Results of early alignment of congenital esotropia

Botulinum toxin augmented surgery versus conventional surgery in the management of large-angle concomitant esotropia: A randomized clinical trial

BACKGROUND

The surgical management of large-angle concomitant esotropia is challenging with high reoperation rates. This study aims to assess the effectiveness and safety of intraoperative botulinum toxin A (BTA) augmentation compared to surgery alone in large angle concomitant esotropia.

MATERIALS AND METHODS

This is a prospective randomized interventional study. Patients with large angle concomitant esotropia (≥55 prism diopter [PD]) were randomly allocated to either surgery only (Group I) or BTA augmented surgery (Group II). The surgical effect in PD/mm was calculated and compared between the study groups at all follow up intervals. Treatment was considered successful if the patients had orthotropia ± 10 PD at their final examinations.

RESULTS

A total of 23 patients were included in the study, 11 in Group I and 12 in group II. The surgical effect was significantly greater in Group II compared to Group I at all follow up durations. The 1-year surgical effect was 32.5% greater in Group II compared to Group I (5.99 ± 0.69 vs. 4.52 ± 0.91 PD/mm, respectively, P = 0.001). The success rate was greater for Group II compared to Group I (75% vs. 63.64%, respectively), but this difference was not statistically significant (P = 0.901).

CONCLUSION

Botulinum toxin augmented surgery is a good alternative to surgery alone in the treatment of large angle concomitant esotropia. BTA injection exerts a significant augmentation effect on medial rectus muscle recessions.

Effects of Surgical Timing on Surgical Success and Long-term Motor and Sensory Outcomes of Infantile Esotropia

PURPOSE

To investigate the effect of surgical timing on long-term motor and sensory outcomes in patients with infantile esotropia.

METHODS

The medical records of patients who underwent strabismus surgery for infantile esotropia were reviewed retrospectively. The patients were divided into three groups according to age at the time of surgery: early group (6 to 11 months), late group (12 to 17 months), and very late group (18 to 27 months). The main outcome measures were final alignment, surgical success rate (the angle of deviation at final follow-up of ≤ 10 prism diopters [PD] of esotropia, no exotropia and no need for reoperation), stereoacuity, visual acuity, and the number of reoperations required during the follow-up.

RESULTS

A total of 79 patients (44 female, 35 male) met the inclusion criteria. The surgical success rate was 25.9%, 23.1%, and 53.8% in the three groups, respectively (P = .035). After a mean follow-up of 96 months, the average number of operations per child was 1.7 ± 0.9, 1.6 ± 0.6, and 1.4 ± 0.6 in the three groups, respectively (P = .020). The measurable stereopsis rate was higher in the early group (37% vs 3.8% and 3.8%, respectively) (P = .001). The amblyopia rate was similar between groups.

CONCLUSIONS

The results show that performing surgery later in life in patients with infantile esotropia increases the motor success rate of surgery. In addition, orthophoria is achieved with fewer surgical operations. However, earlier surgery may improve stereopsis. [J Pediatr Ophthalmol Strabismus. 2020;57(5):319-325.].

Relationship between stereopsis outcome and timing of surgical alignment in infantile esotropia

PURPOSE

To clarify the relationship between stereopsis outcome and timing of surgical alignment in infantile esotropia.

METHODS

The medical records of otherwise healthy patients with infantile esotropia who underwent surgery by 8 years of age were divided into the following groups according to age at time of surgery: very early surgery (≤8 months), early surgery (>8 to ≤24 months) and late surgery (>24 months). Binocular response and stereopsis were compared between groups.

RESULTS

A total of 76 patients were included: 22 in the very early group, 30 in the early group, and 24 in the late group. Binocular response at near was found in 96% of the very early group and in 80% of the early group, significantly higher than the 50% of the late group (P < 0.001 and P < 0.05 [Dunn test], resp.). Stereopsis was present in 77% of the very early group, significantly higher than the 20% of the early group and 13% of the late group (P < 0.001 [Dunn test]). A significant correlation was also found between age (months) at surgery and stereopsis (seconds) outcome (logarithmic fit: y = 2539.4ln(x) + 147.2; R² = 0.2691; P < 0.001).

