Photorefractive keratectomy followed by strabismus surgery for the treatment of partly accommodative esotropia

Refractive surgery as a treatment tool for strabismus: systematic review

The impact refractive surgery has on preoperative horizontal strabismus is rapidly evolving, and this knowledge can provide valuable clinical context when considering refractive surgery as a treatment for strabismus. 515 studies were identified, of which 26 met the inclusion criteria. Analysis indicated that refractive surgery resulted in an overall decrease in the mean uncorrected postoperative angle of deviation caused partially or fully due to refractive error and highlighted the varied outcome of refractive surgery on nonaccommodative horizontal strabismus with limited evidence to suggest refractive surgery for this type of strabismus. Efficacy of refractive surgery in reducing concomitant horizontal strabismus depends on several factors: type of horizontal ocular deviation, patient age, and extent of refractive error. Refractive surgery can be an effective treatment for refractive accommodative horizontal strabismus in patients with stable, mild to moderate myopia or hyperopia and should be considered with careful patient selection for optimum outcome.

Refractive Surgery for Older Children and Adults with Accommodative Esotropia: A Systematic Review

INTRODUCTION

Accommodative esotropia (AET) is characterized by an esodeviation of the eyes due to uncorrected hyperopia, deficient fusional divergence, or high accommodative convergence. Decreasing hyperopia would reduce accommodative convergence and strabismus. We sought to review the existing evidence regarding the outcomes of refractive surgery in patients with AET.

METHODS

A four-database search (Pubmed, ISI Web of Science, Cochrane, and Scopus) was performed from inception to March 2021 using the following MeSH terms: ("Refractive Surgical Procedures" OR "Keratomileusis, Laser In Situ" OR "Photorefractive Keratectomy" OR "Lens Implantation, Intraocular") AND ("Esotropia" OR "Accommodative Esotropia" OR "Refractive Esotropia" OR "Accommodative Strabismus"). No meta-analysis was performed due to studies' heterogeneity.

RESULTS

Twenty-eight studies including 22 case series enrolling 378 patients and 6 case reports enrolling 8 patients were selected among 185 original abstracts. In the case series, a total of 378 patients (726 eyes) were recruited with an age range of 8-52 years. All studies reported mean follow-up periods of at least 12 months. Photorefractive keratectomy was performed in 7 studies, laser-assisted in situ keratomileusis in 9 studies, laser-assisted sub-epithelial keratectomy was reported in 1 study, and 3 studies implanted intraocular lenses, including iris-fixated and collamer. Considering the adult patients with a preoperative corrected esodeviation ≤10 prism diopters (PD) (n = 129), all but 5 (3.9%) presented orthophoria or ≤10PD after refractive surgery. All children but 4 (4.5%) ended up with an esodeviation ≤10PD after surgery with those exceptions being in the range of 11-15PD. Six case reports were included in this review, comprising a total of 8 patients (16 eyes) with an age range of 7-34 years and a follow-up range of 4-48 months. Six case reports were included in this review, comprising a total of 8 patients (16 eyes) with an age range of 7-34 years and a follow-up range of 4-48 months.

CONCLUSION

Evidence produced so far points out that refractive surgery may be an alternative for spectacle correction for adults with AET ≤10PD. There is not enough evidence to recommend its use for patients under 18 years of age. The safety and predictability of these procedures for this purpose remains unclear as the selection criteria used for these patients are much different than the usual indications and there are no studies with long-term follow-up.

Photorefractive keratectomy influences the angle of ocular deviation in strabismus patients with hyperopia

PURPOSE

To evaluate refractive, binocular vision and ocular alignment outcomes of photorefractive keratectomy (PRK) for the treatment of hyperopia in esotropic patients.

METHODS

Medical charts of hyperopic patients with full or partial accommodative esotropia (FAE or PAE) or consecutive exotropia (CE) undergone PRK from 2011 to 2014 were reviewed. The primary outcome was to assess the efficacy of PRK in improving ocular alignment. The secondary outcomes were the assessments of uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), spherical equivalent (SE) and stereoacuity.

RESULTS

Sixty-four eyes of 32 hyperopic patients were included. Three patients were affected by FAE, 24 by PAE and 5 by CE. All FAE patients and 4 PAE patients underwent only PRK; the remaining 25 patients underwent PRK plus strabismus surgery. After PRK, the mean corrected esodeviation decreased significantly in the overall esotropic population [7.15 ± 9.42 prism diopters (PD) vs. 5.04 ± 8.83 PD; p = 0.03] and in particular in the group with small-angle esodeviation (< 20 PD). Conversely, the only 2 patients with an angle of strabismus ≥ 20 PD as well as all CE patients did not show any postoperative variation of the deviation angle. Mean preoperative BCVA did not differ from postoperative UCVA (p = 0.19), while the mean postoperative SE decreased significantly after PRK (p < 0.0001).

