Primary infantile-onset esotropia--20 years later

Esotropia with an accommodative component after surgery for infantile esotropia compared to primary accommodative esotropia

PURPOSE

To compare the clinical outcomes of patients with an esotropia with an accommodative component after infantile esotropia surgery and patients with primary refractive accommodative esotropia.

METHODS

The medical records of patients with postoperative (secondary group) and primary refractive accommodative esotropia (primary group) were reviewed retrospectively. Changes in ocular alignment, refractive error, weaning rate, decompensation rate over time, and sensory outcomes were compared.

RESULTS

The overall change in ocular deviation with glasses correction was -0.5^Δ/year in the secondary group and -0.2^Δ/year in the primary group (P = 0.010). The overall change in spherical equivalent refractive error was -0.2 D/year in the secondary group and -0.3 D/year in the primary group (P < 0.001). The latest stereoacuity result was poorer in the secondary group than in the primary group (P = 0.027). No significant differences in the decompensation or weaning rates were detected between groups.

CONCLUSIONS

The changes in refractive error and the amount of esotropia over time were different between the secondary group and the primary group. Although refractive error was significantly lower and stereoacuity was poorer in the secondary group compared to the primary group, the majority of patients in the secondary group maintained good control of ocular alignment after hyperopic correction.

Outcome of surgery in long-standing infantile esotropia with cross fixation

BACKGROUND

This is a retrospective study to determine the outcomes of the surgical correction in long-standing infantile esotropia with cross fixation.

METHODS

Medical charts of a group of patients with esotropia who had cross fixation and underwent surgery for strabismus between January 1991 and December 2004 were reviewed. The mean follow-up time was 4.7 years. Binocularity was measured by the Worth 4-dot test and Titmus stereo test. Twenty-six patients underwent surgery for strabismus. Twenty-one patients aged 8 to 26 years with a minimum 3-year postoperative follow-up were included. Five patients were excluded because they were lost to follow-up after surgery.

RESULTS

Bimedial recession and resection of one lateral rectus muscle were performed in all patients. Recession of the inferior oblique muscle with anteriorization was performed in patients who had inferior oblique overaction. Orthotropia was attained in 14 patients, whereas residual esotropia was diagnosed in 5 patients. Two patients were diagnosed as having exotropia. Two patients required a second surgery for dissociated vertical deviation. Overall, 9 of the 21 patients had indications of binocular function and 12 remained the same in their stereoacuity.

CONCLUSION

Surgical correction of long-standing infantile esotropia with cross fixation in young adults may improve binocular function and allow long-term alignment stability.

Changes in the functional binocular status of older children and adults with previously untreated infantile esotropia following late surgical realignment

BACKGROUND

Most studies of infantile esotropia concern patients diagnosed in infancy and treated throughout childhood. This prospective study addresses changes in the functional binocular status of older children and adults with previously untreated infantile esotropia, following late surgical realignment.

SUBJECTS AND METHODS

Seventeen patients aged 8 years or more with a history of untreated esotropia occurring within the first 6 months of life were included in this study. All had monocular optokinetic asymmetry, a visual acuity of 20/30 or better in the worse eye, and binocular function assesment preoperatively and postoperatively. All were surgically aligned within 8(Delta) of orthotropia. None had neurologic disease.

RESULTS

Preoperatively, all 17 patients demonstrated a monocular response to Bagolini lenses, while postoperatively 15 (88%) of the 17 demonstrated binocular function with Bagolini lenses (in that they could constantly perceive the major part of both arms of the X generated by the Bagolini lenses) and 13/17 (76%) demonstrated an increase in the binocular field. All 17 had no sensory fusion, either preoperatively or postoperatively, when tested with the Worth 4-Dot test or synoptophore, and no stereopsis with the Titmus stereo test.

CONCLUSIONS

Older children and adults with previously untreated infantile esotropia derive some functional benefits following late surgical realignment. The degree of binocular function may be lower than that achieved in patients aligned before 24 months of age.