CONCLUSIONS

In this study cohort, earlier surgery was associated with better binocularity in patients with infantile esotropia. Our results suggest that very early surgery, at ≤8 months, can improve the chance for postoperative stereopsis, with the caveat that some infants might have had spontaneous esotropia resolution.

Long-term Surgical Outcomes for Large-angle Infantile Esotropia

PURPOSE

To report the long-term surgical outcomes for a cohort of children with large-angle infantile esotropia.

DESIGN

Multicenter, nonrandomized clinical study.

METHODS

Setting: Two tertiary-care pediatric hospitals.

STUDY POPULATION

Children with large-angle (≥55 prism diopters) infantile esotropia.

INTERVENTION

Surgical treatment of infantile esotropia.

MAIN OUTCOME MEASURE

Success rate at final follow-up (postoperative deviation ≤ 10 prism diopters and no need for retreatment).

RESULTS

A total of 88 patients with large-angle infantile esotropia were treated during the 13-year study period. Treatment was bilateral medial rectus muscle recessions in 70 patients, botulinum toxin-augmented surgery in 15 patients, and 3-muscle surgery in 3 patients. After a mean follow-up of 40 months, 20 patients (23%) had a successful outcome compared to 68 treatment failures (77%). Of the 68 treatment failures, 59 had residual or recurrent esotropia and 9 had sequential exotropia. On multivariate logistic regression, treatment modality was the only factor significantly associated with a successful outcome. Specifically, patients treated with botulinum toxin-augmented surgery were more likely to have a successful outcome compared to patients treated with bilateral medial rectus muscle recessions. For the 26 patients (30%) who underwent retreatment, the mean number of procedures was 2.1, and 7 (27%) had a deviation of ≤10 prism diopters at final follow-up.

CONCLUSIONS

The overall success rate for treatment of large-angle infantile esotropia was poor in this cohort, with most failures owing to recurrent or residual esotropia. Botulinum toxin-augmented surgery was associated with a higher success rate at final follow-up.

Time and Factors Affecting the Direction of Re-drift in Essential Infantile Esotropia

PURPOSE

To investigate the development pattern and related factors of postoperative re-drift in infantile esotropia.

METHODS

A total of 112 patients with infantile esotropia who underwent surgery before 3 years of age were included. Surgical outcomes were divided into (1) consecutive exotropia: more than 8 prism diopters (PD) of exodeviation; (2) recurrent esotropia: more than 8 PD of esodeviation; and (3) monofixation syndrome: maintenance of deviations within 8 PD. The occurrence rate, time of onset, and associated factors of the re-drift were evaluated.

RESULTS

At a mean follow-up of 9.5 years, consecutive exotropia developed in 37 patients (33.0%) and recurrent esotropia in 43 patients (38.4%). Whereas 76.7% of total recurrent esotropia cases were identified within postoperative 1 year, consecutive exotropia occurred constantly over 10 years postoperatively. The mean time to consecutive exotropia development from surgery was 78.6 months, greater than that of recurrent esotropia development (8.9 months) (P < 0.001). In multinomial logistic regression using monofixation syndrome as the reference category, fixation preference before surgery (odds ratio [OR]: 6.64, 95% confidence interval [CI]: 2.07 to 21.32) and the rate of myopic progression (OR: 15.07 per -1.00 D/year, 95% CI: 1.23 to 184.86) were associated with consecutive exotropia, whereas increase in the angle of esodeviation on postoperative day 1 (OR: 1.15, 95% CI: 1.04 to 1.26) was correlated with recurrent esotropia.

CONCLUSIONS

This study demonstrates a difference between the development pattern of exotropic and esotropic drift after infantile esotropia surgery. Detailed preoperative assessment and close postoperative observation of deviations and refractive status will help to determine surgical outcomes of infantile esotropia. [J Pediatr Ophthalmol Strabismus. 2018;55(2):128-134.].

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Essential infantile esotropia with inferior oblique hyperfunction: long term follow-up of 6 muscles approach

AIM

To evaluate long term follow-up (10y) of 6 muscle surgical approach in essential infantile esotropia (EIE).

