Long-term follow-up of children with acute acquired concomitant esotropia

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.

Clinical characteristics of acute acquired concomitant esotropia before and after the COVID-19 pandemic: a retrospective analysis

PURPOSE

This study aimed to observe the clinical characteristics of acute acquired concomitant esotropia (AACE) patients in recent five years and to examine the changes in the proportion of AACE cases before and after the COVID-19 pandemic.

METHODS

A retrospective study included 148 patients who underwent strabismus correction surgery for AACE between January 1, 2017, and December 31, 2021. The study analyzed the changing proportion of AACE cases before and after the COVID-19 pandemic and analyzed its clinical characteristics.

RESULTS

Abnormalities in the worth 4 dot examination (both distance and near) were present in 134 cases (90.54%) before surgery, while 140 cases (94.59%) showed normal results after surgery. Near stereoacuity was present in 135 cases (91.22%). The near and distance deviations were (55.01 ± 18.77) PD and (57.30 ± 17.64) PD, respectively, and there was no significant difference between the two (p = 0.279). There were significant differences in the ratio of refractive status among different age groups (p < 0.001), while no statistically significant difference was observed in the ratio of refractive status for near deviation (p = 0.085) or distance deviation (p = 0.116). The proportion of AACE cases after the COVID-19 pandemic was significantly higher than that before the COVID-19 pandemic (p = 0.042). There was no statistically significant difference in the clinical characteristics between the two groups (p > 0.05).

CONCLUSIONS

Myopia is the most common refractive status in AACE. More than half of patients had occupations that involved long hours of close work. The proportion of AACE cases increased significantly after the COVID-19 pandemic.

Effect of 4-week preoperative prism adaptation in preventing postoperative residual esotropia

BACKGROUND

Preoperative prism adaptation (PPA) simulates postoperative status and possibly can predict postoperative undercorrection before surgery in esotropia. The present study aimed to assess the effect of 4-week PPA in preventing postoperative residual esotropia.

METHODS

Seventy-five (75) esotropes who had undergone surgery at a single strabismus center were retrospectively enrolled. They included 25 basic, 31 acute comitant, 10 partially accommodative, and 9 recurrent esotropia patients. The preoperative deviation angle, which had been determined using the alternating prism and cover test, was fully corrected with press-on prisms 4 weeks before surgery. If there was an increase of 5 PD or more of esodeviation, the prisms were changed accordingly at 2 weeks. The deviation angle measured at 4 weeks was determined as the surgical target angle. Patients were then divided into increase (≥ 5 PD increase of angle during 4-week PPA) and non-increase groups. Success was defined as either esodeviation of 8 PD or under or exodeviation of 5 PD or under at distance at postoperative 6 months.

RESULTS

The increase group included 44 patients (58.7%). The mean deviation angle before PPA was 27.4 PD, and after the 4-week PPA, there was an average increase of 9.4 PD. The success rate was 90.9% in the increase group and 96.8% in the non-increase group (p = 0.316). There were no intergroup differences in preoperative clinical characteristics, esotropia types, postoperative deviation angle or postoperative near stereopsis (p > 0.05).

CONCLUSIONS

The results of this study indicated a beneficial effect of 4-week PPA in esotropia of various types, specifically by uncovering the hidden esodeviation in the increase group and simulating the postoperative alignment in both the increase and the non-increase groups.

Effect of the prism and Maddox rod test as the surgical target for type III acute acquired comitant esotropia

Introduction

This study aims to explore more accurate and efficient examination methods to provide precise target surgical measurements for patients with type III acute acquired comitant esotropia (AACE).

Methods

The study conducted a retrospective analysis of 108 patients diagnosed with AACE who received surgical treatment at the Department of Ophthalmology, the First Affiliated Hospital of Fujian Medical University, from January 2018 to September 2023. All patients underwent examinations of the deviation angle, including the Hirschberg test, prism and Maddox rod test (PMT), and prism and alternate cover test (PACT). For the PACT, the minimum value (PACTmin) and maximum value (PACTmax) were obtained based on differences in examination methods, as well as the deviation angle range (PACT range), which represents the difference between PACTmax and PACTmin. Postoperatively, these patients were followed up for at least 6 months to assess changes in eye position and whether diplopia symptoms recurred.

Results

In both near and distant examinations, the results of PACTmax were significantly greater than those of PACTmin (p < 0.001), while the deviation angles obtained from PACTmax and PMT showed no significant statistical difference [p = 0.689 (33 cm), p = 0.436 (5 m)]. There was a strong linear correlation between PACTmin and PMT at both near (R = 0.8887) and distant (R = 0.8950) distances, but each PACTmin corresponded to multiple PMT values. There was no significant difference between the results of PACT range at near and distant distances (p = 0.531). The deviation angles obtained by PMT and PACTmin significantly decreased postoperatively compared to preoperative values, and diplopia disappeared in all patients, with alternative cover test showing no movement or presenting as an esophoria state.

