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.

Long-Term Changes of Hyperopic Refractive Error in Refractive Accommodative Esotropia

PURPOSE: To analyze the long-term changes of hyperopic refractive error in patients with refractive accommodative esotropia. METHODS: We retrospectively reviewed the medical records of 54 patients with accommodative esotropia who underwent at least 36 months of follow-up and had hyperopia more than +1.50 diopter (D). The patients were divided into groups according to the degree of hyperopia: +1.50~ or =+3.00~ or =+5.00 D, the age of their first hyperopic glasses prescription: under two-years old, between two to four-years old and older than four years old, whether or not they had amblyopia, the degree of astigmatism: or =0.75- or =1.25 D and divided into two groups according to the degree of stereopsis: 400 sec. The divided groups were than retrospectively reviewed if they influenced the refractive error at the third year of follow-up using Fisher's exact test, paired t-test, Wilcoxon's signed-ranks test, Mann-Whitney U test, Kruskal-Wallis H test, and ANOVA (p < 0.05). RESULTS: The mean follow-up period was 103.72 +/- 41.82 months for refractive accommodative esotropia. Patients with a greater initial hyperopic refractive err or showed a significant tendency towards emmetropization with a higher rate of hyperopic decrease (p < 0.001), regardless of the hyperopic refractive error. Statistical differences were not observed in patients who started wearing glasses after four-years old, patients with amblyopia, patients with a large degree of astigmatism, and patients with poor stereoacuity. CONCLUSIONS: Long-term changes of hyperopic refractive error in accommodative esotropia showed a significant decrease when initial hyperopic refractive error was high. Wearing hyperopic glasses at an older age and visual functions such as amblyopia, large degree of astigmatism, and poor stereoacuity may influence emmetropization.

What to Predict Favorable Long-Term Sensory Outcome after Surgery for Infantile Esotropia?

PURPOSE: To analyze pre- and post-operative factors associated with favorable long-term sensory outcome after surgical correction for infantile esotropia. METHODS: This study retrospectively examined 40 patients with infantile esotropia who underwent surgery from January 2000 to December 2010. Clinical characteristics analyzed included age at onset, age at surgery, mean preoperative deviation, amblyopia on initial visit, other associated strabismus (Inferior oblique overaction (IOOA), dissociated vertical deviation (DVD), latent nystagmus), initial and subsequent postoperative motor alignment at 1-week and 2-year follow-up, recurrence rate, and stereopsis. Long-term sensory outcome was categorized as favorable (400 arcsec). RESULTS: The mean follow-up period was 92.53 +/- 46.46 months. There were 19 patients (47.5%) in the favorable group and 21 (52.5%) in the unfavorable group. There were no statistically significant differences between the groups with respect to age at onset or surgery, presence of amblyopia, and prevalence of IOOA and DVD, latent nystagmus, or initial postoperative alignment at 1-week. There was a tendency towards worse binocularity with larger preoperative angles of esodeviation, but it was not significant. Binocularity was significantly higher among those who had surgery at age 24 months. Orthotropic alignment within +/-10 PD at 2-year follow-up was 68.4% in the favorable group and 38.1% in the unfavorable group. Reoperation was performed on 8 patients (38.1%) in the unfavorable group and no patients (0.0%) in the favorable group. CONCLUSIONS: Surgical correction of infantile esotropia within the first 2 years of life and maintenance of orthotropic alignment within +/-10 PD without additional surgery with a minimum follow-up of 2 years may be associated with favorable long-term sensory outcome in infantile esotropia.

