Isolated comitant esotropia and Chiari I malformation

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 features and change in incidence of acute acquired comitant esotropia: a 15-year single-centre study in South Korea

BACKGROUND/OBJECTIVES

We investigated the clinical features and change in incidence of AACE in South Korea.

SUBJECTS/METHODS

We reviewed the medical records of AACE patients who visited the Strabismus Clinic of at a tertiary referral hospital from 2007 to 2021. Clinical features were retrieved, including age at onset, angle of deviation, refractive errors, neuroimaging findings, and treatment outcomes. For each year, the proportion of new AACE patients among all new patients who visited the clinic, and the ratio of new AACE patients to new intermittent exotropia (IXT) patients, were analysed to estimate the incidence of AACE.

RESULTS

Overall, 59 patients were included in the study. The mean age of the patients was 24.7 ± 9.3 years; the incidence of AACE was highest in teenagers and young adults. No patients had a history of visual occlusion, recent physical or psychological stress, or uncorrected myopia, unlike to classic AACE; moreover, no patients exhibited abnormalities in neuroimaging. There was a significantly increasing trend in the proportion of new AACE patients among all new patients (linear regression analysis, R2 = 0.778, p < 0.001). There was also a significantly increasing trend in the ratio of new AACE patients to new IXT patients (R2 = 0.803, p < 0.001).

CONCLUSIONS

A new type of AACE, distinct from the classic types, is increasingly common in South Korea; this increasing incidence also appears to be a global phenomenon. Large-scale investigations are needed to define the exact clinical features, incidence, and pathophysiology of this new type of AACE.

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).

Neurological pathologies associated with acute acquired comitant esotropia

Previously reported cases of acute acquired comitant esotropia (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 A or V pattern esotropia, nystagmus, or abnormal ocular and neurological indications (e.g. headache, cerebellar imbalance, weakness, nystagmus, papilloedema, clumsiness, and poor motor coordination).

Clinical features, etiological reasons, and treatment results in patients who developed acute acquired nonaccomodative esotropia

PURPOSE

To evaluate the clinical features, possible etiological reasons, and treatment results in children who developed acute acquired comitant esotropia (AACE) without strabismus in previous years.

METHODS

Medical records of the patients who were diagnosed with AACE between July 2017 and June 2021 were retrospectively reviewed. The children with ocular and orbital pathology, hypermetropia > 2.00 diopters, and anisometropia > 1.00 diopters were not included in the study. Possible etiological factors that could cause esotropia, treatment results, motor, and sensory functions were investigated.

RESULTS

The mean age at first admission, and the onset of AACE, was 8.8 ± 2.9 (4-13) years of three female (23.1%) and 10 male (76.9%) cases. The causes of AACE were determined to be occlusion of the eye due to corneal foreign body removal in one (7.7%), emotional stress in one case (7.7%), and excessive close work, on computer and smartphone screens in the other 11 cases (84.6%). Orthotropia was achieved in cases who underwent strabismus surgery (n = 10) and in cases using the prism (n = 2); except for one case, all (92.3%) achieved binocular single vision (100 s/arc stereopsis and fusion) after treatment, while there was no binocular single vision in any of the cases before treatment.

CONCLUSIONS

Acute acquired comitant esotropia is a rare clinical entity. Successful motor and sensory outcomes can be achieved by strabismus surgery or by prism therapy. It is critical to investigate the patientş with AACE in terms of intracranial pathologies, although rarely seen.