Conclusion

The PMT can provide precise target surgical measurements for type III AACE, making it a fast, effective, and cost-efficient examination method. It is worthy of being promoted and applied in clinical practice.

Risk of serious intracranial pathology in children presenting with acute acquired comitant esotropia

OBJECTIVE

Acute acquired comitant esotropia (AACE) is defined as a sudden-onset constant nonaccommodative esodeviation. The purpose of this study was to determine the risk of serious intracranial pathology in children presenting with AACE.

DESIGN

Retrospective observational cohort study.

SETTING

Tertiary care pediatric hospital.

METHODS

The study included consecutive children who met the diagnostic criteria for AACE and had neuroimaging at a tertiary care pediatric hospital between 2000 and 2020. Patients were identified by searching the radiology database for all children who underwent neuroimaging for esotropia. The primary outcome measure was the proportion of patients with serious intracranial pathology. Secondary outcomes included risk factors for finding likely causative intracranial pathology and the proportion of patients with incidental findings.

RESULTS

A total of 107 patients met the inclusion criteria. Most of the patients (75.7%) had normal neuroimaging. The next most common result was an incidental finding unrelated to the esotropia (18.7%). Five patients (4.7%) had findings with uncertain contribution to esotropia, including 3 cases of type I Chiari malformation. A serious intracranial pathology was found in 1 patient (0.9%) who had a cerebellar medulloblastoma.

CONCLUSION

In this large series of pediatric patients with AACE who underwent neuroimaging, there was a small but nontrivial risk of serious intracranial pathology. In these patients, it is advisable either to obtain neuroimaging or to monitor closely for the development of concerning signs or symptoms.

Neurological pathologies in acute acquired comitant esotropia

BACKGROUND

Acute acquired comitant esotropia (AACE) is an uncommon subtype of esotropia characterized by sudden and usually late onset of a relatively large angle of comitant esotropia with diplopia in older children and adults.

METHODS

A literature survey regarding neurological pathologies in AACE was conducted using databases (PubMed, MEDLINE, EMBASE, BioMed Central, the Cochrane Library, and Web of Science) in order to collect data for a narrative review of published reports and available literature.

RESULTS

The results of the literature survey were analyzed to provide an overview of the current knowledge of neurological pathologies in AACE. The results revealed that AACE with unclear etiologies can occur in many cases in both children and adults. Functional etiological factors for AACE were found to be due to many reasons, such as functional accommodative spasm, the excessive near work use of mobile phones/smartphones, and other digital screens. In addition, AACE was found to be associated with neurological disorders, such as astrocytoma of the corpus callosum, medulloblastoma, tumors of the brain stem or cerebellum, Arnold-Chiari malformation, cerebellar astrocytoma, Chiari 1 malformation, idiopathic intracranial hypertension, pontine glioma, cerebellar ataxia, thalamic lesions, myasthenia gravis, certain types of seizures, and hydrocephalus.

CONCLUSIONS

Previously reported cases of AACE with unknown etiologies have been reported in both children and adults. However, AACE can be associated with neurological disorders that require neuroimaging probes. The author recommends that clinicians should perform comprehensive neurological assessments to rule out neurological pathologies in AACE, especially in the presence of nystagmus or abnormal ocular and neurological indications (e.g., headache, cerebellar imbalance, weakness, nystagmus, papilloedema, clumsiness, and poor motor coordination).

Basic acquired nonaccommodative esotropia patients managed with surgery; a study of 2102 patients

INTRODUCTION

Several studies investigated preoperative clinical features of patients with basic-acquired nonaccommodative esotropia (BANAET); however, their sample sizes were small, and they did not compare the clinical features among cases that needed different surgery times. The main purpose of this study is to compare the preoperative clinical features of patients with BANAET managed with one surgery with patients who underwent two or more strabismus surgery over 10 years.

METHODS

This historical cohort study was performed on the hospital records of 13,252 Iranian strabismic patients who underwent surgery at Farabi eye hospital, Tehran, Iran, from 2012 to September 2022. Of those, 2102 cases with BANAET were selected as the sample size. Data collected included sex, age at the time of first surgery, corrected distance visual acuity (CDVA), refractive error, presence of amblyopia, angle of deviation, and times of surgery.