METHODS

A 6 muscle approach to EIE was retrospectively evaluated in patients with inferior oblique (IO) hyperfunction and lateral rectus (LR) pseudoparalysis, who underwent surgery at different ages. Different clinical characters were analyzed pre- and postoperatively, in patients who underwent a 6 muscles approach ≤4 years of age. All patients underwent a multiple muscles approach: bilateral medial recti (MR) recession (4-5 mm), bilateral LR resection (lower than 7 mm) and bilateral IO recession and anteroposition. Of 108 children with preoperative angle ≥+30 prism diopters (PD) and IO hyperfunction were selected from larger cohort of patients (n=213, 103 females and 110 males) after excluding patients with: angle variability, who underwent reoperation and with incomplete follow up. Preoperative assessment and complete orthoptic examination were performed. Follow-up was performed 3mo, 2, 5 and 10y after surgery. Statistical analysis was performes using SAS statistical software package (version 9.1, SAS Institute Inc., Cary, NC, USA).

RESULTS

Ten years follow up data analysis showed the following percentage of orthotropic patients: (0 PD): 3mo, 22.2%; 2y, 16.7%; 5y, 25.0% and 10y, 27.8%. A slight, significant (P<0.01), increase of 2y follow up residual deviation was found when compared to 3mo one. Stationary surgical results is reported during time, with a trend of mean residual deviation reduction (P=0.04).

CONCLUSION

Our results confirm the reliability of multiple muscles surgical approach in the treatment of patients affected by EIE with OI hyperfunction.

Essential Infantile Esotropia: Postoperative Sensory Outcomes of Strabismus Surgery

BACKGROUND

The optimum age for Essential Infantile Esotropia surgery is a controversial subject. Sensory status was evaluated in patients who underwent surgery at different ages in a retrospective study. The setting of the study is the ophthalmology department of a teaching hospital.

METHODS

Different clinical characters were analyzed pre- and postoperatively; nine different surgeries were performed. A total of 188 patients presented valid postoperative sensorial data, divided in two groups: surgery at ≤2 years (n=69) or >2 years (n=119). Sensory status was dichotomized in binocular single vision (BSV) and exclusion. Univariate differences were assessed with the chi-square test (or Fisher exact test). To identify the independent role of factors associated with the sensory status, all variables showing in univariate analyses a significant association (p<0.05) with the outcome variable were entered into a multivariate logistic regression model. All statistical tests were two-sided.

RESULTS

Multivariate analysis confirmed that children operated >2 years were 0.4 times less likely to obtain BSV compared with children operated at ≤2 years (AOR. 0.38, 95% C.I. 0.17-0.89, p=0.025). Patients operated on by OO MR rec.+ OO LR res. + OO IO rec.-ap. (intervention type 6) were about 11 times more likely to have BSV than those by OO rec.MR + unilateral res. LR (operation type 2); AOR.: 10.67, 95% C.I.: 1.34 - 85.29, p=0.026). Twenty-nine patients (12.1%) operated at ≤2 years of age underwent a reoperation, compared to 33 (8.6%) who underwent surgery after two years (p>0.05).

CONCLUSIONS

Our findings suggest to perform EIE surgery between age 1 and 2 and, when indicated, to prefer a six-muscle approach in order to achieve a better sensory function.

Predictive value of age, angle, and refraction on rate of reoperation and rate of spontaneous resolution in infantile esotropia

In the Early vs. Late Infantile Strabismus Surgery Study (ELISSS), 13.5% of children operated at 20 months vs. 3.9% of those operated at age 4 had gross binocular vision (Titmus Housefly). Reoperation rates were 28.7% in the former vs. 24.6% in the latter group and, although all were eligible for surgery at baseline at 11 SD 3.7 months, 8% in the early group vs. 20% in the late group were never operated, mostly because their angle decreased spontaneously. We assessed the predictive value of age, angle, and refraction in these matters.