CONCLUSIONS

Our study confirmed that PRK eliminates the accommodative component of the deviation. In addition, this procedure seems to reduce or eliminate also the non-accommodative component of esodeviation (especially in small-angle deviation), thus suggesting to postpone strabismus surgery after PRK when esotropia and hyperopia coexist.

The Effect of Hyperopic Laser in Situ Keratomileusis on Refractive Accommodative Esotropia

PURPOSE

To evaluate the efficacy of laser in situ keratomileusis (LASIK) for discarding spectacles and simultaneously correcting ocular alignment in patients with refractive accommodative esotropia.

METHODS

LASIK was performed on 20 eyes of 10 patients (mean age, 24.3 years; range, 11 to 43 years) using a Technolas 217C excimer laser. The target refraction was emmetropia. Visual acuity (uncorrected and best-corrected), refractive error, and ocular alignment were recorded before and after LASIK. Minimum follow-up was 12 months.

RESULTS

The mean preoperative uncorrected and corrected angle of deviation was 37.1 prism diopters (PD) (range, 17 to 80; standard deviation (SD), 19.8)) and 14.74 PD (range, 0 to 50; SD, 12.9) of esotropia, respectively, which changed to 7.2 PD (range, 0 to 50; SD, 15.78) without correction postoperatively (p=0.005). Of 20 eyes, 15% lost one line of best-corrected visual acuity, 10% gained two lines, and 75% showed no change.

CONCLUSIONS

LASIK could be considered an alternative treatment for patients with refractive accommodative esotropia with intolerance to glasses and contact lenses.

Accommodative esotropia: the state of the art

PURPOSE

To review the state of the art of Accommodative Esotropia (AE) through careful study of what has been reported up to the point in literature.

METHODS

A literature search was done on PubMed using key words including "Accommodative esotropia", "Infantile esotropia", "Strabismus" and "Accommodation". We systematically reviewed and critically appraised what has been written about AE and we tried to analyze that according to the current management of AE.

RESULTS

Accommodative Esotropia (AE) is a form of strabismus characterized by convergent misalignment of the visual axes that can be associated with hyperopia and abnormal fusional divergence. Also abnormal accommodative convergence/accommodation ratio could be found. In lots of cases, AE initially presents as an intermittent esodeviation at age 1.5 to 4 years. The prevalence of AE has been estimated near 1-2% in the United States. The only treatment with an optical correction usually is successful in re-establishing alignment, but surgical correction is necessary in approximately 30% of cases.

Treatment of adults with accommodative esotropia using implantable collamer lenses

PURPOSE

To evaluate the efficacy and safety of the implantation of an implantable collamer lens (ICL) for accommodative esotropia in adults.

METHODS

From May 2011 to May 2012, 3 adults with complete accommodative esotropia underwent ICL implantation with 12 months of follow-up. Inclusion criteria included having an appropriate anterior chamber depth and endothelial cell count, and hyperopia that was not typically responding well to corneal refractive surgery. Preoperative and postoperative visual acuity, refraction, eye position, corneal endothelial cell count, intraocular pressure, anterior chamber depth, and complications (intraoperative and postoperative) were observed.

RESULTS

Cycloplegic refraction changed from 6.04 ± 0.53 preoperatively to 0.41 ± 0.21 postoperatively (t = 38.9, P < .001). Before surgery, the average esotropia at near (without glasses) was 25 prism diopters (range: 20 to 30 prism diopters). After surgery, all patients achieved orthophoria or microesophoria. Postoperative uncorrected visual acuity at distance and near significantly increased (P < .05), best-corrected visual acuity at near did not change significantly (P = .36), and best-corrected visual acuity at distance improved significantly (P = .03). The average decline in corneal endothelium cell density was 10.3% and remained stable during the follow-up period. One patient complained of glare when driving at night after surgery and this phenomenon gradually disappeared after 3 months. No other intraoperative and postoperative complications, such as ICL-related iris depigmentation, atrophy, glaucoma, or cataracts (partial or complete), were observed.

CONCLUSIONS

The preliminary results of this small case study demonstrated that the use of ICL implantation to treat accommodative esotropia in adults was effective and safe; however, a larger scale study is necessary.

The influence of compliance with the use of refractive correction in hyperopic children on accommodation

PURPOSE

To indicate the relationship between constant, correct use of hyperopic spectacles and relaxation of accommodation in children.

METHODS

After thorough ophthalmic examination (cycloplegia included), 52 children 2.5 to 9 years old were detected with hyperopia >3 D, out of all examined within a year. These children were fully or partially corrected, with hyperopic glasses, depending on whether accommodative esotropia was or was not present. Constant and correct use of spectacles was strongly suggested to all children. During follow-up 3 and 6 months later, the amount of manifest hyperopia was measured in each case by an autorefractometer (without the use of cycloplegic factor).

