Distance stereopsis in patients with accommodative esotropia.

PURPOSE: We aimed to evaluate distance stereoacuity (DS) in patients with successfully treated accommodative esotropia (AET) and its association with other clinical factors. METHODS: The medical records of 176 children with refractive AET with a follow-up period ≥ 1 year were reviewed to identify a cohort of patients who achieved a stable alignment within 4 prism diopters (PD) of orthotropia at both distance and near fixation. Age of onset, duration of misalignment, uncorrected near and distance deviation, accommodative convergence/accommodation ratio, refractive error, presence of anisometropia and amblyopia, near stereopsis were evaluated as predictors of outcome. DS was measured using the Distance Randot Stereo test and near stereoacuity by Randot Stereotest. The patient group was compared with 50 age-matched normal controls for DS. RESULTS: Fifty-six patients were included, and 38 patients had DS at the final visit. All patients with DS attained uncontoured near stereopsis (UCNS). UCNS was present only in 11 patients without DS (p = 0.001). Anisometropia (p = 0.997), uncorrected near deviation (p = 0.224), distance deviation with correction (p = 0.255), and high hypermetropia (p = 0.998) were not associated with DS. The multivariable regression model showed a significant positive correlation between UCNS and DS (OR = 31.14 (95% CI 2.25-430.48); p = 0.01). Contoured near stereopsis outcome was significantly different between the patients with and without DS (p = 0.001 for animals and p = 0.003 for circles). Compared with the control group, the patient group yielded lower DS scores (p = 0.001). CONCLUSION: Distance Randot Stereotest can be useful in measuring binocular vision recovery after successful realignment in refractive AET patients. Patients attaining normal scores for near stereopsis tests after optical correction revealed subnormal thresholds for DS.

Advances in the diagnosis and treatment of acute acquired comitant esotropia.

Acute acquired comitant esotropia (AACE) is mainly characterized by sudden onset, accompanied by diplopia, without extraocular muscles paralysis or ocular motility disorders. In recent years, the incidence of AACE has been increasing, researchers have found that this phenomenon may be related to the widespread use of electronic devices and the increase in the number of people working from home during the COVID-19 pandemic. However, its neural mechanisms have not been fully elucidated. This article primarily reviews the latest developments in the diagnosis and treatment of AACE from the perspectives of etiology and treatment methods, aiming to provide direction for future in-depth exploration of the pathogenesis and treatment approaches of this disease.

Factors influencing the therapeutic effect of hyperopic correction on esotropia in patients with partially accommodative esotropia.

OBJECTIVES: To collate data on partially accommodative esotropia (PAET) to better understand this condition's aetiology and to evaluate and predict the therapeutic effect of a hyperopic correction on PAET. METHODS: Eighty-nine consecutive patients diagnosed with PAET with a spherical equivalent (SE) refractive error >+2.50 D were included in this retrospective review. Clinical characteristics, including gender, age, SE, angle of esodeviation, accommodative convergence/accommodation (AC/A) ratio, near-distance disparity (NDD) and anatomical features of the rectus muscles were compared among different PAET subgroups. Multiple linear regression was used to identify independent factors that influenced the therapeutic effect of a hyperopic correction on esotropia. RESULTS: No significant differences were observed for the angle of esodeviation as a function of age in individuals with PAET. The incidence of SE in PAET participants >9 years old was significantly greater than in those <5 and 6-8 years of age. The therapeutic effect of hyperopic correction on esotropia was positively associated with SE both at distance and near. In addition, the limbus insertion distance (LID) of the lateral rectus (LR) muscle was positively associated with NDD at distance, but negatively associated at near. CONCLUSION: A greater incidence of hyperopia was observed in older (>9 years old) PAET patients. A hyperopic correction had a greater effect on esotropia in individuals with a higher SE, larger LID of the LR muscle and a smaller NDD.

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.

Resolution of cyclic esotropia with 5-year follow-up after brief Fresnel prism treatment.

Cyclic esotropia is a rare form of strabismus that is characterized by a recurring esotropic deviation, usually with a 48-hour cycle. On esotropic days, the patient has a constant deviation with suppression, followed by a day with straight eyes and good binocular function. We report a case of cyclic esotropia in which the cycling resolved with 2 months of Fresnel prism for the amount of the distance deviation on her "straight" days. Five years later, with low plus hyperopic correction, she remains with a stable esophoria and normal stereopsis.

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.

24†Primary outcomes of management of convergence excess esotropia at moorfields eye hospital.