METHODS

The ELISSS reoperation rates were first compared with those found in nine series of consecutive cases in nine university clinics operated during one particular year, between 6 and 23 years previously. Logistic regression was used to estimate the effect of postoperative angle and clinic on the chance of reoperation. Secondly, a meta-regression analysis was done of these and other reported reoperation rates. The mean age at operation and the mean duration of follow-up were regressed on the logistically transformed reported reoperation rates. Finally, to estimate the chance of spontaneous decrease of the angle without surgery, a random-effects model was fitted on the 6-monthly orthoptic measurements of angle and refraction in the ELISSS that antedated surgery, loss to follow-up, or final examination. In the random-effects model (see online-only supplement link or visit, www.simonsz.net), for ELISSS patients the random effect was defined as the deviation of the average angle, the fixed effect. A vector was defined based on age and spherical equivalent of the patient. The variance around the prediction consisted of uncertainty in the estimations, random effects, and residuals.

RESULTS

In the retrospective study, 204 patients who had been first operated between 6 and 23 years previously were eligible. A reoperation had been performed in 32 (19.3%) of the remaining 166 children who were 4.33 SD 1.35 years old at first surgery. The reoperation rate was 7.3% for those with a postoperative angle of -4° to +4° (N = 82), 25% for postoperative divergence > 5°, and 29% for postoperative convergence 10° to 14°. Strabismologists overestimated the reoperation rates at double. In the meta-regression analysis, 12 studies were included. Reoperation rates were between 60% and 80% for children first operated around age 1 and approximately 25% for children operated around age 4 (best fit: -0.221 Ln [age in months] + 1.1069; R(2) = 0.5725). Finally, in the predictions of random-effects model, a small angle at age 1 and hyperopia of approximately +4 increased the chance of spontaneous decrease of the angle into a microstrabismus.

DISCUSSION

The benefit of early surgery for gross binocular vision is balanced by a higher reoperation rate and an occasional child being operated that would have had a spontaneous decrease into a microstrabismus without surgery. The fact that, in the ELISSS, hyperopia was associated with a decrease of the angle underscores the benefit of early refractive correction.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Long-term follow-up of congenital esotropia in a population-based cohort

PURPOSE

To report the long-term outcomes of a population-based cohort of children diagnosed with congenital esotropia during a 30-year period.

METHODS

The medical records of all patients diagnosed with congenital esotropia as residents of Olmsted County, MN, from January 1, 1965, through December 31, 1994, were retrospectively reviewed.

RESULTS

A total of 130 children were diagnosed during the 30-year period at a median age of 7.4 months with a mean deviation of 30(Delta). During a median follow-up of 11.9 years, 126 patients underwent a mean of 1.8 strabismus surgeries. The risk for undergoing a second surgery was significantly greater in patients with a larger presenting angle (p = 0.017) and a younger age at first surgery (p = 0.006). The Kaplan-Meier rate of having a second surgery was 51% at 10 years and 66% at 20 years. For those with 6 weeks or more of follow-up from the final surgery, last examined at a mean age of 15.1 years, 42 of 94 (45%) were within 8(Delta) of orthotropia and 30 of 98 had some level of stereopsis (</=3000 arcsec).

CONCLUSIONS

In this population-based study of children with congenital esotropia, a second surgery was necessary in half the patients after 10 years and was more likely in those patients with a larger presenting angle and a younger age at first surgery. Approximately half of the patients were within 8(Delta) of orthotropia and one-third had measurable stereopsis after a mean of 10.9 years of follow-up.

Accommodative esotropia following surgical treatment of infantile esotropia: frequency and risk factors

PURPOSE

We aimed to examine the frequency of and risk factors for the development of accommodative esotropia following surgical treatment for infantile esotropia.

METHODS

A total of 29 children were recruited. Potential risk factors for the development of accommodative esotropia included: sex; angle of deviation at initial and final visits; cycloplegic refractive error at initial and final visits; increase in hyperopia; amblyopia; amblyopia treatment; age at surgical treatment; pre- and postoperative latent nystagmus; dissociated vertical deviation or inferior oblique muscle overaction; additional surgical procedures; unstable alignment, and binocular sensory status.