RESULTS

The mean age was 18.9 ± 15.6 [1200 (57.1%) males and 902 (42.9%) females] and the median age was 14 years. In 1599 (76.1%) patients, esotropia was managed with one surgery; however, 342 (16.3%) cases were managed with two surgeries and 161 (7.6%) patients underwent three or more surgeries. The mean angle of horizontal deviation at distance and near in patients managed with two and ≥3 surgeries was significantly higher than in cases managed with one surgery (P < .001). Amblyopia was observed in 289 (18.1%) patients who were managed with one surgery, 69 (20.2%) patients with two surgeries and 43 (26.7%) patients with three or more surgeries (P < .001). Patients with BANAET managed successfully with only one surgery were younger, had better CDVA, lower astigmatism and less horizontal angle of deviation at distance and near than those who underwent two or more surgeries (all P < .001).

DISCUSSION

The higher astigmatism, lower CDVA, greater angle of horizontal deviation, and higher frequency of amblyopia were found in the preoperative examinations of BANAET patients managed with two or more surgeries compared with cases managed with only one surgery.

Sensory eye dominance following surgically correction for acute acquired concomitant esotropia of adulthood

BACKGROUND

Acute acquired concomitant esotropia (AACE) is an unusual presentation characterized by acute onset of esotropia after infancy. For patients with AACE of adulthood, the outcome of surgery, which is a common treatment, often shows successful recovery of stereopsis. However, whether surgically corrected patients with AACE of adulthood achieved balanced eyes is yet unclear.

METHODS

Here, we used a binocular phase combination paradigm to quantitatively assess the ocular dominance of 22 surgically aligned patients with AACE of adulthood, which all had regained normal stereopsis after the surgery and 14 adult controls with normal vision. The sensory eye dominance was quantified as the interocular contrast ratio, termed balance point, at which each eye contributed equally to the perception of cyclopean grating.

RESULTS

We found that, normal controls had a mean balance point value close to unity (0.96 ± 0.01), whereas adult AACE patients exhibited apparent interocular imbalance (0.76 ± 0.04), which was significantly different from control group (Mann-Whitney U = 135, P < 0.001, two tailed). In addition, the balance point of adults with AACE didn't correlate with the interval between onset of esotropia and the surgery (r =  - 0.262, p = 0.239), or the length of postoperative follow-up period (r = 0.127, p = 0.575).

CONCLUSION

Our results suggest that, for patients with AACE of adulthood whose eyes had been straightened, there is still residual sensory imbalance which may be a potential risk factor for AACE of adulthood.

Epidemiology, clinical features, and surgical outcomes of acute acquired concomitant esotropia associated with myopia

PURPOSE

To analyze epidemiology, clinical features, and surgical outcomes of type III acute acquired concomitant esotropia (Bielschowsky esotropia (BE)).

METHODS

The medical charts of patients diagnosed with acquired concomitant esotropia between 2013 and 2021 were reviewed. Assessed data were age, gender, age at diplopia onset, age at the diagnosis, refraction, visual acuity, neuroimaging, diplopia onset, angle of deviation, stereopsis, surgical procedure, amount of surgery, and relapse of diplopia after surgery. Moreover, we investigated the correlation between the use of electronic devices and the onset of diplopia.

RESULTS

One hundred seventeen patients (mean age 35.07 ± 15.81 years) were included in the study. The mean delay to the diagnosis was 3.29 ± 3.62 years. Myopia range was 0 to 17 diopters spherical equivalent. 66,3% spent more than 4 hours a day using laptops, tablets, or smartphones at the onset of diplopia, and 90,6% presented a subacute onset. None showed neurologic signs or symptoms. Patients who underwent surgery were ninety-three, with a rate of surgical success of 93.6%, and a relapse rate of 17.2%. A negative correlation resulted between pre-operative deviation and age at diagnosis (ρ = -0.261; p<0.05), whereas factors associated with surgical failure were older age at diplopia onset (p = 0.042) and longer delay between onset and diagnosis (p = 0.002).

CONCLUSION

We registered an outstanding increase in prevalence of BE, which could be related to the exponential increase in the use of electronic devices for professional, educational, and recreational purposes. A prompt diagnosis and an augmented dose of surgery allows good motor and sensory results.

Non-adjustable surgery for acute acquired comitant esotropia under general anesthesia

Purpose:

To investigate the surgical results of the non-adjustable suture technique under general anesthesia for the correction of acute acquired comitant esotropia.

Study design:

Retrospective case study.

Methods:

Patients with acute acquired comitant esotropia who underwent corrective surgery from September 2008 to June 2018 were included. Surgical treatment was conducted based on the measured maximum angle after occlusion for at least 1 h; all surgeries were performed using the non-adjustable suture technique under general anesthesia. Motor success was categorized into three groups: good, ortho; fair, 2 to 8 prism diopters (PD); and poor, over 8 PD. Sensory success was divided into two groups: good (no diplopia with binocular vision) and poor (no stereopsis with diplopia).

