKGROUND: Age-related distance esotropia (ARDE), is an acquired, small, comitant esodeviation that is greater at distance than at near. It occurs in older adult patients without a history of neurological event or prior strabismus. It has been observed more frequently in White adults than in other racial groups. The purpose of this study was to assess the demographic and clinical characteristics of patients with ARDE presenting at a tertiary neuro-ophthalmology clinic. METHODS: In this retrospective study, ICD-9/10 (ICD-9 378.85 and ICD-10 H51.8) codes were used to identify all patients with ARDE from 2005 to 2020 seen in a single tertiary neuro-ophthalmology clinic. ARDE was defined as esotropia greater at distance than near with associated clinical signs of adnexal tissue laxity. Patients with history or findings compatible with other etiologies of strabismus, such as thyroid eye disease, neuromuscular disorders, sensory deviations, sudden onset of diplopia, and high myopia, as well as those with prior strabismus surgery, were excluded. RESULTS: A total of 89 patients (59 females [66%]) met inclusion criteria. Mean patient age was 76.6 years. All patients were White except for a single patient of African descent. Mean follow-up time was 25.2 months. Mean esodeviation at distance on presentation was 6.6Δ. Of the 87 patients electing nonsurgical treatment, 80 achieved remission of diplopia symptoms with prism therapy alone. Of the 89 patients, 59 had no neuroimaging. CONCLUSIONS: ARDE in our neuro-ophthalmology clinic population was diagnosed almost exclusively in older White adults. Prism therapy was effective for a majority of our patients.

Management of acute acquired comitant esotropia in children.

Aim: This report aims to discuss and review the diagnosis and management of acute acquired comitant esotropia (AACE) in children and to add several cases to the limited literature available on this unusual condition in the pediatric population. Materials and methods: We present two cases of AACE with large-angle deviations that were investigated and followed-up according to current recommendations. Both cases required strabismus surgery for AACE, but different procedures were chosen, with good postoperative results. Results: Unilateral recession of the medial rectus and resection of the lateral rectus (R&R) were performed in one case and bilateral medial rectus (MR) recession in the other, with resolution of the diplopia and full recovery of binocular vision. Discussion: Although isolated AACE is usually benign, studies have reported the presence of intracranial disease in up to 10% of cases, making it a potential first sign of an underlying serious pathology. Therefore, AACE should be investigated as a medical emergency and neuroimaging should be performed in all patients with unclear onset of AACE, as well as in those with associated neurological symptoms, such as headache, cerebellar imbalance, weakness, or nystagmus. Conclusion: Acute acquired comitant esotropia (AACE) is an infrequent type of esotropia that usually appears in older children. It is characterized by esotropia and diplopia with acute onset. Neurological examinations and neuroimaging should be performed to exclude any potential intracranial disease. Treatment of AACE without underlying neurological disease is focused on managing the diplopia and resolving the esotropia. Strabismus surgery has good motor and sensory results and can successfully restore good binocular function. Abbreviations: AACE = Acute acquired comitant esotropia, LR = lateral rectus, MR = medial rectus, PD = prism diopters, R&R = recession and resection, BSV = binocular single vision, PAT = prism adaptation test.

Prevalence and clinical characteristics of age-related distance esotropia.

Age-related distance esotropia (ARDET) is characterized by an esodeviation greater at distance than near in older aged patients and generally managed with prism spectacles or surgery. The purpose of this study is to describe the prevalence, clinical characteristics, and natural history of age-related distance esotropia in a defined population. The medical records of all adult (≥19 years of age) residents of Olmsted County, Minnesota, diagnosed with an esodeviation at least 2 prism diopters (PD) greater at distance than near, from 1 January 1985, through 31 December 2004, were retrospectively reviewed. Seventy-three (9.7%) of 751 new cases of adult-onset strabismus were diagnosed with age-related distance esotropia during the 20-year period. The mean age of onset was 70 years (range, 19 to 93 years) and 48 (65.8%) were female (p = .007). The mean angle of esodeviation was 7.6 (range, 2 to 20) prism diopters (PD) at distance and 0.4 (range, 10 PD of XT to 12 PD of ET) PD at near. The Kaplan-Meier rate of progression, as defined by a ≥ 6 prism diopter (PD) increase in esotropia, was 50% by 15 years after diagnosis. Half of the patients had hypertension, while one-third had coronary artery disease or other cardiac comorbidities. Age-related distance esotropia comprised 1 in 10 adults with new-onset strabismus in this population and was significantly more common among women. Hypertension and cardiovascular disease may be risk factors for this form of strabismus, and approximately half of the patients worsened over a 15-year period.

