Resultados quirúrgicos de la esotropía adquirida comitante aguda. Causas y clasificación / Surgical outcomes of acquired acute comitant esotropia. Causes and classification

Objetivo Estudiar los resultados del tratamiento quirúrgico de las esotropías comitantes adquiridas y analizar sus posibles causas. Métodos Estudio retrospectivo de pacientes operados de esotropía aguda comitante desde 2017-2021. Se analizó la desviación horizontal de lejos y cerca, el equivalente esférico, y uso excesivo de tablets y smartphones. Se consideró buen resultado sensorial la presencia de estereopsis y motor si la deviación era≤10 dioptrías prismáticas (dp), y sin diplopía al final del seguimiento. Resultados Se incluyeron 15 casos (60% mujeres), edad media: 29,07 años (el 86,66%≥16 años). El tiempo medio desde el inicio de los síntomas hasta la cirugía: 23,3 meses. La media de la desviación horizontal preoperatoria fue de 19,73±7,2dp de cerca y 22,93±7,3 dp de lejos, disminuyendo al final del seguimiento a 3,33±3,8dp de cerca y 3,86±3,9dp de lejos (p<0,001). Un 66,6% refería diplopía. Un 46,66% tenían esoforias o microestrabismos descompensados, un 86,66% miopía y el 33,33% refería uso excesivo de tablets y smartphones. En 10 casos se realizó retroceso de rectos medios. El resultado motor fue bueno en un 93,33% de los casos y sensorial en 46,66%, con desaparición de la diplopía. Conclusiones La cirugía fue un excelente tratamiento para resolver la desviación y la diplopía. Las esoforias y los microestrabismos representaron casi la mitad de los casos y el excesivo uso de tablets y smartphones la tercera parte de la muestra. La mayoría de los sujetos eran miopes (AU)

Purpose To study the results of surgical treatment of acquired concomitant esotropia and its posible causes. Methods Retrospective study of the patients with acute acquired esotropia that were operated on since 2017 to 2021. Distance and near horizontal deviation, spherical equivalent and the excessive use of the tablets and smartphones were analyzed. A good sensorial outcome was considered when stereopsis was recovered and good motor outcome if horizontal deviation was≤10 prism diopters (pd) at the end of the follow-up. Results A total of 15 cases were included (60% women), mean age: 29.07 years (86.66%≥16 years). Mean time since the beginning of the symptoms to the surgery was 23.3 months. Mean horizontal preoperative deviation was 19.73±7.2pd at near and 22.93±7.3dp at distance decreasing to 3.33±3.8pd at near and 3.86±3.9pd at distance (P<.001). The 66.6% had diplopia. The 46.66% had decompensated esophoria or microesotropia, 86,66% myopia and the 33.33% referred excesive use of the tablets and smartphones. The medial rectus recession were done in 10 cases. A good motor outcome was obtained in the 93.33% of the cases and sensorial outcome in the 46.66% without diplopía. Conclusion Surgery was an excellent treatment to resolve the deviation and diplopia. The esophorias and microesotropias represented near the half of the cases and the excesive use of the tablets and smartphones were the third part of the sample. Most of the patients had myopia (AU)

Long-term development of refractive error in refractive, nonrefractive and partially accommodative esotropia.

