Photorefractive keratectomy in the management of refractive accommodative esotropia in young adult patients

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.

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.

Accommodative Esotropia Treatment Plan Utilizing Simultaneous Strabismus Surgery and Photorefractive Keratectomy

PURPOSE

Accommodative esotropia is a common cause of acquired esotropia. Pathogenesis varies among patients but usually includes excessive hyperopia and a high accommodative convergence/accommodation ratio or tight medial recti. The present study reviews an individualized treatment plan combining photorefractive keratectomy (PRK) and strabismus surgery to correct these problems.

DESIGN

This study is a retrospective, interventional case series.

METHODS

Records for 15 patients who were treated for accommodative esotropia were reviewed. Patient ages ranged from 11 to 19 years. PRK and strabismus surgery were performed on 11 patients, and PRK only on 4 patients. The goal was to create a physiologic refractive error, good visual acuity (VA), and straight eyes without correction.

RESULTS

All patients were spectacle free at 6-month follow-up. Twenty-four of 30 eyes had VA equal to preoperative VA without correction. Three eyes had a 1-line reduction and 2-line reduction in VA. The alignment results were ±10 prism diopters in 13 of 15 patients. Spherical refractive outcomes were 18 of 30 eyes within 1 diopter (D) of target and 12 of 30 eyes within 2 D of target. Astigmatism refractive outcomes were 21 of 30 eyes <1 D, 7 eyes 1-2 D, and 2 eyes >2 D. Two patients complained of halos at night, and 1 patient had peripheral corneal haze.

CONCLUSION

Simultaneous PRK and strabismus surgery is safe and effective in treating accommodative esotropia. An individualized treatment plan can result in a physiologic refractive error, good VA, and a spectacle-free existence.

Hyperopic corneal refractive surgery in patients with accommodative esotropia and amblyopia

PURPOSE

To explore whether hyperopic excimer corneal refractive surgery can affect ocular alignment and stereopsis in patients with both accommodative esotropia and amblyopia.

METHODS

In this prospective study, 26 eyes of 13 patients with accommodative esotropia and amblyopia underwent bilateral hyperopic corneal refractive surgery: 9 patients underwent laser in situ keratomileusis (LASIK); 4, laser epithelial keratomileusis (LASEK). The main ocular examinations included pre- and postoperative best-corrected and uncorrected visual acuity, refractive error, ocular alignment, and stereopsis.

RESULTS

Preoperative cycloplegic refraction in the right eyes was +5.64 ± 2.09 D; in the left eyes, +5.91 ± 1.97 D. After surgery, refraction in the right eyes was +1.13 ± 1.21 D; in the left eyes, +1.44 ±1.53 D. The mean logMAR uncorrected visual acuity was 0.46 ± 0.30 before surgery and 0.32 ± 0.25 after surgery (t = 5.72, P = 0.001). The mean pre- and postoperative best-corrected visual acuity were 0.31 ± 0.28 and 0.29 ± 0.25, respectively; there was no significant difference between the two groups (t = 1.23, P = 0.22). The average uncorrected esotropia was 37.92(Δ) ± 9.12(Δ) before surgery and 2.76(Δ) ± 2.80(Δ) after (P < 0.001). Using a synoptophore, 2 patients (15.3%) had preoperative stereopsis and 11 patients (84.6%) had postoperative stereopsis. No patients experienced lower stereopsis postoperatively.

CONCLUSIONS

In this cohort, hyperopic corneal refractive surgery can improve the alignment, uncorrected visual acuity, and stereopsis in patients with accommodative esotropia and amblyopia.

Photorefractive keratectomy on purely refractive accommodative esotropia

CONTEXT

Results on refractive keratectomy of the treatment of young patients with purely refractive accommodative esotropia.

AIMS

Evaluating the results of refractive keratectomy (PRK) on the treatment of young patients with purely refractive accommodative esotropia.

METHODS AND MATERIAL

This prospective study comprised patients with purely accommodative hyperopic esotropia. Patients underwent a complete ophthalmologic examination that included pre-operative and post-operative best corrected visual acuity (BCVA) and uncorrected visual acuity (UCVA) (at 3, 12, and 24 months), alignment and sensory outcomes; keratometry, pachymetry, and corneal topography.

STATISTICAL ANALYSIS USED

paired T-student.

RESULTS

Twenty eyes of 10 patients (mean age 21.5 years) were treated. The pre-operative mean UCVA was 0.70 logMAR (SD ± 0.177) and 0.02 logMAR (SD ± 0.029) two years later. The pre-operative BCVA was 0.02 logMAR (SD ± 0.037) and 0.01 (SD ± 0.026) two years later. The mean spherical equivalent (SE) in cyclopegia was + 3.92 D (range: +2.75 to +5.00 D; SD = 0.62) pre-operatively, -0.69 D (range -0.5 to -1) at three months and 0 D (range: -0.25 to 0.25) at one and two years later. After surgery, all patients were orthophoric without correction and stereopsis was unaffected by PRK.

CONCLUSIONS

A two-year follow-up showed that photorefractive keratectomy was an effective treatment for esotropia associated with mild to moderate hyperopia in young adults with purely refractive accommodative esotropia.