"Pulsating proptosis and heavy eye syndrome precipitated by neurofibromatosis type 1: A case report".

RATIONALE: Neurofibromatosis type 1 (NF1) is a hereditary disease characterized by café-au-lait spots, peripheral neurofibromas, Lisch nodules, optic nerve glioma, and sphenoid wing dysplasia. Pulsating proptosis is associated with a sphenoid bony defect. Heavy eye syndrome is characterized by acquired esohypotropia in patients with high myopia. This study aimed to describe the presentation of pulsating proptosis and heavy eye syndrome precipitated by NF1 and its management. PATIENT CONCERNS: A 41-year-old woman presented with progressive pulsating proptosis and hypodeviation of the right eye over the past 2 years. The axial length of the right eye was 36.81 mm. The right eye presented with esohypotropia and hypoglobus. The ocular motility examination showed limitations in all directions, especially in supraduction. Brain computed tomography revealed sphenoid wing dysplasia of the right orbit. The meningocele protruded through the orbital defect, lifting the globe. Brain magnetic resonance imaging demonstrated superior rectus muscle (SR) medial displacement and lateral rectus muscle inferior displacement. Physical examination revealed café-au-lait macules and neurofibromas on the trunk. DIAGNOSIS: NF1 with pulsating proptosis and heavy eye syndrome. INTERVENTIONS: The patient declined neurosurgery due to risk and economic reasons. To manage her main concern regarding cosmetics, we performed orbital floor decompression, SR resection with advancement, maximal hang-back recession of the inferior rectus muscle, and a partial Jensen's procedure. OUTCOMES: Proptosis was reduced. The eye position became more symmetrical. The range of eye movements was also increased. LESSONS: This case describes a rare synchronous presentation of pulsating proptosis and heavy eye syndrome precipitated by NF1. Adult-onset presentation implied a progressive process in NF1. The case also showed a different etiology from that of typical heavy eye syndrome. It reminds ophthalmologists that orbital imaging should be performed in high myopia patients with strabismus to evaluate the extraocular muscle pathway. Furthermore, the case demonstrated a management that avoided the risk and expensive cost of neurosurgery, which has not been reported.

Reverse exercises in a case of intractable diplopia.

The aim of this presentation is to highlight how orthoptic exercises can be adapted from the standard implementation and gain results in an intractable diplopia case. A 16-year-old male presented with a 20 prism diopters residual right esotropia and intractable diplopia following Surgery and Botulinum Toxin. Having had further BT and surgery ruled out and no success with Fresnel prisms or occlusion, he commenced on standard orthoptic exercises without success. Additional orthoptic assessment discovered that the patient could achieve binocular single vision (BSV) on convergence at 10 cm. The patient then proceeded on a course of exercises to help extend this area of BSV. These exercises included a reverse dot card and a variation of the distance cat stereogram. Over the next couple of visits, the area of binocularity was extended to 30 cm and the esotropia measured 18 prism diopters. However, the patient felt that progress was slow, and they were keen to learn to drive and so opted for an occlusive contact lens instead. It is unfortunate that the patient did not continue with the exercise program as it showed potential to increase his area of BSV. However, this case does demonstrate how utilizing current knowledge concepts of both exercises and BSV, and adapting them to a specific patient could lead to improvement in the likes of intractable diplopia and be a potential management option.

Outcomes in accommodative esotropia with a high AC/A ratio.