Surgery and botulinum toxin in congenital esotropia

BACKGROUND

In a previous study we investigated the advantages and drawbacks of early and delayed injection of botulinum toxin as primary treatment of infantile esotropia with nystagmus in abduction (IENA). We carried out a further study to investigate the role and efficacy of surgery in this condition and to determine the possible effect of previous injection of both medial recti with botulinum toxin in patients requiring a final horizontal surgical correction.

METHODS

Review of the records of 44 patients (24 girls and 20 boys) with IENA seen between 1979 and 1998 who had undergone at least one horizontal surgical procedure. The outcomes in the 16 patients who had previously received botulinum toxin were compared with those in the 28 patients for whom surgery was the primary treatment.

RESULTS

There was a negative correlation between the pretreatment esotropic angle and age (Pearson's r = -0.45, p < 0.05). The first visit to a surgical specialist took place very late (mean age 43 months [standard deviation (SD) 39 months]). Of the 35 children seen during the period in which botulinum toxin was available, 20 (57%) had additional factors inducing unsteadiness of binocular vision (e.g., moderate to severe initial relative amblyopia, initial ametropia). Administration of 5 units of botulinum toxin before 18 months of age destabilized dissociated vertical deviation. Overall, 39 patients (89%) had a final residual deviation of less than 10 prism dioptres. The first surgical correction was horizontal and vertical-torsional in 30 patients (68%). A total of 23 patients (52%) required some retreatment (botulinum toxin or surgery or both). Children treated initially with botulinum toxin had less surgery than those with initial surgery (mean recession or resection 8.9 mm [SD 4.5 mm] vs. 14.2 mm [SD 4.0 mm]) as well as fewer horizontal muscles operated (mean 1.6 [SD 0.6] vs. 2.3 [SD 0.6]).

INTERPRETATION

Surgery with or without further interventions is a reasonable approach for IENA with delayed diagnosis and in cases associated with unsteadiness of binocular vision or with nonhorizontal deviations. Initial treatment with botulinum toxin, injected into both medial recti, is effective, reducing the amount of further horizontal surgery and favouring postoperative stability, except in children under 18 months, in whom injection of 5 units induces unbalanced dissociated vertical deviation.

Botulinum treatment of infantile esotropia with abduction nystagmus

PURPOSE

To examine the effect of botulinum toxin type A (BTA) on the final correction of esotropia, A and V patterns, overaction of the oblique muscles, and dissociated vertical deviation (DVD) in infantile esotropia with nystagmus in abduction.

METHODS

This retrospective study examined 54 patients treated with simultaneous bilateral medial injection of BTA. Subjects were divided into two groups: group 1 (first injection <18 months of age) and group 2 (first injection >18 months of age).

RESULTS

Pre-BTA, group 1 patients had an angle of esotropia noticeably higher and fewer A patterns than group 2 patients. Post-BTA, group 2 received significantly fewer injections of BTA than group 1. The magnitude of the A patterns improved. Prior frequency of DVD increased significantly in group 1 (100%): 79% of DVD was decompensated compared with 47% in group 2. Overall success was obtained in 14% and 58% of groups 1 and 2, respectively.

CONCLUSION

We do not support BTA treatment in infantile esotropia with nystagmus in abduction prior to age 18 months. After 18 months, the horizontal results are excellent and neither the incidence nor the degree of previous DVD are decompensated, resulting in high success rates for overall deviation and improving anisotropy in A.

Early surgery for infantile esotropia

AIM

To investigate the postoperative eye alignment and binocular visual function after early surgery for infantile esotropia.

METHODS

Both the postoperative eye position and stereopsis were reviewed using the Titmus stereo test in nine patients who received uniocular medial rectus recession and lateral rectus resection under general anaesthesia before 8 months of age and were followed up for a minimum of 4 years.

RESULTS

Orthophoria was attained in three cases, whereas esotropia was found in four patients. Dissociated vertical deviation was noted in two other cases at the final examination. Static stereoacuity was achieved in five cases. These results also showed that most infants in whom stereopsis was attained had satisfactory eye alignment during the follow up period and at the final examination. Infants who did not achieve stereopsis still had deviation throughout the follow up period.