Convergence excess ET (CXE) is an esotropia with binocular single vision (BSV) at distance fixation but esotropia on accommodation for near fixation with near distance disparity (1). In this retrospective chart review our 1ry question:to evaluate the initial treatment to address CXE, whether this treatment successful or not, secondary question: to evaluate primary and final outcomes for control of near esotropia. Successful outcome defined as residual distance and near esotropia and near distance disparity of less than 10PD.We included patients with CXE managed at Moorfields Eye Hospital from 2003 until 2022, defined as 'esotropia with BSV at distance but esotropia on accommodation for near with near distance disparity over 8-10 PD while the eye is corrected with the full cycloplegic refraction'. All age groups were included, amblyopic eyes were excluded.668 patients were reviewed from 2005-2022, the mean age was 7.9years (+/- 6), first line treatment was bifocal glasses in 60%, which was successful in 83%, bi-medial recession was offered to 12.5%, only » of which were improved, Botulinum toxin administered to 3%, bimedial posterior fixation sutures done in 1.5% which did not improve condition. Other lines included single vision glasses and Bangerder foil to relieve double vision. The final outcome was well controlled esophoria in 65% of cases. Binocular single vision achieved in 28%.The management of convergence excess esotropia is still controversial, in our cohort most patients were managed with bifocals, the final motor and sensory outcomes were variable between patients. More than half of patients had satisfactory motor alignment. However, the sensory outcome was much less.

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.

Efficacy of binocular vision training and Fresnel press-on prism on children with esotropia and amblyopia.

PURPOSE: In the process of clinical diagnosis and treatment of amblyopia, we have found that the treatment time of this disease was significantly different among different patients. The purpose of this study was to compare the efficacy of binocular vision training (BVT) and Fresnel press-on prism (FPP) on children with esotropia combined with amblyopia. METHODS: From May 2015 to December 2018, a total of 101 children aged 3-9 years with esotropia and amblyopia who were in our hospital were enrolled in this randomized clinical trial. They were randomly divided into combined group (48 cases) and prism group (53 cases): the children in the prism group received FPP treatment, and those in the combined group received the combined treatment of BVT and FPP. The visual acuity, the binocular function and the strabismic therapeutic effects were compared between two groups. RESULTS: After treatment, the visual acuity in both groups was both significantly improved compared with that before treatment (P = 0.0079). The binocular-monocular function, including synoptophore visual function and the Titmus stereopsis, in both groups was significantly improved compared with those before treatment (P < 0.05), and it was more significant in the combined group compared with the prism group (P < 0.05). The cure rate of strabismus was 87.50% (42/48) and 30.19% (16/53) in the combined group and the prism group, respectively, and there was significant difference between groups (P = 0.0036). The cure time was shortened with the lower of the degree of esotropia. CONCLUSION: BVT combined with FPP can effectively promote the recovery of binocular vision in children with esotropia combined with amblyopia, and some children can achieve complete cure of strabismus.

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.

[Short-term outcomes of prism treatment in a manner of reducing prism diopters step by step for small-angle acute acquired concomitant esotropia].

Objective: To investigate the short-term efficacy of the prism treatment in a manner of reducing prism diopters step by step for small-angle acute acquired concomitant esotropia (AACE). Methods: Retrospective case series study. The clinical data of 17 AACE patients with strabismus ≤25 prism degrees (PD) including 6 males and 11 females, aged 14 to 60 years, who underwent the prism treatment in the Strabismus and Pediatric Ophthalmology Clinic of Shanxi Eye Hospital from October 2018 to June 2020 were collected. The prism treatment was conducted by a step-by-step reduction of prism diopters. An under-corrected prism was applied to the patient for the first time, and the degree of the prism was reduced gradually with the decrease in the degree of strabismus. Statistical analysis was performed after 6 months of treatment. The treatment success was defined as obtaining orthotropia and deleting diplopia when prism glasses were weaned off. The strabismus degree, Worth 4 dot test results, near stereopsis (Titmus stereopsis) and synoptophore fusion function before and after treatment were compared, and the factors affecting the curative effect were analyzed. Statistical methods mainly included paired t-test, Wilcoxon rank sum test, the Fisher exact test and univariate logistic regression analysis. Results: Among these 17 patients, 15 had myopia and 2 had emmetropia. Pretherapeutic esodeviation was (13.94±5.83) PD at near (33 cm), and was (15.76±5.24) PD at distance (6 m). After 6 months of treatment, 7 patients were successfully cured. The deviation angle at distance [(10.60±7.16) PD] and near [(9.80±6.00) PD] of the remaining 10 patients at 6 months after prismatic treatment was significantly smaller than that before treatment [(17.50±5.40) PD and (16.10±5.47) PD; t=3.69, 4.10; both P<0.01]. The Titmus stereogram showed that 2 cases had no stereopsis, 6 cases had peripheral stereopsis, 3 cases had macular stereopsis, and 6 cases had foveal stereopsis before treatment. Stereopsis was significantly improved at 6 months after prismatic treatment, with 3 cases havimg macular stereopsis and 14 cases having foveal stereopsis (Z=-2.99; P<0.01). The Worth-4-dot test disclosed that, the number of patients who saw four lamps at distance and near was 0 and 2 before treatment, and 7 and 9 after treatment, respectively, and the difference was statistically significant (both P<0.05). The divergent fusional amplitude and convergent fusional amplitude in the synoptophore at 6 month after treatment was not significantly different from that before treatment (both P>0.05). The efficacy of treatment was not significantly related to the duration from onset to treatment, the pretherapeutic esodeviation, the Titmus stereoacuity, cycloplegic refractive error, and age (all P>0.05). None of the 7 patients, who were successfully cured had a recurrence of esotropia or diplopia during the observation period of 6 to 24 months (median, 11 months). Conclusions: Prism treatment in a manner of step-by-step reduction of prism diopters can significantly diminish the degree of esotropia and improve the binocular function in small-angle AACE. Furthermore, some patients could be cured, achieving orthophoria without diplopia.