Clinical Manifestation after Surgical Correction of Consecutive Esotropia

PURPOSE: To report the clinical outcome of patients with consecutive esotropia (ET) in the pre- and post-operative periods and at the last postoperative visit. METHODS: The present study included 12 patients who underwent surgery for the correction of consecutive ET. The angle of deviation, duration of consecutive ET, and surgical and non-surgical methods for correction of consecutive ET were investigated. The sensory status was evaluated before the surgery of exotropia (XT), during consecutive ET and after the surgery for consecutive ET. RESULTS: The average angle of deviation before the surgery of XT was 27.5 PD and 3 patients had lateral incomittancy. Alternate occlusion treatment was performed in all patients, and 10 patients wore Fresnel prisms. The average angle of deviation of consecutive ET was 24.3 PD. After an average of 30 months postoperative consecutive ET, 9 patients were orthotropic or had deviation within 8 PD, 2 patients had 15 PD ET, and 1 patient had 20 PD XT. There were 3 patients whose stereopsis was aggravated and 1 patient had poorer fusion during consecutive ET, and recovered after the surgery for consecutive ET. No patients had a decrease in visual acuity. CONCLUSIONS: As a result of alternate occlusion and Fresnel prisms during consecutive ET after surgery of XT, the incidence of aggravation in binocularity was low, and the cases with aggravated binocularity were recovered after surgical correction of consecutive ET. The surgical success rate was 75% in consecutive ET.

Horizontal lang two-pencil test as a screening test for stereopsis and binocularity.

Purpose: To assess the horizontal Lang two-pencil test as a bedside test to detect gross stereopsis. Materials and Methods: Eighty-four strabismic subjects divided into two groups based on the amount of deviation, and 40 normal subjects were studied. Sensory status examination including binocularity and stereopsis were evaluated with Bagolini, Titmus test and the Netherlands organisation for applied scientific research (TNO), Randot, synoptophore and horizontal Lang two-pencil test. Results: The subjects in the group with smaller deviation showed better performance on all the four stereo tests and over 90% demonstrated presence of fusion. When compared to TNO and Randot for determining presence of stereopsis, the horizontal Lang two-pencil test demonstrated sensitivity of 100% and 83.9%, specificity of 77.8% and 73.7%, and negative predictive value of 100% and 100% respectively. It also showed 100% specificity as a test for binocularity when compared with the Bagolini striated glass test. Conclusion: Horizontal Lang two-pencil test, an easily performed test with a high sensitivity and negative predictive value can be used as a screening test to detect gross stereopsis and binocularity.

Clinical Course of Patients with Consecutive Esotropia Angle Larger Than Preoperative Angle After Exotropia Surgery

PURPOSE: To report the clinical course of severe consecutive esotropia (ET) with an esotropic angle at postoperative day 1 larger than the preoperative exotropia angle (XT). METHODS: Patients with ET angles at postoperative 1 day greater than their preoperative XT angles were included; the case of lost lateral rectus during surgery was excluded. Preoperative clinical characteristics and the course of postoperative alignment were analyzed, and binocularity was compared between the preoperative state and the postoperative state. RESULTS: The mean preoperative angle of XT of 13 patients was 23 prism diopters (PD) at distance and 27PD at near. Lateral incomitancy was observed in 9 patients. One day postoperatively, the mean angle of ET was 27PD at distance and 25PD at near, and alternate occlusion therapy was performed in all patients. However, the angle of ET was decreased 10PD or less in only 3 patients. All 13 patients were managed with Fresnel prisms, and 4 patients had orthotropia. Another 4 patients used glass prisms because they had ET of 8PD or less, and the remaining 5 patients still showed an ET with 12PD or more. Binocularity after surgery was worse than that before surgery in 64% of patients. CONCLUSIONS: For patients with ET angles at postoperative 1 day greater than preoperative XT angles, the frequency of lateral incomitancy was high. Alternate occlusion and Fresnel prism treatment were needed in all patients. Recovery from orthotropia and the prognosis of binocularity were relatively poor.