CONCLUSIONS

It was concluded that early surgery in infantile esotropia is beneficial to achieve binocular visual function, but it is necessary to confirm a stable angle of deviation with accurate preoperative evaluation, and to maintain good postoperative eye alignment throughout the follow up period.

The timing of surgical alignment for congenital (infantile) esotropia

At this time, the beneficial effect of accurate alignment by age 2 in congenital esotropia has been well established by clinical and laboratory studies. There is, however, only scanty clinical evidence that alignment before age 1, much less before 6 months of age, may yield a better quality of binocularity (i.e., refined stereoacuity) than alignment by age 2. Pitfalls of very early alignment are present. In addition, the ophthalmologist must be vigilant in following the initially aligned patient and be ready to treat vertical motor defects, amblyopia, and acquired refractive errors. The need for additional horizontal surgery after initial alignment is also common. The optimum result in the surgical treatment of congenital esotropia generally shows binocularity that is within the confines of a monofixation syndrome, and refined stereoacuity remains an elusive target and a rare outcome, no matter at what age the alignment is achieved.

Untreated essential infantile esotropia: factors affecting the development of amblyopia

PURPOSE

A concomitant esotropia, presenting within the first 6 months of life, associated with a high incidence of dissociated vertical deviation, manifest latent nystagmus and asymmetric optokinetic nystagmus is termed essential infantile esotropia. Most studies concern patients diagnosed in infancy and treated throughout childhood. This paper addresses the factors that may influence the development of amblyopia in patients who remain untreated until visual adulthood.

METHODS

During a 3 year period 113 patients aged 8 years or more with a history of esotropia occurring within the first 6 months of life were examined for the study. All patients underwent full ocular motility assessment and cycloplegic refraction, and only those with one or more signs of essential infantile esotropia were included.

RESULTS

Of the 113 patients, 16 (14.3%) had a difference of 2 or more lines in the visual acuity of the two eyes and were diagnosed as having amblyopia. Anisometropia was present in 10 of the 16 (62.5%). The correlation between anisometropia and amblyopia was statistically significant (p = 0.0001).

CONCLUSIONS

Amblyopia following early surgical intervention in essential infantile exotropia is well documented, but the risk is outweighed by the chance of obtaining some form of binocular vision. However, where access to ongoing therapy is not available, patients with essential infantile esotropia, free alternation and no anisometropia have a significant chance of retaining good visual acuity in both eyes if surgery is delayed until visual adulthood.

Clinical characteristics and long-term postoperative results of infantile esotropia and myopia

PURPOSE

To determine the short-term (6 month) and long-term (4 year) surgical results of infantile esotropia in a control group of 100 patients, as compared to a myopia (-2.0 to -5.0 diopters [D]) group of 13 patients and to a high-myopia (greater than -8.0 D) group of 14 patients.

METHOD

A retrospective chart review with selection according to inclusion criteria.

RESULTS

All 14 high-myopic patients (100%) achieved short-term unacceptable result of large-angle (greater than 20 prism diopters) deviation as compared to 29 (29%) and four (31%) of the patients in the control and myopia groups, respectively (P < 0.0001). Eighty (80%) of the patients in the control group and 10 (77%) in the myopia group achieved long-term favorable postoperative results of subnormal binocular vision, microtropia, or small-angle (less than 20 prism diopters) deviation, with no statistical differences between the two groups. In contrast, 10 (71%) of the patients in the high-myopia group achieved a final unacceptable result of large-angle deviation, as compared to 20 (20%) and three (23%) in the control and myopia groups, respectively (P < 0.0001). Persistent preoperative amblyopia was associated with a higher percentage of unfavorable surgical results and was more frequent in the high-myopia group (50%) as compared to the control group (14%) (P = 0.0004).

CONCLUSIONS

Careful attention must be directed preoperatively toward reversing amblyopia and correcting refractive errors because persistent amblyopia at the time of surgery was associated with a higher percentage of unacceptable postoperative large-angle deviation. The conventional amount of recession or resection of muscles should be increased in high-myopic cases with infantile esotropia, because less effect is produced per millimeter of recession/resection initially and, in the long-term, the constant stimulus to accommodative convergence apparently causes recurrent esotropia.