Comparison of Long-term Stereoacuity Improvement Between Patients With Initial Subnormal Stereopsis and Nil Stereopsis in Refractive Accommodative Esotropia.

PURPOSE: To compare improvement in long-term stereoacuity between patients with refractive accommodative esotropia (RAET) with initial subnormal stereopsis (between 120 and 1,980 arcsec of stereoacuity) and nil stereopsis. METHODS: The medical records of patients 4 years and older who had RAET with initial subnormal stereopsis and nil stereopsis and a minimum follow-up period of 5 years were retrospectively reviewed. Improvement in stereoacuity at the last follow-up visit and the factors that could influence it were compared between the initial subnormal stereopsis and the nil stereopsis groups. RESULTS: A total of 79 patients (mean age: 6.3 ± 1.9 years) were included: 31 patients with initial subnormal stereopsis and 48 patients with nil stereopsis. The mean follow-up time was 11.7 ± 1.8 years (range: 5 to 21 years). At the last follow-up visit, a statistically significantly greater number of patients with initial subnormal stereopsis demonstrated improvement in stereoacuity and also achieved 60 arcsec of stereoacuity compared with those with nil stereopsis. Age at onset, duration of esodeviation, mean hyperopia, amblyopia, anisometropia, and follow-up duration were not significantly different between the initial subnormal stereopsis and the nil stereopsis groups. The initial mean near and distance deviations with hyperopic correction were significantly smaller in patients with initial subnormal stereopsis. A significantly greater number of patients with initial sub-normal stereopsis had fusion at distance. CONCLUSIONS: Patients with RAET with initial subnormal stereopsis have greater chances of stereoacuity improvement and recovery of 60 arcsec of stereoacuity than those with nil stereopsis. Patients who initially have nil stereopsis may develop normal stereoacuity. Smaller initial deviations with hyperopic correction and fusion at distance indicate a favorable prognosis for stereoacuity improvement. [J Pediatr Ophthalmol Strabismus. 2022;59(4):248-253.].

Acquired Esotropia in an Adolescent Wearing Orthokeratology Lenses.

Orthokeratology is a procedure involving the use of reverse-geometry lenses to temporarily correct refractive errors. Switching from spectacles to orthokeratology lenses may influence binocular visual function and accommodation. This is the first report of orthokeratology lens-associated acquired esotropia, a form of distance esotropia, in an adolescent with myopic anisometropia. [J Pediatr Ophthalmol Strabismus. 2022;59(1):e7-e10.].

"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.

[Optical correction principles of accommodative esotropia].

Accommodative esotropia is the most common type of esotropia in children. The patients often need to wear hyperopic glasses to correct eye positions and improve vision and binocular function. However, the course of accommodative esotropia is usually long, so it is necessary to monitor the refractive changes for a long time. Maintaining full hyperopic correction will interfere with the emmetropia development of the eyeball, and undercorrection of hyperopia will lead to the risk of esotropia decompensation. These often bring confusion when clinicians prescribe glasses. The benefits of accommodative esotropia with a high accommodation convergence/accommodation ratio from fitting bifocal lenses and the effect of prisms on residual esotropia have also been controversial topics in this field. In this article, we combine the research status and clinical practice to present some points of view for the peer reference. (Chin J Ophthalmol, 2021, 57: 331-335).

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.