Results:

40 patients (21 male and 19 female, 28.78 ± 15.32 years old) were included. Preoperative esodeviation was 28.0 ± 12.8 PD. Mean refractive error was − 2.5 ± 2.5 D (spherical equivalent). After the occlusion of one eye, 14 patients (35%) showed an esodeviation increase of more than 5 PD. There were 70% good, 25% fair, and 5% poor outcomes regarding motor success. 96% of the patients demonstrated good sensory success.

Conclusion:

The non-adjustable correction based on the maximum angle after 1 h had a relatively excellent motor and sensory success rate.

Altered voxel-wise degree centrality associated with patients with comitant exotropia

Objective of the study is to investigate the altered intrinsic functional hubs in patients with comitant exotropia (CE) using the voxel-wise degree centrality (DC) analysis method. A total of 28 CE patients and 28 healthy controls (HCs) similarly matched in sex, age, and education level were recruited in this study. All subjects underwent a resting-state functional MRI scan, the voxel-wise DC method was applied to evaluate brain network hubs alterations in CE patients. Then, the DC maps between two groups were chosen to be classification features to distinguish patients with CE from HCs based on the support vector machine (SVM) model. The algorithm performance was evaluated by a permutation test. Compared with HCs, CE patients exhibited significant enhanced DC value in the left cerebelum 8 and the right cerebelum 3; and remarkably decreased DC value in the right precentral gyrus, right anterior cingulated, and paracingulate gyri (two-tailed, voxel level: P < 0.01; GRF correction, cluster level: P < 0.05). However, no relationship was found between the observed average DC of the different brain regions and the clinical features ( P > 0.05). In addition, the SVM model showed an accuracy of 83.93% to clarify CE patients from HCs using the DC maps as a classification feature. CE patients displayed altered functional network hubs in multiple brain areas associated with cognition and motor control, and the DC variability could classify patients from HCs with high accuracy. These findings may assist to understand the neuropathological mechanism for the disease.

Abnormal Low-Frequency Oscillations Reflect Abnormal Eye Movement and Stereovision in Patients With Comitant Exotropia

Background: Patients with comitant exotropia (CE) are accompanied by abnormal eye movements and stereovision. However, the neurophysiological mechanism of impaired eye movements and stereovision in patient with CE is still unclear.

Purpose: The purpose of this study is to investigate spontaneous neural activity changes in patients with CE using the amplitude of low-frequency fluctuation (ALFF) method and the machine learning method.

Materials and Methods: A total of 21 patients with CE and 21 healthy controls (HCs) underwent resting-state magnetic resonance imaging scans. The ALFF and fractional amplitude of low-frequency fluctuation (fALFF) values were chosen as classification features using a machine learning method.

Results: Compared with the HC group, patients with CE had significantly decreased ALFF values in the right angular (ANG)/middle occipital gyrus (MOG)/middle temporal gyrus (MTG) and bilateral supplementary motor area (SMA)/precentral gyrus (PreCG). Meanwhile, patients with CE showed significantly increased fALFF values in the left putamen (PUT) and decreased fALFF values in the right ANG/MOG. Moreover, patients with CE showed a decreased functional connectivity (FC) between the right ANG/MOG/MTG and the bilateral calcarine (CAL)/lingual (LING) and increased FC between the left PUT and the bilateral cerebellum 8/9 (CER 8/9). The support vector machine (SVM) classification reaches a total accuracy of 93 and 90% and the area under the curve (AUC) of 0.93 and 0.90 based on ALFF and fALFF values, respectively.

Conclusion: Our result highlights that patients with CE had abnormal brain neural activities including MOG and supplementary motor area/PreCG, which might reflect the neural mechanism of eye movements and stereovision dysfunction in patients with CE. Moreover, ALFF and fALFF could be sensitive biomarkers for distinguishing patients with CE from HCs.

Effect of the base-out recovery point as the surgical target for acute acquired comitant esotropia

PURPOSE

To evaluate the treatment efficacy of the preoperative base-out recovery point as the surgical target angle for acute acquired comitant esotropia.

METHODS

Prospective study. Twenty-two patients with acute acquired comitant esotropia (AACE) underwent strabismus surgery based on the target angle of the preoperative base-out recovery point. The postoperative deviation, positive fusional vergence, and negative fusional vergence were evaluated and compared with those of 23 normal individuals.