RESULTS

Out of the 52 children, 37 who participated in our study fully complied with hyperopic spectacle treatment, wearing their glasses constantly and correctly. The 15 others wore their glasses partially or not at all or made incorrect use of them. During follow-up 3 and 6 months later, refractive measurements of manifest hyperopia in the first group of children were identical or similar to the refractive power of their glasses. On the contrary, in the second group of children, strong accommodation did not allow the expression of hyperopia, and in a few cases myopic refractive measurements appeared (similar to those on the first examination, before spectacle treatment was prescribed).

CONCLUSIONS

Constant and correct use of hyperopic spectacles leads to relaxation of accommodation in children and is thus an accurate indicator of compliance.

Refractive surgery for accommodative esotropia: past, present, and future

INTRODUCTION

Refractive surgery has the potential to be a definitive treatment for accommodative esotropia, yet it has not been widely embraced. This article reviews the current literature on refractive surgery to treat accommodative esotropia.

METHODS

A literature search was performed using the following terms: refractive surgery, photorefractive keratectomy, laser-assisted keratomileusis, intraocular lens, hyperopia, accommodative esotropia, children, pediatric.

RESULTS

Fifteen series of patients treated with refractive surgery for accommodative esotropia were identified and summarized.

CONCLUSIONS

Refractive surgery holds promise for the treatment of accommodative esotropia, although treatment risks are present and additional investigation is needed.

Laser in situ keratomileusis for the treatment of refractive accommodative esotropia

PURPOSE

To demonstrate the effectiveness of refractive surgery with an excimer laser to correct hyperopia and convergent strabismus caused by compensatory accommodation of refractive error.

DESIGN

Prospective, interventional, noncomparative case series.

PARTICIPANTS

Forty-six eyes of 23 patients with hyperopia and fully or partially refractive accommodative esotropia.

METHODS

Patients were treated with an excimer laser and the LASIK technique between 2000 and 2010.

MAIN OUTCOME MEASURES

Preoperative and postoperative refractive spherical equivalent and ocular alignment.

RESULTS

Mean age ± standard deviation [SD] was 25 ± 12.6 years. Mean hyperopia ± SD was 3.67 ± 1.28 diopters (D) before surgery and 0.21 ± 0.59 D after surgery (P<0.001). The mean angle of deviation without correction was 21.0 prism diopters (Δ) before surgery and 3.7 Δ after surgery (P<0.001).

CONCLUSIONS

Refractive surgery with excimer laser is a promising option for the treatment of refractive accommodative esotropia.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Photorefractive keratectomy for the treatment of purely refractive accommodative esotropia: 6 years' experience

AIMS

To report the long term outcomes of photorefractive keratectomy (PRK) for the treatment of hyperopia associated with purely refractive accommodative esotropia.

METHODS

This study was a retrospective chart review of 40 patients aged 17-39 years who underwent PRK to eliminate their dependence on glasses. Pre- and postoperative best spectacle corrected visual acuity (BSCVA), uncorrected visual acuity (UCVA), refractive spherical equivalent (SEQ), ocular alignment and stereoacuity were reviewed.

RESULTS

Forty patients (80 eyes) with a mean age of 27.9 years were treated for a mean preoperative SEQ of +3.06 D hyperopia. The mean final postoperative SEQ was +0.06 D. Preoperative BSCVA was 0.04 logarithm of the minimum angle of resolution (logMAR), and did not change postoperatively. Mean UCVA significantly improved from 0.30 logMAR preoperatively to 0.08 logMAR post-operatively. Mean pre-operative esotropia at distance and near was 18.6 prism D. All patients were orthophoric without correction at the 1 month, 1 year and final postoperative evaluations. Visual acuity, refractive error and alignment remained stable after the 1 year postoperative examination. Stereoacuity was unchanged in 80% of patients postoperatively. There were no complications.

CONCLUSION

PRK can be used to treat low to moderate hyperopia associated with purely refractive accommodative esotropia in young adults.

Laser in situ keratomileusis for treatment of fully or partially refractive accommodative esotropia

PURPOSE

To evaluate the efficacy and safety of laser in situ keratomileusis (LASIK) in partially refractive accommodative esotropia (pRAE) and fully refractive accommodative esotropia (fRAE).

METHODS

Forty-two eyes of 21 patients who had LASIK for correcting hyperopic refractive error were evaluated. Refractive errors, uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA), ocular alignment, and stereopsis were recorded before and after LASIK.