Accommodative esotropia (AE) is a convergent deviation due to an excess of the convergence linked to the innervational stimulus for accommodation and it is usually associated to the presence of hyperopia. The development of hyperopia over time has been widely described but the lack of comparative analysis among accommodative esotropia subtypes, does not allow to verify the existence of different developmental patterns. In this study we aimed to describe the long term changes of refractive error in patients affected by accommodative esotropia as a function of the strabismus type: refractive (RAE), non-refractive (NRAE) and partially accommodative esotropia (PAE). The medical records of 66 patients (24 RAE, 22 PAE, 20 NRAE), who wore the full correction of their cycloplegic refraction error during the entire follow up period, were retrospectively reviewed. Mean outcome was the analysis of the variations, among groups, of refractive error over time; differences between mild (≤3.00D) and high (≥5.00D) hyperopia, effects of amblyopia and relationship with AC/A ratio were also investigated. All patients were followed up from approximately 4 years of age to 20, with mean follow up of 16.06±0.29 years. Our results described similar non-linear trend of refractive error development among groups. The initial increase of hyperopia (up to 7-8 years) was followed by a decreasing trend persisting up to adulthood (approximately 20 years of age). During this period, spherical equivalent decreased at a lower mean annual rate in patients affected by RAE (-0.07D) compared to other groups (NRAE -0.11D, p = 0.003 and PAE 0.13D, p = 0.002). In all groups, however, significant amount of hyperopia was found at last examination; indeed the observed difference in SE values from baseline to the end of follow up, was not significant (RAE: +0.27D, 95% C.I. -0.49 to +1.04D, p = 0.472; PAE: -0.69D, 95% C.I. -1.67 to +0.28D, p = 0.154; NRAE: -0.39D, 95% C.I. -1.11 to +0.34D, p = 0.278). AC/A ratio, amblyopia and amount of initial hyperopia appeared to have no significant role in longitudinal change of the refractive error. In conclusion, this study provides a complete overview, from childhood to adulthood, of refractive error development in different form of accommodative esotropia.

Acute Acquired Concomitant Esotropia: Clinical features, Classification, and Etiology.

Acute acquired concomitant esotropia (AACE) is a rare, distinct subtype of esotropia. The purpose of this retrospective study was to describe the clinical characteristics and discuss the classification and etiology of AACE.Charts from 47 patients with AACE referred to our institute between October 2010 and November 2014 were reviewed. All participants underwent a complete medical history, ophthalmologic and orthoptic examinations, and brain and orbital imaging.Mean age at onset was 26.6 ±â€Š12.2 years. Of the 18 cases with deviations ≤ 20 PD, 16 presented with diplopia at distance and fusion at near vision at the onset of deviation; differences between distance and near deviations were < 8 PD; all cases except one were treated with prism and diplopia resolved. Of the 29 cases with deviations > 20 PD, 5 were mild hypermetropic with age at onset between 5 and 19 years, 16 were myopic, and 8 were emmetropic with age at onset > 12 years; 24 were surgically treated and 5 cases remained under observation; all 24 cases achieved normal retinal correspondence or fusion or stereopsis on postoperative day 1 in synoptophore; in 23 cases diplopia or visual confusion resolved postoperatively. Of the 47 cases, brain and orbital imaging in 2 cases revealed a tumor in the cerebellopontine angle and 1 case involved spinocerebellar ataxia as revealed by genetic testing.AACE in this study was characterized by a sudden onset of concomitant nonaccommodative esotropia with diplopia or visual confusion at 5 years of age or older and the potential for normal binocular vision. We suggest that AACE can be divided into 2 subgroups consisting of patients with relatively small versus large angle deviations. Coexisting or underlying neurological diseases were infrequent in AACE.

[Long-term efficacy of Fadenoperation associated to conventional surgery in the treatment of esotropia with distance-near incomitance: About 55 cases]. / Efficacité à long terme de la Fadenoperation associée à une chirurgie conventionnelle dans le traitement des ésotropies avec incomitance loin-près: à propos de 55 cas.

OBJECTIVE: The purpose of this study is to evaluate the short-, medium- and long-term efficacy of posterior fixation sutures with conventional surgery in controlling strabismus in the case of esotropia with distance-near incomitance. MATERIALS AND METHODS: This is a retrospective study of consecutive patients with partially accommodative and non-accommodative esotropia associated with distance-near incomitance who underwent posterior fixation sutures along with conventional surgery. The preoperative and postoperative distance and near deviation measurements and the distance-near incomitance were evaluated at 1, 6 and 12 years. Surgical success was defined as a postoperative distance angle and a distance-near incomitance less than 10 prism diopters (PD). RESULTS: In total, 55 patients were included. Preoperatively, the mean distance deviation, near deviation and distance-near incomitance were 15.9 (± 3.4), 29.7 (± 5.8) and 13.8 (± 3.1) PD, respectively. Postoperatively, the mean distance deviation was 1.6 (± 0.8) PD (P < 0.001) at 1 year, 2.8 (± 1.6) PD (P< 0.005) at 6 years and 5.6 (± 2.4) PD (P < 0.05) at 12 years. The mean near deviation was 7.8 (± 2.3) PD (P < 0.001) at 1 year, 10.5 (± 3.7) PD (P < 0.005) at 6 years and 15.2 (± 4.4) PD (P < 0.05) at 12 years. The mean distance-near incomitance was 5.2 (± 1.8) PD (P < 0.01) at 1 year, 7.7 (± 2.8) PD (P < 0.05) at 6 years and 9.6 (± 3.2) PD (P > 0.05) at 12 years. The success rate was 91, 78 and 58% at 1, 6 and 12 years, respectively. CONCLUSION: Distance-near incomitance is a source of amblyopia. It needs to be corrected while treating an esotropia. This study seems to confirm the short- and medium-term efficacy of posterior fixation sutures along with conventional surgery in the treatment of this problem. It also seems to show progressive, albeit partial, loss of its long-term efficacy.