RESULTS

The mean follow-up period was 18.68 ± 19.48 months. At the last follow-up, 19 (86.4%) of 22 subjects had orthophoria, whereas 3 (13.6%) had minimal esophoria. The postoperative angle of deviation was significantly smaller than the preoperative angle of deviation at near (P < 0.001) and distance (P < 0.001). Postoperative sensory fusion was significantly better than preoperative fusion at near (P < 0.001) and distance (P < 0.001). The postoperative stereoacuity improved significantly after the surgery at near (P < 0.001) and distance (P < 0.001). Compared with the controls, the convergence and divergence amplitudes in the AACE patients were similar at distance (P > 0.05) but were still narrower at near (P < 0.001).

CONCLUSION

Good alignment and binocular balance were obtained with the surgical target angle of the base-out recovery point in AACE.

[Acute Acquired Comitant Esotropia Type 2 - A Retrospective Analysis]

BACKGROUND

Acute acquired comitant esotropia (AACE) is an uncommon form of strabismus. The main characteristics of AACE Type 2 in childhood are: acute onset of strabismus around 3 years of age, large and comitant angle of strabismus, absence of accommodative component, hyperopia of not more than 3 dpt, and measurable stereopsis. Strabismus surgery is urgently indicated in AACE Type 2 in order to avoid maldevelopment or loss of stereopsis. Therefore, in order to better describe the characteristics of AACE Type 2, we performed a retrospective analysis of patients previously seen in our clinic.

PATIENTS AND METHODS

Retrospective analysis of data from patients who underwent strabismus surgery between October 2011 and September 2019 due to suspected AACE Type 2 could be confirmed during postoperative visits by evaluating ocular alignment and stereopsis at our hospital. Analysed data included: age and symptoms at first visit, visual acuity, refractive status, correction by glasses, age at surgery, period of time between first symptoms and surgery, surgical procedure, stereopsis and angle of strabismus (before surgery and 1 day, 3 months, and 12 months after surgery). Ethical approval was obtained from the Cantonal Ethics Committee of Zurich.

RESULTS

18 patients (12 male, 6 female) with mean hyperopia of 1.4 ± 0.6 dpt were identified as meeting the inclusion criteria during the defined time period. Amblyopia was present at first assessment in two patients. Strabismus surgery was performed at 2.0 to 11.1 years of age and between 0.4 and 24.6 months after onset of symptoms. Surgery was performed within 6 months after onset of symptoms in 12/18 children. Before surgery, angle of strabismus at near was measured as 38 ± 10 prism diopters (PD) and was reduced after surgery to 3 ± 3 PD at 3 months and 2 ± 2 PD at 12 months. Stereopsis was confirmed in 5/18 patients one day after surgery and in 18/18 patients 12 months after surgery.

CONCLUSION

Our analysis showed that our patients with diagnosis of AACE Type 2 had mild hyperopia and large comitant non-accommodative esotropia; prognosis for recovery of stereopsis is excellent. Preoperative amblyopia does not exclude the diagnosis of AACE Type 2. Therapeutic intervention is advisable within a short period of time after first symptoms and the diagnosis of AACE Type 2.

Clinical Classification of Acquired Concomitant Esotropia

BACKGROUND

Classification and management of acquired concomitant esotropia is controversial. We sought to establish a simple clinical classification in order to determine in which cases further investigations in search of underlying pathologies are necessary.

PATIENTS AND METHODS

Observational retrospective study of the files of 175 consecutive patients examined in our unit between 2009 and 2018 for acute convergent strabismus. One hundred and nine patients were selected, after exclusion of infantile, incomitant, or mechanical esotropias, residual esotropias, and patients examined on a single occasion. All patients received a complete orthoptic and ophthalmological examination. We grouped the patients according to their common characteristics.

RESULTS

We established the following categories: 1. Acute esotropia of large angle (20 to 45 prism diopters [PD]), accompanied by mild hyperopia (mean 1.2 D) in children (n = 16) and moderate myopia (mean 3.7 D) in adolescents and adults (n = 13). 2. Decompensated micro-esotropia, which is distinguished from the other categories by the presence of abnormal retinal correspondence (n = 33). 3. Decompensated esophoria, with intermittent deviations of 5 to 30 PD, esotropia being compensated part of the time (n = 25). 4. Esotropia present only at a distance in patients over 50 years of age (n = 20). 5. Small-angle esotropia (< 15 PD) greater at a distance, associated with oculomotor cerebellar syndrome (n = 2). Complementary examinations (MRI or CT scan) were performed on 21 patients, leading to the discovery of a posterior fossa astrocytoma in a 4-year-old boy.