Clinical characteristics and long-term postoperative results of infantile esotropia

We classified 103 patients (206 eyes) with infantile esotropia and an average of 8.7 years of postoperative follow-up into four outcome groups. Of 103 patients, 28 (27%) had subnormal binocular vision; 24 (23%) had microtropia; 43 (42%) had small-angle deviation (< 20 prism diopters); and eight (8%) had large-angle deviation. A chi 2 analysis showed a significant difference (chi 2 = 16.22, P = .005) in the distribution of amblyopia among these four outcome groups. Visual acuity of 20/30 or better was attained in 174 of the 206 eyes (84%). The eyes of all 28 patients in the subnormal binocular vision group remained aligned after an average of eight years. In contrast, the eyes of six of 30 patients (20%) in the microtropia group and 11 of 43 (26%) in the small-angle deviation group lost the stability of horizontal alignment. We found that the two variables of latent-manifest nystagmus and persistent amblyopia at the time of surgery lead to less satisfactory outcomes. In contrast, patients with smaller preoperative angle of deviation or surgery completed before 1 year of age demonstrated an increased incidence of optimal (subnormal binocular vision) or desirable (microtropia) results. We recommend performing surgery after amblyopia has been thoroughly treated, and, whenever possible, completing the surgical treatment by 1 year of age.

19th annual Frank Costenbader Lecture--the origins of congenital esotropia

Congenital esotropia develops in the first 4 months of life in an infant who lacks the inborn mechanism for motor fusion. It manifests as an esotropia which is not eliminated by correction of hyperopia and occurs in an otherwise neurologically normal infant. The earliest practical time for surgery is 4 months of age. The eye is anatomically suited for surgery at this age and also, this is the earliest age that congenital esotropia can be diagnosed with confidence. The best attainable result of treatment of congenital esotropia is subnormal binocular vision. This result is more likely to be attained if infants are aligned by 18 months of age. Satisfactory alignment is produced in 80% to 85% of infants in one procedure with an appropriate bimedial rectus recession. An array of motor defects including DVD, latent nystagmus, oblique dysfunction, and A- and V-pattern appear at varying times after successful alignment. These associated findings are commonly found with, but are not unique to, congenital esotropia. The onset and clinical picture of congenital esotropia is satisfactorily explained by a theory first suggested by Worth that the strabismus is caused by an inborn defect in the motor fusion mechanism and aggravated by esotropital factors as suggested by Chavasse. In contrast to congenital esotropia, all other strabismus can be thought of as occurring on a secondary basis in a person with the inborn capacity for motor fusion, but who failed to maintain it because of conatal insurmountable strabismus (congenital third nerve palsy), who lost it because of acquired (postnatal) strabismus, who uses a strategy such as head posture alteration to retain fusion under favorable circumstances (Duane syndrome), who has intermittent strabismus with part-time suppression (X(T)), or who is maintaining alignment with nonsurgical means (refractive esotropia). For the future, I believe that advances in the management of congenital esotropia will depend on a better understanding of etiology leading to design and use of innovative nonsurgical techniques to discourage convergence and stimulate bifoveal fusion.

The long-term results of surgical correction of childhood esotropia

The results of surgical management by one ophthalmologist of 102 patients with congenital esotropia and 74 patients with acquired esotropia in childhood were analysed. The majority of patients had undergone a monocular recession-resection procedure, with 91% and 93% of patients showing a reduction in the angle, of more than five degrees, following surgery for congenital and acquired esotropia respectively. Unexpectedly, varying the amount of lateral rectus resection from 3 to 6 mm, when combined with a constant 5 mm medial rectus recession, did not produce significantly different amounts of change in the ocular alignment after surgery. Patients with congenital esotropia generally developed a stable postoperative angle later than patients with acquired esotropia. The degree of improvement of ocular alignment with surgery was independent of hypermetropia, presence of preoperative amblyopia or fusion.