Strabismus.

Defining the type of strabismus creates a framework for work-up and management. Comitant esotropia is most commonly a childhood condition treated with glasses and surgery. Comitant exotropia is often a childhood condition that may require surgical correction. Microvascular disease is the most common cause of ocular cranial nerve palsies in adult patients.

Acute acquired comitant esotropia of childhood: a classification based on 48 children.

PURPOSE: To identify characteristics of pediatric patients who develop acute acquired comitant esotropia (AACE) with and without intracranial disease. METHODS: We reviewed the charts of 48 children consecutively referred to the hospital with AACE during a 13-year period. Inclusion criteria were acute onset of comitant esotropia, available data on ophthalmologic, orthoptic and neurologic examinations. Children with neurological signs, AACE recurrence or hyperopia <+3 dioptres (D) underwent brain computed tomography or magnetic resonance imaging. Patients without imaging were followed. RESULTS: In all, 48 cases were recorded. The mean age at onset was 4.7 years, being significantly higher among children with intracranial disease. Seven cause-specific types of AACE in childhood were identified: The acute accommodative (n = 15, 31%), decompensated monofixation syndrome or esophoria (n = 13, 27%), idiopathic (n = 9, 19%), intracranial disease (n = 3, 6%), occlusion related (n = 3, 6%), AACE secondary to different aetiologic disease (n = 3, 6%) and cyclic AACE (n = 2, 4%). Intracranial disease included hydrocephalus, pontine and thalamic glioma. Of the children with intracranial disease, 2 of 3 had no obvious neurological signs at onset. Four significant risk factors for intracranial disease were identified as follows: larger esodeviation at distance, recurrence of AACE, neuro signs (papilledema) and older age at onset (>6 years). CONCLUSION: In a large case series of children with AACE and by review of literature, we identified seven cause-specific types of AACE. Intracranial disease was present in 6%, and four risk factors were identified to guide clinicians when to perform brain imaging. Findings suggest AACE of childhood to be differentiated from AACE of adulthood.

Comitant horizontal strabismus in South African black and mixed race children--a clinic-based study.

PURPOSE: To examine the types of comitant horizontal strabismus in children belonging to the two largest ethnic groups of the Western Cape, South Africa. METHODS: Retrospective review of 2371 children presenting with comitant horizontal strabismus to a single, large, pediatric tertiary referral center in Cape Town, South Africa, between 1997 and 2007. RESULTS: 81% of children were of mixed race and 19% were black. The overall esotropia:exotropia ratio was 73:27. For black children this was 85:15 and for mixed race, 71:29. The overwhelming majority of black children had congenital esotropias (74%), whereas accommodative esotropia was rare (9%). In mixed race children, esotopias were more equally divided between congenital (46%) and accommodative types (35%). Exotropias were uncommon in black children, and were mainly constant (61%). Intermittent exotropias predominated in mixed race children (55%). CONCLUSION: Congenital esotropia remains common in South African black children, and of the few who presented with exotropia, most had constant type. Accommodative esotropias were more prevalent in South African mixed race children, but in smaller proportions than in other studies. Exotropias were mostly intermittent in this ethnic group, and showed a similar profile to that in white American children.

Classifying stability of misalignment in children with esotropia using simulations.