Clinical Characteristics of Exodeviation

PURPOSE: In order to evaluate the incidence and clinical characteristics of exodeviation according to the Kushner's classification. METHODS: We prospectively studied the 820 patients with exodeviation from 1998 to 2003. One hundred thirty patients with systemic abnormalities, eye disease except exodeviation, or histories of previous strabismus operations were excluded. Best-corrected visual acuity, alternate prism cover test or Krimsky test, duction/ versions, funduscopy, and cycloplegic refraction were performed in every patient, and Bielschowsky phenomenon, Worth 4 dot test and Titmus stereotest, in possible patients. We categorized exodeviations according to the Kushner's classification. RESULTS: Of the remaining 690 patients with exodeviation, 318 were male and 372 were female. Age of onset of exodeviation was 3.9 years. Basic exodeviation was most common (76.5%), and followed by tenacious proximal fusion (7.1%), convergence insufficiency (2.8%), proximal convergence (0.6%), pseudo-convergence insufficiency (0.6%) and high AC/A ratio (0.4%). Binocular fusion both at near and at distance was observed in 30% (148 patients) of the patients. The incidence of amblyopia and dissociated vertical deviation was 13.9% and 8.5%, respectively. Bielschowsky phenomenon was observed mostly in patients with early-onset exodeviation. CONCLUSIONS: Basic exodeviation was most commonly observed, followed by tenacious proximal fusion and convergence insufficiency. Patients with exodeviation showed an onset age of 3.9 years and accompanied by an amblyopia and dissociated vertical deviation in 14% and 5%, respectively. One third of the patients showed binocular fusion.

The Influence of the Head Posture on the Motor Alignment and Sensory Status in the Patients with the Abnormal Head Posture

PURPOSE: To analyze clinical manifestations of the abnormal head posture of ocular origin and to evaluate the effect of the abnormal head posture on the improvement of binocularity. METHODS: In this prospective study 58 patients with abnormal head posture of ocular origin were enrolled. Best corrected visual acuity, Titmus stereotest, Worth four dot test at near and far and the deviations at far were recorded in the abnormal head posture and the forced primary position. Changes of the head postures and the stereoacuity were evaluated postoperatively in the operated cases. RESULTS: The most common cause of abnormal head posture was superior oblique palsy and the most common type of that was head tilt. The deviating angles were significantly decreased in 30 patients (80%) and not changed in 8 patients (20%) of 38 patients with strabismus in abnormal head posture compared to the forced primary position. However, the results of Titmus stereotest improved only in 28% of patients in abnormal head posture. Six among 7 patients with nystagmus showed the disappearance of nystagmus in the abnormal head posture. Twenty (90%) among 22 patients who had surgical procedures showed improvement in the head posture. CONCLUSIONS: The abnormal head posture improved the motor alignment in most of the strabismus patients. However, in many patients it failed to improve the sensory status or binocularity. Most patients who had surgical procedures showed the improvement of abnormal head posture.

Postoperative Binocularity and Binocular Visual Field in Long-standing Strabismus

We compared preoperative binocularity and binocular visual field with postoperative ones in heterotropic patients without any treatment during the critical period for the development of binocular visual function. Nineteen patients were enrolled: seven of them had esotropia and twelve patients had exotropia. All of them showed suppression of deviating eye. The mean preoperative extent of binocular visual field measured by Goldmann perimeter was 112.1 degrees(+/-20.3) in esotropia, 114.4 degrees(+/-9.5) in exotropia. In postoperative Bagolini test, six of esotropic patients (85.7%) and twelve exotropic patients (100%) showed fusion. In Titmus test, one case of esotropic patient (14.3%) showed stereopsis of 100 arc of second while seven cases of exotropic patients(58.3%) showed stereopsis of 100 arc of second or more. Mean postoperative extent of binocular visual field was 113degree(+/-13.5) in esotropia and 112.9degree(+/-7.4) in exotropia. There was no significant difference between pre- and post operative extent of binocular visual field. Conclusively, we suggest the binocularity could be improved by the surgical alignment in adults with long-standing strabismus. We could not observe, however, any significant difference between pre- and postoperative extent of binocular visual field.

Early Surgery for Infantile Esotropia

It is known that early surgery between 6 and 24 months of age obtains better binocularity in infantile esotropia. We selected 59 patients who had infantile esotropia with onset before 6 months of age and underwent surgery at 10 years of age or less. Stereopsis was tested in 51 patients after surgery. Thirty four patients(66.7%) showed gross stereopsis. The patients who underwent surgery at 2 years of age or less, developed gross stereopsis in 80.8%. The patients who had their eyes aligned their eyes between 2 and 4 years of age, gross stereopsis was demonstrated in 64.3%, white the patients underwent surgery more than 4 years of age developed gross stereopsis in 36.3%. The younger the patients at the time of surgery, the greater the percentage of gross stereopsis was shown(p0.05). This study revealed that early surgery, before 2 years of age, yields better outcome for sensory fusion and good alignment.