PURPOSE: The purpose of this retrospective cohort study was to report the outcomes of high AC/A ratio accommodative esotropia (AET) among children. METHODS: The medical records of all children <19 years diagnosed with accommodative esotropia and a high AC/A ratio while residing in Olmsted County, Minnesota, from January 1, 1975, through December 31, 2004, were retrospectively reviewed. RESULTS: A total of 512 patients were diagnosed with AET during the 30-year study period, of which 395 (77.1%) had fully accommodative ET, 117 (22.8%) had partially accommodative ET and 106 (20.5%) had a high AC/A ratio. Of the 93 (87.7 %) high AC/A patients managed with bifocals, 50 (53.8 %) discontinued their use after a mean of 58.7 (range: 5.6-229) months. The Kaplan-Meier rate of discontinuing bifocals was 24.5% at 3 years, 36.4% at 5 years, and 61.4% at 10 years. Patients who discontinued bifocals were more likely to have had strabismus surgery (44% vs 18.6%, p = 0.009) than those who did not discontinue bifocals. The high AC/A patients managed with bifocals achieved similar stereoacuity outcomes to those who did not wear bifocals (p = 0.65) and were no more likely to require surgery (p = 0.13). CONCLUSION: Among this cohort of children with accommodative esotropia and a high AC/A ratio, bifocal use was discontinued in the majority of children within 10 years, and more commonly among those who underwent strabismus surgery. The use of bifocals was not associated with a higher likelihood of undergoing surgery or enhanced stereopsis compared to those who did not use them.

Combined passive and active treatment in strabismic amblyopia with accommodative component.

BACKGROUND: Treatment of amblyopia in esotropic subjects with accommodative component currently consists of optical correction and subsequent occlusion, or penalisation, of the dominant eye. This treatment obtains a good outcome in visual acuity but poor outcomes in binocular vision. An intervention protocol that could improve the outcome of conventional treatment is presented. METHODS: A retrospective study in subjects with amblyopia associated with both fully accommodative and partially accommodative esotropia is presented. Subjects were refracted under cycloplegia and treated with occlusion (passive therapy). Subjects who did not achieve orthotropia through optical correction (partially accommodative esotropia) performed an active therapy (full-time prismatic correction and subsequent fusional vergence therapy or surgery in larger angles > 12 prism dioptres). After treatment, the subjects were examined by a masked optometrist in an external ophthalmology clinic. RESULTS: Twenty-six subjects (12 males and 14 females) aged from six to 13 years (median 8.50; interquartile range [IQR] 3) were included. Median age of detection was three years (IQR 1). All the subjects were hyperopic. In the baseline, median best-corrected visual acuity of the amblyopic eye was 0.40 logMAR (IQR 0.30) and 0.00 logMAR (IQR 0.01) in the dominant eye. After the treatment, the median best-corrected visual acuity in the amblyopic eye was 0.06 logMAR (IQR 0.08). These differences were statistically significant (p < 0.001). All subjects acquired stereoacuity equal or better than 800'' with the Randot Preschool Stereoacuity Test. CONCLUSIONS: The proposed treatment highlights the management of amblyopia in esotropic subjects with accommodative component. This intervention protocol could help to determine if the treatment has to be passive (in fully accommodative esotropia) or a combination of passive and active therapies (in partially accommodative esotropia).

[Neglected childhood strabismus: Epidemiological, clinical and therapeutic aspects]. / Strabisme de l'enfance négligé : aspects épidémiologiques, cliniques et thérapeutiques.

INTRODUCTION: In an environment where strabismus is poorly understood and management centers rare, we studied the epidemiological, clinical and therapeutic aspects of neglected childhood strabismus. MATERIALS AND METHODS: This was a retrospective study carried out from March 1st, 2013 to September 30, 2018. Neglected childhood strabismus was defined as strabismus occurring in the first 5 years of life, for which the patient was over 7-years-old at the time of first consultation. The variables studied were age at first consultation, gender, age of onset, type of strabismus, etiology of strabismus, angle of deviation and rate of surgery. RESULTS: We found 113 cases of neglected childhood strabismus among the 430 cases of strabismus seen during the study period. There were more females (n=64) than males. The mean age was 17.7±10.5 years. There were 73 exotropias (64.6 %). The mean angle of deviation was 41.2±12.2PD. Strabismus was early in 70.8 % of cases. Innervational strabismus accounted for 86.7 % of cases. The most frequent refractive error was hyperopic astigmatism (55.3 %). Of the 45 patients who were seen again after full-time wear of their full cycloplegic correction, 2 were orthotropic. Surgery was performed in 60.5 % of cases. The average postoperative angle of deviation was 6.6±9.4PD. CONCLUSION: Management of neglected childhood strabismus provides good results and should therefore be encouraged in order to improve the quality of life of affected patients.

Prism treatment of acute acquired concomitant esotropia precipitated by visual confusion.