CONCLUSIONS

The recognition of decompensated micro-esotropia and esophoria, as well as distance esotropia of the elderly, avoids unnecessary additional investigations, which are indicated in any type of acute comitant strabismus if associated with any neurological sign or symptom (e.g., headaches, nausea, vertigo, imbalance, poor coordination, nystagmus, or papilledema). In the absence of neurological findings, there is no consensus about the indication of neuroimaging in large-angle acquired concomitant esotropia, but long-term follow-up of patients that do not undergo neuroimaging is strongly recommended in order to identify later occurring intracranial diseases. This is of particular importance with children.

Acute Acquired Comitant Esotropia: Etiology, Clinical Course, and Management

Purpose

To identify the etiologies, clinical course and management of acute acquired comitant esotropia in Ramathibodi Hospital, Thailand.

Methods

Thirty patients who were diagnosed with acute acquired comitant esotropia at Ramathibodi Hospital from January 1 2017 to December 31 2019 were identified using electronic medical records, from which demographic, etiology, clinical course and management, laboratory, and neuroimaging data were collected.

Results

The etiologies of acute acquired comitant esotropia were Swan (16.67%), Burian–Franceschetti (30.00%), Bielschowsky (36.67%), Arnold Chiari malformation (3.33%) and decompensated esophoria (13.33%). Mean age of onset was 19.8 ± 18.3 years. Mean angle of esodeviation was 28.4 ± 12.1 prism diopters for distance fixation and 29.3 ± 11.8 prism diopters for near fixation. Refraction differed between age groups: children under 10 years had mild hyperopia (median +0.63 diopters, first quartile +0.25 diopters, third quartile +0.75 diopters) and teenagers (10–18 years old) had emmetropia to mild myopia (median +0.25 diopters, first quartile −2.50 diopters, third quartile +0.75 diopters), whereas adults had mild to moderate myopia (median −0.75 diopters, first quartile −5.25 diopters, third quartile ±0.00 diopters). Twelve patients (40.00%) were prescribed spectacles and surgical intervention was performed in 26 patients (86.67%). All patients except one case of Arnold Chiari malformation (96.67%) maintained normal binocular function and alignment following strabismus surgery or spectacles correction.

Conclusion

Bielschowsky was the most common etiology of acute acquired comitant esotropia in our study. We suggest that refraction should be performed in all patients with acute acquired comitant esotropia. Most etiologies were benign and might not require neuroimaging. However, neuroimaging is recommended in those with atypical presentations, such as nystagmus, headache, or cerebellar signs. Surgical intervention with a 0.5–1.0 mm increase in recession was effective for restoring ocular alignment and binocular function in our patients.

Surgical Outcomes of Medial Rectus Recession and Lateral Rectus Resection for Large-angle Deviations of Acute Acquired Concomitant Esotropia

Purpose

This study aimed to evaluate the surgical outcomes of unilateral medial rectus recession and lateral rectus resection (R&R) for patients with large-angle deviations of acute acquired concomitant esotropia (AACE) without a neurological disease. Further, we have also suggested the surgical dosage of R&R for large-angle deviations of AACE.

Methods

This was a retrospective study of patients with AACE who underwent surgery and followed up after surgery for at least 6 months between September 2016 and March 2020. Among them, patients with ocular deviations of ≥30 prism diopters (PD) who underwent unilateral R&R were included.

Results

Seventeen patients with AACE were enrolled in this study (mean age, 23.5 years; four females). The mean amount of deviation was 40.00 PD at distance and near (range, 30–55 PD). Fifteen patients (88.2%) had myopia. The mean interval between the initial visit and surgery was 7.7 months (range, 4–20 months). All included patients had resolved diplopia after the surgery. Most patients with decreased stereoacuity displayed stereoacuity recovery after surgical treatment. At the final visit (mean follow-up period, 12.8 months), the mean angle of esodeviation was 0.82 PD (range, 6–0 PD) at distance and 0.47 PD (range, 4–0 PD) near. No patient displayed over-correction or adduction limitations in the operated eye.

Conclusions

The unilateral R&R procedure presented favorable surgical outcomes for patients with large-angle deviations of AACE. These results and proposed surgical dosage guidelines may be useful for surgeons in planning the surgical treatment of large-angle deviations of AACE.

Surgical outcomes of acute acquired comitant esotropia of adulthood

Background

Acute acquired comitant esotropia (AACE) is a type of strabismus characterized by a sudden onset of large angle esotropia with diplopia, which often occurs in children after infancy, teenagers, and young adolescents. However, studies on the surgical outcomes of only adults are rare. The purpose of this article is to analyze the surgical outcomes for adult patients diagnosed with AACE.