OBJECTIVE: To determine the sensitivity and specificity of several classification rules for stability and instability of angle in childhood esotropia. METHODS: We conducted 10 000 Monte Carlo simulations of participants with no actual change in angle of esotropia during follow-up, where "observed" changes in ocular alignment were sampled from a distribution of measurement errors for the prism and alternate cover test. Additional simulations were conducted for a range of "true" changes (1.0, 2.5, 4.2, 5.0, 7.5, and 10.0 prism diopters [PD] per visit) with up to 10 follow-up visits. We then estimated sensitivities and specificities for specific rules for retrospectively classifying stability (all measurements within 0, 5, 10, or 15 PD) and instability (≥2 measurements differing by ≥10 PD, etc) across a fixed number of visits. Results were extended to classifying ocular alignment stability and instability prospectively based on a varying number of measurements. RESULTS: For a series of 4 measurements, the rules that optimized sensitivity and specificity were "all measurements within 5 PD" for stability and "at least 2 measurements differing by 15 PD or more" for instability. For a series of 3 measurements, all 3 measurements needed to be identical to confirm stability. CONCLUSIONS: We derived definitions of stability and instability in childhood esotropia using estimates of actual measurement error that may be useful for clinical practice and for future clinical studies of esotropia.

Convergence excess esotropia: a proposed new classification and the effect of monocular occlusion on the Ac/A ratio.

BACKGROUND: Convergence excess esotropia defines an esotropia on accommodation at near fixation with binocular single vision and motor fusion at distance fixation associated with a high accommodative convergence: accommodation (Ac/A) ratio. The effect of occlusion on exotropia has been well described and is known to alter the Ac/A ratio. This study examines the effect of monocular occlusion on convergence excess esotropia. METHODS: The Ac/A ratio was measured using the gradient method at 1/3 and 6 m in 10 patients with convergence excess esotropia immediately prior to and following a 30-minute period of monocular occlusion. RESULTS: Clinically and statistically significant differences to the angle of deviation and the Ac/A ratio were found in some patients following occlusion. CONCLUSION: Ac/A ratio measurement in convergence excess esotropia is influenced by fusional tenacity. Disrupting this fusion with a period of monocular occlusion results in changes to the angle of deviation in some patients, suggesting subcategorization of this condition into true and simulated convergence excess esotropia. Measurements of the Ac/A ratio are influenced by fixation distance.

[The esotropia of the convergence-excess type subdivided into two forms].

There are two types of convergence excess esotropia in the classification of strabismus in our country. One is nonrefractive accommodative esotropia and another is nonaccommodative convergence excess esotropia. Inadequate heterophoria method to determine the AC/A ratio does not distinguish between a high AC/A ratio and nonaccommodative convergence excess. The diagnosis of nonrefractive accommodative esotropia is based on the presence of a high AC/A ratio as established with the gradient method to distinguish this condition from nonaccommative convergence excess.

Incidence and types of childhood esotropia: a population-based study.

OBJECTIVE: To describe the incidence and types of childhood esotropia in a defined population. DESIGN: Retrospective population-based cohort. PARTICIPANTS: All pediatric (<19 years of age) residents of Olmsted County, Minnesota, diagnosed with an esodeviation (> or =10 prism diopters) from January 1, 1985, through December 31, 1994. METHODS: The medical records of all potential patients identified by the resources of the Rochester Epidemiology Project were reviewed. MAIN OUTCOME MEASURES: Incidence and types of childhood esotropia. RESULTS: Three hundred eighty-five cases of childhood esotropia were identified during the 10-year period, yielding an annual age- and gender-adjusted incidence of 111.0 (95% confidence interval, 99.9-122.1) per 100,000 patients younger than 19 years of age. This rate corresponds to a cumulative prevalence of approximately 2.0% of all children younger than 6 years, with a significant decrease in older ages (P<0.0001). Of the 385 study children, the specific forms and percentages of esotropia diagnosed were as follows: fully accommodative, 140 (36.4%); acquired nonaccommodative, 64 (16.6%); esotropia associated with an abnormal central nervous system, 44 (11.4%); partially accommodative, 39 (10.1%); congenital, 31 (8.1%); sensory, 25 (6.5%); paralytic, 25 (6.5%); undetermined, 13 (3.4%); and other, 4 (1.0%). CONCLUSIONS: The incidence of childhood esotropia from this self-referred population-based study is comparable with prevalence rates reported among Western populations. Esotropia is most common during the first decade of life, with the accommodative and acquired nonaccommodative forms occurring most frequently. The congenital, sensory, and paralytic forms of childhood esotropia were less common in this population.