Objective: Acute acquired concomitant esotropia (AACE) is a distinct subtype of esotropia. The purpose of this retrospective study was to describe the clinical characteristics and discuss the diagnostic and therapeutic management, and evaluate the effect of prism treatment.Methods: The records of 30 patients who presented with acute-onset diplopia at the General Hospital of Central Theater Command from August 2015 to November 2018 were reviewed. All patients underwent a complete medical history, ophthalmological and orthoptic examinations, and brain and orbital imaging. The patients were followed up between 2 and 8 months (mean 3.9 ± 1.2). Angle of strabismus, refractive error, stereopsis, and results of treatment with prisms were analyzed. Level of stereopsis was assessed before and after prismatic correction. Patient satisfaction was assessed with a telephone follow-up survey.Results: The mean age of the 30 patients was 29.7 ± 10.3 years (range 14-52). All patients complained about uncrossed diplopia, only at distance. The esophoria was concomitant in all cases ranging from 12 to 60 prism diopters (PD) at distance (mean 35.80 ± 14.17) and from 10 to 46 PD at near (mean 26.23 ± 11.46) (t = 6.51, P <.001). Cycloplegic spherical-equivalent refraction averaged -5.25 ± 1.67 D (range -0.50 to -8.13), 28 patients were myopic and 2 were emmetropic, all did not wear glasses for near work. All patients received brain and orbital computed tomography scans and magnetic resonance imaging and, in some cases, neurological examinations were performed. All of these examinations were normal. In 27 out of 30 patients treated with prisms, the diplopia resolved, whereas three patients were not satisfied with prismatic correction and underwent surgery. With prisms the esophoria was concomitant, ranging from 6 to 23 PD at distance fixation and from 4 to 18 PD at near fixation. Out of 30 patients, 23 patients were satisfied, 3 patients were not satisfied because their vision remained uncomfortable and 4 patients had an intermediate score.Conclusion: AACE was characterized by a sudden onset of concomitant non-accommodative esotropia with diplopia or visual confusion. In most cases, prismatic correction had a favorable effect with a resolution of diplopia. It offers a good treatment alternative in the early stage, when the angle of strabismus is unstable and surgery is not without risk.

A Comparative Study of Prism Adaptation and the Augmented Surgery Formula in the Management of Acquired Comitant Esotropia.

PURPOSE: To compare two methods of surgical augmentation (prism adaptation and the augmented surgery formula) in the management of acquired comitant esotropia. METHODS: Forty patients were included in this prospective study and assigned to either the prism adaptation (20 patients) or augmented surgery (20 patients) group. After preoperative prism adaptation, patients in the prism adaptation group were classified as prism adaptation responders (fusers) or non-responders (non-fusers). All patients in the prism adaptation group underwent surgery for the prism-adapted angle. Patients in the augmented surgery group underwent surgery based on the augmented surgery formula, defined as the average of the near deviation without correction and the distance deviation with correction. RESULTS: In the prism adaptation group, 6 patients (30%) were prism responders, whereas 14 (70%) were non-responders. The 3-month motor success rate was significantly higher in the prism adaptation group (90%) than the augmented surgery group (55%) (P = .013). The 6-month motor success rate was not significantly higher in the prism adaptation group (95%) than the augmented surgery group (80%) (P = .151). The improvement in the 6-month outcome was mainly attributed to hyperopic spectacle power reduction after 3-month postoperative evaluation to correct consecutive exotropia. CONCLUSIONS: Although prism adaptation is superior in precisely determining the surgical target angle, the success rates were comparable between the two groups after hyperopic spectacle power reduction. This obviates the need for prism adaptation, except in cases of non-accommodative esotropia. To maximize the benefit of prism adaptation, it is recommended that all patients with prism adaptation (responders and non-responders) undergo surgery for the prism-adapted angle. [J Pediatr Ophthalmol Strabismus. 2020;57(2):108-119.].

Long-term outcomes of prismatic correction in partially accommodative esotropia.