Clinical characteristics and aetiology of acute acquired comitant esotropia

CLINICAL RELEVANCE

Acute acquired comitant esotropia (AACE) is characterised by the acute onset of diplopia which affects work and life.Background: To describe the clinical characteristics and discuss the aetiology of acute acquired comitant esotropia.Methods: The medical records of 51 patients with AACE were retrospectively analysed, and their age, occupation, daily average time spent on near work, angle of deviation, refractive error and aetiology were analysed.Results: The age at onset of AACE was eight to 55 years. Thirty-nine patients were aged 12 to 36 years (76.5%), and 42 patients (82.4%) were myopic. The angle of deviation was 20^Δ (12^Δ to 35^Δ) during near fixation and 25^Δ (18^Δ to 40^Δ) during distance fixation. The deviation during distance fixation was larger than that during near fixation, the difference being statistically significant (p < 0.001). The daily average time of near work before onset was 9.0 h (8.0 h to 10.0 h); 35 patients (68.6%) spent more than 8 h performing near work. Their occupations included students, accountants, information technology staff, and those who required electronic use for a long time. There is no correlation between the angle of deviation and the time of near work (p > 0.05). Among the 51 patients, three had intracranial diseases. Diplopia resolved in 47 cases following treatment. The angle of deviation post-treatment was 0^Δ (0^Δ to 5^Δ) during near and 0^Δ (0^Δ to 3^Δ) during distance fixation.Conclusion: AACE occurs mostly in myopic older children and adults. The onset of esotropia is related to long-term near work. AACE patients mostly present an angle of deviation that is larger during distance than near fixation. Intracranial disease is an infrequent but important cause of AACE that needs to be excluded in all cases.

Botulinum toxin for the treatment of cyclic esotropia in a child with Chiari type I malformation

We report the case of a 4-year-old boy who presented with cyclic esotropia in the setting of a Chiari type I malformation. He was treated with a single administration of botulinum toxin and remained orthotropic at 7-months. To our knowledge, this is the first reported case of cyclic esotropia with Chiari I malformation successfully treated using botulinum toxin.

When pediatric acute acquired comitant esotropia is not caused by a neurological disease

BACKGROUND

Acute acquired comitant esotropia (AACE) is a relatively rare type of pediatric strabismus, often described as a possible presentation of intracranial pathology. The risk of having neurological disease in isolated AACE is not clear, because many previously published cases had other neurological or ophthalmological abnormalities. The purpose of this study was to analyze the incidence of neurological abnormalities in children presenting with AACE and otherwise normal neurological and ophthalmological evaluations.

METHODS

The medical records of consecutive patients >4 years of age with AACE examined by a single practitioner from 2014 to 2018 were reviewed retrospectively. The main outcome measure was the presence of neurological disease. Children with duction deficits, incomitant esodeviations, and hyperopia of >2.00 D were excluded.

RESULTS

A total of 20 children (11 males; mean age, 9.8 ± 4.1 years) were included. Mean esodeviation was 29.5^Δ ± 14.8^Δ (range, 10^Δ-55^Δ). All had an otherwise normal ophthalmological and neurological evaluations. Of the 20, 19 (95%) had normal brain neuroimaging. One child that did not have neuroimaging was followed over 2 years without developing any neurological sequelae.

CONCLUSIONS

In our study cohort, pediatric AACE not accompanied by other ophthalmic and neurological abnormalities was not a manifestation of intracranial pathology. In such cases, the decision to perform neuroimaging should take into account other factors, including caregivers' preferences and availability for close monitoring.

Divergence insufficiency alleviated by posterior fossa decompression with duraplasty in a patient with Chiari type 1.5 malformation

The authors present a case of Chiari type 1.5 malformation with the uncommon presenting symptoms of esotropia and diplopia due to divergence insufficiency in a 12-year-old girl. Imaging at initial diagnosis revealed cerebellar herniation with extension of the tonsils to the C2 vertebral body, a retroflexed odontoid, and a small cervical syrinx. The patient was initially treated with an uncomplicated Chiari malformation decompression without dural opening. Repeat imaging revealed an adequate decompression. Three months postoperatively the patient's diplopia recurred and she underwent repeat posterior fossa decompression with dural opening and duraplasty. Following repeat decompression with dural opening and duraplasty, the patient's diplopia had not recurred by the 2-year follow-up.https://thejns.org/doi/abs/10.3171/2018.5.PEDS1886.