[Antinomic horizontal deviations: esodeviation associated with exodeviation. Clinical features and surgery]. / Déviations horizontales antinomiques: association d'une exodéviation et d'une ésodéviation. Aspects cliniques et chirurgie.

INTRODUCTION: Antinomic deviations are defined as a basic exoposition of the eyes associated with innervational convergence excess leading to an esoposition. PATIENTS AND METHODS: Thirty-four patients with both exodeviation and esodeviation were studied. Surgery consisted in lateral recti (LR) recess with fadenoperation on the medial recti. RESULTS: Four types of antinomic deviations were found: 1- Primitive exodeviation with an excess of physiological accommodative vergences; 2- Consecutive exodeviation due to surgical overcorrection of an accommodative esotropia; 3- Infantile exodeviation with fixation in adduction, DHD +/- convergence excess; 4- Consecutive infantile exodeviation: overcorrection of a congenital esotropia. CONCLUSION: Although fadenoperation on the medial recti may seem paradoxical in exodeviations, it is the most logical procedure to deal with convergence excess and fixation in adduction prevalence. Adjustable sutures for the lateral recti recess appear safer and more predictible in these difficult cases.

Some clinical characteristics of V-pattern exotropia and surgical outcome after bilateral recession of the inferior oblique muscle: a retrospective study of 22 consecutive patients and a comparison with V-pattern esotropia.

BACKGROUND AND PURPOSE: A V-pattern exotropia (XT) with bilateral overaction of the inferior obliques (IO) and/or underaction of the superior obliques (SO) is a common finding. The clinical characteristics of this condition in a large series are not available in the scientific literature. Also, data is lacking about the surgical outcome of graded bilateral IO recession. Lastly, a comparison of the pre- and postoperative findings of a V-pattern exotropia population with those of a V-pattern esotropia population is also lacking in the literature. SUBJECTS AND METHODS: Twenty-two consecutive patients without complicating factors were fully evaluated and submitted to bilateral graded recessions of the IO; 19 were also operated for a horizontal binocular alignment imbalance. RESULTS: Preoperative findings: The distribution of V patterns showed 77.2% in the range of 15 to 25 prism diopters (PD) and 22.8% in the range 26 to 35 PD. An overaction of the IO was present bilaterally in 86.4% of the patients and unilaterally in 4.5%. Bilateral underaction of the SO was observed in 4.5% and unilateral in 13.6%. Bilateral overaction of the SO was seen in 18.2% and unilateral in 31.8%. Elevation in adduction was observed bilaterally in 13.6% and unilaterally in 31.8%. A vertical deviation was seen in 50.0% and a marked tendency of it to vanish or diminish in the up- and down positions, as well as at near, was observed. After surgery, 72.7% had less than 15 PD of V pattern or less than 10 PD of A pattern; 36.4% had the V pattern fully corrected. Surgery eliminated a vertical imbalance in 72.7% of the patients, reduced in 9.1%, left unchanged in 9.1% and increased in 9.1% Of the 11 patients devoid of vertical deviation, 72.7% remained so and in 27.3% a vertical deviation was created. Binocularity: There was an improvement of the fusional status with surgery, (ascertained with the Worth Four Dot Test and the major amblyoscope measurement). CONCLUSION: All cases were in the range of 15-35 PD preop'. Overaction of the IO was a prominent finding. Underaction of the SO was less prevalent as compared with a V-ET population. Overaction of the SO was observed bilaterally in 18.2% and unilaterally in 31.8%, a finding never detected in a V-ET population. A vertical imbalance was observed in one-half of the cases. A good outcome (collapse of the V pattern) was obtained with bilateral graded recession of the IO, This procedure is relatively safe concerning the vertical alignment.

Common forms of childhood esotropia.

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