PURPOSE: In partially accommodative esotropia (PAET), prism glasses can correct small angles of residual esotropia but the long-term effect of prismatic correction alone without surgery has not been reported. We aimed to investigate the long-term outcome of prism glasses after full hypermetropic correction for PAET. METHODS: This retrospective, case-control study was performed for children aged 10 years or younger with a residual esotropia of ≤ 20 prism diopters (PD) after full hypermetropic correction who were fitted with prism glasses and followed-up for 3 years or more. Clinical characteristics and the angle of esodeviation were obtained at each follow-up examination. Successful motor outcome after 3 years of prismatic correction was determined if the residual angle of esotropia after full hypermetropic correction was ≤ 10PD. Patients who eventually weaned off prism glasses were noted. RESULTS: Among 124 patients, 30.6% achieved success and 7.3% weaned off prism glasses after 3 years of prism-wear. Smaller amount of latent esodeviation (P = 0.001) revealed by prism adaptation and good fusional response at near with the Worth 4-dot test were significant prognostic factors of success by multivariate analysis (P = 0.033). After 3 years of wearing prism glasses, the rate of improvement in stereoacuity was higher in the Success group (60.5% vs 27.9%) (P = 0.001), however, there was no significant difference between the prism-weaned group and prism-wearing group within the Success group (P>0.05). CONCLUSION: Prism glasses for small angle PAET can be a treatment option in patients who have a small angle of latent esodeviation revealed by prism adaptation and good sensory fusion at near. Otherwise, early surgery may be advisable as the majority of patients showed suboptimal outcome even after long-term prism-wear.

Characteristics of Patients Who Are Not Responsive to Alternate Patching for Overcorrected Intermittent Exotropia.

PURPOSE: To compare the characteristics of patients with surgically overcorrected intermittent exotropia treated with alternate patching. METHODS: The medical records of 51 patients who underwent bilateral lateral rectus muscle recession for intermittent exotropia and required alternate patching to correct postoperative overcorrection were retrospectively reviewed. Patients with postoperative esodeviation ≥18 prism diopters (PD) were started on alternate patching on postoperative day 1, whereas those with postoperative esodeviation of 10 to 17 PD were started after 2 weeks. Postoperative esodeviation <10 PD was considered as slight intentional overcorrection after exotropia surgery. Patients not responsive to alternate patching treatment were defined as those with postoperative esodeviation ≥10 PD after 3 months of treatment. Sex, family history, age, refractive error, amblyopia, stereopsis, suppression, type of exotropia, surgical method, preoperative and postoperative angle of deviation, and start time of alternate patching were compared. RESULTS: Among 51 patients, 29 patients responded to alternate patching and 22 patients did not respond. Female sex (p = 0.04), larger preoperative exodeviation at distance (p = 0.04), late onset of postoperative maximal esodeviation (p < 0.01), larger postoperative maximal esodeviation at near (p = 0.02), and late initiation of alternate patching (p = 0.01) were associated with patients in the non-responsive group. Although postoperative angle of deviation was similar for 2 weeks, the angle of postoperative esodeviation was significantly larger in the non-responsive group than in the responsive group, beginning at 1 month postoperatively. CONCLUSIONS: Female sex, large preoperative exodeviation, late initiation of alternate patching, and large esodeviation 1-month postoperative predisposed patients to be resistant to alternate patching for postoperative overcorrection.

The Effect of Botulinum Toxin Augmentation on Strabismus Surgery for Large-Angle Infantile Esotropia.

PURPOSE: To determine whether botulinum toxin augments the effect of strabismus surgery in pediatric patients with large-angle infantile esotropia. DESIGN: Retrospective, comparative, case series. METHODS: Setting: Tertiary-care pediatric hospital. STUDY POPULATION: Patients with large-angle infantile esotropia. INTERVENTION: Treatment with botulinum toxin-augmented bilateral medial rectus muscle recessions ("augmented-surgery group") or traditional bilateral medial rectus muscle recessions ("surgery-only group"). MAIN OUTCOME MEASURE: The effect of surgery on ocular alignment at 4 months, measured in prism diopters of change per mm of surgery (PD/mm). RESULTS: There were 14 patients in the augmented-surgery group and 16 patients in the surgery-only group. The mean effect on alignment was significantly greater in the augmented-surgery group compared to the surgery-only group at 4 months (5.7 ± 1.3 vs 4.0 ± 1.4 PD/mm, P = .002) and at 1 year (5.4 ± 1.2 vs 3.7 ± 1.2 PD/mm, P = .002). There was a partial loss of treatment effect between 4 months and 1 year in both groups, which was similar in magnitude (P = .57). On linear regression, there was a trend toward a positive correlation between botulinum toxin dose and treatment effect, but this was not statistically significant (P = .09). CONCLUSIONS: Botulinum toxin augments the surgical effect of medial rectus muscle recession. Botulinum toxin-augmented surgery may be an alternative to traditional options for large-angle infantile esotropia. A surgical dosing table is proposed for this technique.