RESULTS

Sixteen patients with fRAE and 5 with pRAE were evaluated. Mean age at the time of surgery was 19.00+/-3.79 years. Mean follow-up time was 12.19+/-4.51 months. For the fRAE group, the mean preoperative angle of deviation without spectacle correction was +19.13+/-5.87 prism diopters (PD); all were orthophoric with spectacles. Postoperatively, all these patients achieved less than 10 PD of deviation without spectacles. For the pRAE group, the mean preoperative angle of deviation was +32.60+/-9.81 PD and +14.60+/-6.14 PD without and with spectacles, respectively. Postoperatively, the mean angle of deviation was +13.60+/-5.72 PD and +12.80+/-5.40 PD without and with spectacles, respectively. For all 21 patients, the preoperative mean spherical equivalent (SE) with cycloplegia was +4.94+/-1.43 diopters (D); it was +1.49D+/-0.70 D postoperatively. Three eyes lost 1 line of BCVA and 3 eyes gained 1 line. No intraoperative complication was recorded.

CONCLUSIONS

LASIK is a safe and effective method for treating refractive error and creating orthophoria in fRAE. In pRAE, it eliminates the refractive component of deviation safely and effectively.

LASIK and PRK in refractive accommodative esotropia: a retrospective study on 20 adolescent and adult patients

PURPOSE

To evaluate the clinical results obtained with excimer laser treatment of fully refractive accommodative esotropia.

METHODS

Fully refractive accommodative esotropia was corrected in 17 patients with laser in situ keratomileusis (LASIK) and in 3 patients with photorefractive keratectomy (PRK). The mean age of the patients at time of refractive surgery was 18.8 years (range 14 to 24 years). All surgical procedures were performed under local anesthesia. The preoperative and postoperative data were retrospectively analyzed with regards to visual acuity, ocular alignment, and stereopsis.

RESULTS

The mean preoperative deviation without correction was 18.1Delta for near vision and 13.7Delta for distance vision. After refractive surgery the mean postoperative deviation was 4Delta esophoria at near, and 2.5Delta of esophoria at distance: 10 patients (50%) showed esophoria for both distance and near vision, 2 patients (10%) esophoria only for near vision, and 8 patients (40%) orthophoria for both distance and near vision. Emmetropia (-/+1.00 D) was obtained in 97.5% of eyes (39 of 40). The mean correction obtained with excimer laser was +4.62 D(range +2.25 to +7.75, SD 4.52). The preoperative BSCVA was in all eyes greater than or equal to 20/30. There were no significant differences observed between the preoperative and postoperative mean best-corrected visual acuity (p=0.32). There were no complications. The follow-up period lasted a mean of 30.2 months.

CONCLUSIONS

The treatment of fully refractive accommodative esotropia with excimer laser was found effective and safe, even in young or adolescent patients. More studies are needed to increase the patient experience and extend the follow-up period in order to evaluate the stability of these results over time.

Surgical Correction of Hyperopia

Surgical attempts to correct hyperopia have yielded varying results over the last 130 years. These techniques include the reshaping of the cornea through incisions, burns, or lamellar cuts with removal of peripheral tissue; the addition of central inlays; laser ablations; and the replacement of the crystalline lens. By examining the success of each surgical technique, the refractive surgeon may be able to make an informed decision on its indications and limitations, based on the specific patient's characteristics. Reporting the outcomes and complications of hyperopic surgery will help refine our approach to the management of an increasingly hyperopic and presbyopic population.

Refractive laser surgery in children with coexisting medical and ocular pathology

PURPOSE

To report the visual, refractive, and functional outcomes of photorefractive keratectomy (PRK) and of laser-assisted subepithelial keratectomy in a group of children with significant refractive error and underlying medical conditions or ocular pathology who were noncompliant with traditional management.

SETTING

Nonhospital surgical facility and a hospital clinic.

METHODS

This case series comprised 5 individual cases of anisometropic amblyopia and/or high myopia. Underlying medical and ocular conditions were as follows: upper eyelid hemangioma with oblique myopic astigmatism, Pelizaeus-Merzbacher leukodystrophy with nystagmus, Klippel-Trenaunay-Weber syndrome with glaucoma, incontinentia pigmenti with unilateral optic nerve atrophy, and Goldenhar syndrome with unilateral optic nerve hypoplasia. Photorefractive keratectomy or LASEK was performed in 6 eyes of 5 patients. Age range at the time of surgery was 1.0 to 7.0 years. All procedures were performed under general anesthesia.

RESULTS

Best corrected visual acuity improved by 2 lines in 2 patients and 1 line in 2 patients by 6 months after surgery. Stereopsis and/or fusional status improved in 3 patients. Amblyopia treatment compliance improved in 1 patient. Alignment improved without strabismus surgery in 2 cases. A functional vision survey demonstrated a positive effect on the ability of all 5 children to function in their environment.

CONCLUSION

During the period of visual cortical plasticity, refractive surgery, by eliminating the refractive component of amblyopia and by promoting fusional ability, provides considerable improvement in children, even those with underlying medical conditions associated with ocular pathology.