Methods

Medical records of 24 patients who had undergone surgery for AACE were retrospectively analyzed. The main outcome measures were the final motor and sensory success rate after surgery and factors affecting motor and sensory outcomes. Motor success was considered alignment within 8 prism diopter (PD) at both near and distance and sensory success was stereoacuity ≥ 60 sec/arc.

Results

The preoperative mean esodeviation angles were 33.1 ± 10.4 PD at distance and 33.3 ± 11.2 PD at near. The mean period of postoperative follow up was 7.5 ± 4.5 months (range 1–8 months). The postoperative mean esodeviation angles at final follow-up time were 3.4 ± 6.1 PD at distance and 3.8 ± 6.7 PD at near. The surgical motor success rate at final follow-up was 79.2% (19/24). The sensory success rate at final follow-up was 50.0% (12/24). The factor affecting the motor outcome was the type of surgery (p < 0.05). The factor affecting sensory outcome was postoperative follow-up time (p < 0.05).

Conclusions

Surgery type appears to affect surgical motor outcomes in adults with AACE. Although the sensory outcome was favorable, it seems that regaining bifoveal fixation takes time.

Augmented bimedial rectus muscles recession in acute acquired concomitant esotropia associated with myopia

OBJECTIVE

To review the clinical features of acute acquired concomitant esotropia in myopia and the results of augmented bilateral symmetrical medial rectus recession.

METHODS

The medical charts of 50 patients diagnosed with acute acquired concomitant esotropia associated with myopia between 2013 and 2018 were reviewed. The dose-response was calculated, and the relationship of sex, age, refraction, best-corrected visual acuity (BCVA), preoperative deviation angle, and stereopsis with surgical results were analysed.

RESULTS

Forty-six patients (mean age 40.1 ± 18.1 years) were included in the study. Preoperative esotropia angle at near and distance were, respectively, 26.0 ± 7.5 PD and 25.2 ± 7.9 PD. Surgery amount was 12.1 ± 1.8 mm of recession, and surgical success was achieved in 38 patients (82.6%). No overcorrections were recorded. At 1-year follow-up, the mean deviation angle at distance and at near was 1.9 ± 2.4 and 1.7 ± 2.1 PD, and no recurrences were observed. The average dose-response was 1.8 ± 0.6 PD/mm and was positively correlated with preoperative angle of deviation (R² = 0.799, p < 0.001) and negatively correlated with age (R² = -0.365, p = 0.013). Conversely, there were no significant associations between dose-response and sex, refractive error, BCVA, or stereopsis (all p > 0.05). Factors associated with surgical failure were a lower amount of recession and absence of stereopsis.

CONCLUSIONS

Augmented bilateral medial rectus recession allows good motor and sensory results in patients with acute acquired concomitant esotropia associated with myopia.

Outcomes of Medial Rectus Recession With Adjustable Suture in Acute Concomitant Esotropia of Adulthood

PURPOSE

To review and analyze the surgical outcomes of bilateral medial rectus recession with adjustable suture in acute concomitant esotropia of adulthood (ACEA).

METHODS

The charts of all adults diagnosed as having ACEA between 2004 and 2017 were reviewed. Best corrected visual acuity, refractive error, ocular alignment measured in prism diopters (PD), and stereopsis were examined at presentation, 1 day postoperatively, and final follow-up visit (median: 10 months; range: 4 to 144 months). All patients underwent bilateral medial rectus recession using adjustable suture surgery and topical anesthesia. Statistical analysis was used to calculate surgical dose-responses and to study possible correlations with clinical parameters.

RESULTS

Fifteen patients diagnosed as having ACEA were included. The mean age was 39.2 ± 10.7 years, and the mean refractive errors in the right and left eyes were -3.97 ± 2.87 and -3.60 ± 2.74 diopters (D), respectively. Average esotropia deviations at near and distance were 22.7 ± 7.2 and 23.0 ± 7.5 PD. All patients improved with medial rectus recession (mean: 12.0 ± 2.2 mm) with a final mean deviation of 0.7 ± 1.8 PD. The mean dose-responses at 1 day postoperatively and final visit were 1.86 ± 0.58 and 1.83 ± 0.43 PD/mm, respectively. There was a significant positive correlation between surgical dose-responses at 1 day postoperatively and final visit and preoperative deviation (R² = 0.55; P < .001; R² = 0.66; P < .001), whereas there were no significant correlations with age, sex, refractive error, BCVA, or stereopsis (all P > .05).

CONCLUSIONS

Good postoperative and final outcomes are achieved with large medial rectus recessions in ACEA. A larger dose-response can be expected in large preoperative deviations, independent of other clinical and ocular parameters. [J Pediatr Ophthalmol Strabismus. 2019;56(2):101-106.].