Decompensated Esophoria as a Benign Cause of Acquired Esotropia

PURPOSE

To determine informative clinical and magnetic resonance imaging (MRI) characteristics of patients with symptomatic adult acquired, comitant esotropia due to decompensated esophoria.

DESIGN

Retrospective, interventional case series.

METHODS

Setting: Institutional.

STUDY POPULATION

Patients with decompensated esophoria who developed acute acquired comitant esotropia.

OBSERVATION PROCEDURES

Ophthalmic examination, stereopsis, and strabismus measurements at distance and near using prism cover tests in diagnostic gaze positions were performed. Patients underwent high-resolution surface coil MRI of extraocular muscles with target fixation, and MRI of the brain. Strabismus surgery was performed under topical anesthesia with adjustable sutures wherever possible. Paired t testing was used to evaluate postoperative changes with 0.05 considered significant.

MAIN OUTCOME MEASURE

Clinical and MRI characteristics, and surgical outcome of patients with decompensated esophoria.

RESULTS

Eight cases were identified involving subjects of mean age 29 ± 9.4 (range: 20-48) years having gradually progressive intermittent horizontal, binocular diplopia for 10 months to 3 years. Mean preoperative esotropia was 31 ± 12 Δ at distance and 29 ± 12 Δ at near, although this was intermittent in 5 patients who exhibited enhanced fusional divergence. Neurologic evaluation and MRI of brain, orbits, and extraocular muscles were unremarkable in all cases. Orthotropia was successfully restored in all by standard or enhanced doses of bimedial rectus muscle recession surgery, improving mean stereoacuity from 535 to 68 arc seconds, although 5 patients exhibited 2-14 Δ asymptomatic residual esophoria.

CONCLUSION

Decompensated esophoria is a benign clinical entity causing acute, acquired, comitant esotropia treatable with enhanced medial rectus recession.

Acute Acquired Comitant Esotropia in Adults: Is It Neurologic or Not?

Objectives. Acute acquired comitant esotropia (AACE) can be a diagnostic challenge for ophthalmologists and neurologists because of its association with neurological pathologies. Our study describes a series of adult patients with AACE of undetermined etiology. Methods. Data on the clinical findings of patients presented with AACE of undetermined etiology with a minimum follow-up of 1 year were retrieved from the medical records and the results analyzed. Results. A series of 9 esotropia cases (age range: 20-43 years) was reviewed. All patients had full duction and versions, without an A-pattern or V-pattern. All patients had esotropia for distance and near. Neurological evaluation in all cases was normal. Among patients, 3 were treated with prisms, 4 were treated with strabismus surgery, and 1 was treated with botulinum toxin injections; 1 patient declined treatment. In treated patients posttreatment sensory testing indicated restoration of binocularity that remained stable throughout follow-up of 1-9 years. The patient that declined treatment had binocular function with base-out prisms. Conclusion. Acute onset esotropia may be seen without a neurological pathology in adults. Good motor and sensory outcomes can be achieved in these patients with AACE of undetermined etiology via surgical and nonsurgical methods.

Nonsurgical treatment for esotropia secondary to Arnold-Chiari I malformation: A case report

A 14-year-old girl with diplopia and esotropia secondary to Arnold-Chiari I malformation was surgically treated with Arnold-Chiari I malformation decompression (suboccipital craniectomy), C1 and partial C2 laminectomy, and duraplasty. The residual esotropia was treated with compensatory prisms and vision therapy more than 1 year after Arnold-Chiari malformation surgery. The esotropia was resolved after approximately 3.5 months of treatment. Five years later, the patient continued to maintain fusion without compensatory prism.

Chiari Type І Malformation Associated With Morning Glory Disc Anomaly

Morning glory disc anomaly (MGDA) is a congenital malformation of the optic disc that has been reported in association with midline craniofacial defects such as basal encephalocele, hypertelorism, cleft lip and palate, and agenesis of the corpus callosum. We describe a 44 year-old woman with MGDA and Chiari type capital I, Ukrainian malformation, an association not previously reported.