Reduction of Consecutive Esotropia Using Modified Contralateral Recession and Resection for Recurrent Intermittent Exotropia.

PURPOSE: To report consecutive esotropia in contralateral lateral rectus recession and medial rectus resection for recurrent intermittent exotropia after unilateral lateral rectus recession and medial rectus resection and to evaluate the surgical outcome of modified contralateral lateral rectus recession and medial rectus resection for exotropia after unilateral lateral rectus recession and medial rectus resection. METHODS: A total of 36 patients were included in this retrospective study. As a primary surgery for exotropia, all patients underwent unilateral lateral rectus recession and medial rectus resection on the non-dominant eye. Patients were subsequently assigned to either conventional contralateral lateral rectus recession and medial rectus resection (surgical dosages based on Wright's surgical table) (n = 19; conventional group) or modified contralateral lateral rectus recession and medial rectus resection (surgical dosages reduced by 5 prism diopters on Wright's surgical table) (n = 17; modified group) for recurrent exotropia. Surgical success rates were evaluated. Reoperation or prism glasses prescription rates due to consecutive esotropia were evaluated. RESULTS: The mean follow-up durations after reoperation were 25.8 and 24.0 months in the conventional and modified groups, respectively. The surgical success rates were 73.7% and 82.4% (P = .538, Fisher's exact test) and the recurrence rates were 0% and 17.6% (P = .059, Fisher's exact test), respectively. The reoperation or prism glasses prescription rates due to consecutive esotropia were 26.3% and 0%, respectively (P = .025, Fisher's exact test). CONCLUSIONS: Final outcomes were better in the modified group compared to the conventional group. Consecutive esotropia was significantly more frequent in the conventional group than in the modified group. In surgery for recurrent exotropia, a reduction of the surgical dosage will reduce the incidence of consecutive esotropia. [J Pediatr Ophthalmol Strabismus. 2018;55(1):53-58.].

[Optic nerve hypoplasia and septo-optic dysplasia]. / Optikushypoplasie und septooptische Dysplasie.

Optic nerve hypoplasia (ONH) is one of the most common causes of congenital visual impairment. It was first described in 1915 and represents a developmental disorder of the central nervous system. It is often associated with intracranial midline defects and is then referred to as septo-optic dysplasia (SOD). The symptoms of ONH range from minimal visual dysfunction to significant visual impairment with sensory defect nystagmus and even blindness. The ONH is often associated with further systemic, endocrinological and neurological abnormalities requiring a close interdisciplinary treatment of the patients.

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

INTRODUCTION: Evaluation of a single injection of botulinum toxin A in infantile esotropia as an alternative choice to surgery in a retrospective cases serie. METHODS: 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. RESULTS: 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%). CONCLUSIONS: 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.

Comparison of Botulinum Toxin With Surgery for the Treatment of Acute-Onset Comitant Esotropia in Children.

PURPOSE: To determine whether botulinum toxin is as effective as strabismus surgery in the treatment of acute-onset comitant esotropia in children. DESIGN: Retrospective, nonrandomized, comparative clinical study. METHODS: Setting: Tertiary care pediatric hospital. STUDY POPULATION: Forty-nine children with acute-onset comitant esotropia. INTERVENTION: Treatment with either botulinum toxin ("chemodenervation group") or standard incisional strabismus surgery ("surgery group"). MAIN OUTCOME MEASURE: Success rate at 6 months (total horizontal deviation of 10 prism diopters or less and evidence of binocular single vision). RESULTS: There were 16 patients in the chemodenervation group and 33 patients in the surgery group. The success rate was not significantly different at 6 months (81% vs 61%, P = .20) or at 18 months (67% vs 58%, P = .74). The median angle of deviation and median stereoacuity were not significantly different at 6 or 18 months. The chemodenervation procedure was not inferior to incisional strabismus surgery at 6 months. The duration of general anesthesia (5 vs 71 min, P < .001) and time in the post-anesthesia care unit (37 vs 93 min, P < .001) were significantly shorter in the chemodenervation group. Botulinum toxin injection payment averaged $874 per procedure compared with $2783 for strabismus surgery. CONCLUSIONS: Botulinum toxin is at least as effective as surgery in the treatment of acute-onset comitant esotropia at 6 months while reducing the duration of general anesthesia and healthcare costs.