Clinical features of acute acquired comitant esotropia in the Chinese populations

Acute acquired comitant esotropia (AACE) is an unusual presentation of esotropia that occurs after infancy. This study was aimed to study the clinical features and the differences between children and adult patients with AACE in the Chinese populations.This was a retrospective analysis of patients diagnosed with AACE over 4 years; 69 patients (25 females and 44 males) were identified. The patients were divided into 3 groups: < 10 year-old (n = 6, 8.7%), 10-18 year-old (n = 23, 33.3%), and ≥18 year-old (n = 40, 58.0%). Patients underwent medical history, brain and orbital computed tomography, and ophthalmological and orthoptic examinations.The refractions of AACE patients varied among age groups: patients < 10 year-old had mild hypermetropia, while older children and adults showed moderate-to-high myopia (P < .001). The mean angles of esotropia were significantly larger in young children compared with older children and adults (P = .005). There was no significant difference in binocularity detected by either synoptophore or TNO stereoscopic testing among different disease durations. Stereopsis detected by synoptophore and TNO testing showed no significant difference at duration within half a year, but the stereopsis measured by TNO was significantly worse than that detected by synoptophore with extending disease duration (P < .05).AACE seems to occur mostly in older children and adults in the Chinese population. Younger children with AACE seem to demonstrate a common trait of mild hypermetropic refractive errors, while myopia can be seen in older children and adult patients. The duration from onset to treatment of esotropia does not affect the preoperative binocularity.

Outcomes after the surgery for acquired nonaccommodative esotropia

Background

To analyze the surgical outcomes for patients diagnosed with acquired nonaccommodative esotropia (ANAET).

Methods

In this retrospective study, the medical records of 35 patients who had undergone the surgery for ANAET with a postoperative follow-up period of 6 months or more were reviewed. The main outcome measures were postoperative esodeviation angle, final success rate, and factors affecting surgical outcome. Surgical success was considered to be an alignment within 8 prism diopters (PD) at distance and near.

Results

The preoperative mean esodeviation angles were 37.3 ± 13.7 PD at distance and 38.6 ± 16.6 PD at near. The postoperative mean esodeviation angles at distance were as follows: 4.2 PD at day 1, 4.0 PD at month 1, 3.9 PD at month 3, 4.9 PD at month 6, 4.7 PD at year 1, and 4.8 PD at final follow-up. There was no statistically significant difference in angle of esodeviation between the initial postoperative period (day 1 to month 6) and the final follow-up day (p > 0.05). The surgical success rate at final follow-up was 65.7% (23/35). Among the 12 patients for whom the surgery failed, 9 (24.3%) showed esotropia and 3 (8.1%) exotropia of more than 8 PD. Six patients (16.2%) underwent reoperation (4 for esotropia and 2 for exotropia). There was no factor influencing surgical outcome (p > 0.05).

Conclusions

The surgical outcome in patients with ANAET was relatively favorable: the final success rate was 65.7% and the reoperation rate was 17.1%.

Transient Esotropia in the Child: Case Report and Review of the Literature

The aim of this report is to investigate the possible causes of acute acquired onset of transient esotropia (AATE) in children and to help to differentiate ophthalmoplegic migraine (OM) from accommodative spasm (AS). A case of an 8-year-old Caucasian female affected by AATE and diplopia is described. The day before AATE onset, the patient complained of slight headache without nausea and vomiting, with spontaneous resolution. AATE diagnosis is challenging. The most likely ophthalmological causes of AATE are AS and OM. In these cases it is important to evaluate the presence of both a familial history of recurrent headaches and an AATE associated with migraine, ptosis, nausea, and vomiting. A full ophthalmological evaluation and a thorough refractive examination in cycloplegia are mandatory to exclude ophthalmological causes.

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 ± 12.2 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.

Unusual Presentation of Spasm of Near Reflex Mimicking Large-Angle Acute Acquired Comitant Esotropia

We report the case of an 11-year-old boy who presented with sudden esotropia, binocular diplopia, and blurred vision. The patient was neurologically normal. He had a large, constant, comitant, alternating esotropia associated with minimal accommodative spasm. Ocular motility and pupillary reactions were normal. He was diagnosed to have spasm of the near reflex presenting as acute onset of esotropia. The esotropia was persistent despite treatment and eventually resolved with prolonged cycloplegic therapy. This unusual case illustrates that spasm of the near reflex can have unique and variable presentations. Spasm of the near reflex needs to be considered in the differential diagnosis of every case of acute, acquired, comitant esotropia. This is the first case of spasm of the near reflex where persistent esotropia is reported in the absence of any neurological disorder.