Divergence insufficiency

INTRODUCTION AND PURPOSE

To compare the clinical characteristics of a population of patients with divergence insufficiency in the absence of associated neurologic disease to those patients with divergence insufficiency and an associated neurologic disorder.

PATIENTS AND METHOD

A retrospective review of 251 patients diagnosed with divergence insufficiency and/or divergence paralysis. Clinical features include the age at onset, fusional divergence amplitudes, the size of the esodeviation, treatment offered, and the presence or absence of associated neurologic conditions. Classification into primary and secondary divergence insufficiency solely depended on the absence or presence of neurologic disorders, respectively.

RESULTS

The incidence of neurologic disease associated with divergence insufficiency was 17%. The average age at onset was 62 years for primary and 51 years for secondary divergence insufficiency. Nystagmus was noted in 43% of secondary divergence insufficiency patients and 0.01% of primary divergence insufficiency patients. Both groups exhibited decreased fusional divergence at distance fixation while retaining normal fusional divergence at near.

CONCLUSIONS

The majority of patients were classified as primary divergence insufficiency. Though this form of divergence insufficiency is neurologically benign, it may easily mask a more severe neurologic condition for which the presenting symptom is also diplopia for distance viewing only. These results show the importance of obtaining a detailed history regarding the symptoms, as well as documenting neurologic signs, particularly nystagmus, when investigating divergence insufficiency.

Progressive cerebellar tonsillar herniation with recurrent divergence insufficiency esotropia

The Chiari malformations are characterized by herniation of posterior fossa contents through the foramen magnum. Chiari I malformation is currently defined as ectopia of the cerebellar tonsils more than 5 mm below the foramen magnum. Extension of the cerebellar tonsils up to 3 mm may be found in the normal population. Although Chiari malformations are congenital, symptoms often do not manifest until the third and fourth decades of life, or even later. Patients usually present with headache, lower cranial nerve palsies, downbeat nystagmus, ataxia, or dissociated anesthesia of the trunk and extremities. Definitive diagnosis is made by magnetic resonance imaging (MRI), which shows the compressed tonsils extending through the foramen magnum into the cervical subarachnoid space. One of the rare presenting signs of Chiari I malformations is acquired esotropia with a divergence insufficiency pattern. We report such a case in which the initial neuroimaging showed tonsillar herniation, but of insufficient magnitude to meet diagnostic criteria for Chiari I malformation. When the strabismus recurred after initially successful eye muscle surgery, follow-up scan showed progressive tonsillar herniation.

Resolution of acute acquired comitant esotropia after suboccipital decompression for Chiari I malformation

PURPOSE

To report a case of acute comitant esotropia successfully treated with suboccipital decompression in a 9-year-old male patient with Chiari I malformation.

DESIGN

Interventional case report.

METHODS

A 9-year-old male with Chiari I malformation had acute onset of diplopia, headache, and comitant esotropia.

RESULTS

About 9 months after suboccipital decompression, diplopia resolved and there was near orthophoria on examination 15 months after surgery.

CONCLUSION

In view of our case and after a review of literature, we advocate primary suboccipital decompression to treat acute comitant esotropia in patients with Chiari I malformation. A follow-up period of at least 1 year rather than 6 months seems necessary to assess surgery effects.

Strabismus surgery in the treatment of paralytic strabismus

Strabismus surgery may restore limited binocular function and improve cosmesis in patients with paralytic strabismus. Evaluation of the amount of residual function of the affected extraocular muscles is essential to determine which surgical procedure will yield the best results. Standard muscle resection techniques are effective for patients who have paretic extraocular muscles with residual function. Muscle transposition procedures are indicated for patients with total paralysis of an extraocular muscle. Autogenous and alloplastic materials may be required to fix the eye in primary position in patients with total paralysis of multiple extraocular muscles. This article discusses the recent literature regarding the evaluation and management of patients with paralytic strabismus. Current concepts regarding extraocular muscle transposition and the use of autogenous materials are emphasized.