RESULTS

Overall, 14 (48.2%) of 29 children developed accommodative esotropia during the 36- to 132-month postoperative follow-up period. Twelve (85.7%) of the 14 patients developed refractive accommodative esotropia and two developed non-refractive accommodative esotropia. The onset of accommodative esotropia occurred at a mean of 8.8 months (range 6-24 months) after the initial surgical alignment. This corresponded to a mean age of onset for accommodative esotropia of 43.2 months. We determined that, among children with infantile esotropia, those who had hyperopia of > or = 3.0 D and increasing hyperopia after surgery and those who did not develop dissociated vertical deviation during the follow-up period were more likely to develop accommodative esotropia.

CONCLUSIONS

Children who have the established risk factors should be followed closely for the development of accommodative esotropia. The treatment of these children with appropriate glasses may prevent the development of adverse effects of accommodative esotropia on sensory and motor functions.

Effect of preoperative stability of alignment on outcome of strabismus surgery for infantile esotropia

INTRODUCTION

Some strabismus surgeons wait until the angle of deviation stabilizes prior to operating on patients with infantile esotropia. This study evaluated whether a preoperative increase in the angle of deviation affected surgical outcomes.

METHODS

This was a retrospective comparative case series in which records of patients with infantile esotropia, who had surgery performed before age 2 years and who were followed for at least 2 years postoperatively, were reviewed to identify two groups for comparison: the first had </=5(Delta) change in the angle of deviation between the first office visit and time of surgery; the second had a >/=10(Delta) increase in the angle of deviation prior to surgery. In the latter group, surgery was performed for the angle present at the time of surgery. Outcomes were considered successful if the patients had microtropias.

RESULTS

Fifteen patients were identified in each group. The interval between the first office visit and time of surgery was the same in both groups (mean, 2 months). Outcomes were successful in 11 of 15 (73%) in each group (no significant difference, p = 0.659).

CONCLUSIONS

There was no difference in outcome between children whose angles of deviation were stable and those whose angles increased prior to surgery. This indicates that strabismus surgery does not need to be delayed while waiting for the angle of deviation to stabilize. Surgical correction may therefore be achieved at an earlier age, which may have a beneficial effect on outcome.

Motor coordination in children with congenital strabismus: effects of late surgery

BACKGROUND

Strabismus is one of the most common visual disorders in infancy. While there is a great attention on the effects of the timing of surgery as to the development of binocular vision, little is known about the possible influence of congenital strabismus on perceptual-motor and more generally, on neuromotor development.

AIMS

Aim of this study was to investigate perceptual-motor and motor coordination abilities of 19 children with essential congenital esotropia who underwent a late surgery (after 4 years), compared to 23 age-matched controls.

METHODS

Children were tested using the Movement Assessment Battery for Children (Movement ABC) that were performed both 1-week before surgery (T1) and about 3 months (+/-2 weeks) after surgery (T2).

RESULTS AND CONCLUSIONS

At T1, abnormal or borderline results were found in more than half of the children with strabismus, as opposed to only about 17% of the controls. At T2 none of the children showed abnormal Movement ABC total scores and there was no difference in global scores between the study and the control group. The two groups also did not show any significant difference in individual items of the movement ABC with the exception of those assessing ball skills. Our results suggest that surgical correction of strabismus, even when performed after the 4th year of life, appears to be effective in improving perceptual-motor and motor function.

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

BACKGROUND

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

SUBJECTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Can ophthalmologists repair the brain in infantile esotropia? Early surgery, stereopsis, monofixation syndrome, and the legacy of Marshall Parks

Can ophthalmologists repair defects of visual cortex circuitry in infants who have esotropia? The answer to this question encompasses both sensory and motor behaviors because the clinical hallmarks of the disorder are stereoblindness and absence of motor fusion, which manifests as convergently deviated eyes. Functional recovery of sensory and motor fusion in infantile esotropia was a consuming interest, if not career-defining passion, of Marshall Parks. The purpose of this work is to pay tribute to Parks' legacy by showing how human and animal studies, conducted largely during the last 25 years, support both his clinical insights and treatment philosophy.

Decision analysis with Markov processes supports early surgery for large-angle infantile esotropia

PURPOSE

To assess tradeoffs in time spent with aligned visual axes or stereopsis and risked reoperations between three strategies for the treatment of large-angle infantile esotropia: first surgery at 6, 24, or 48 months of age.

DESIGN

Decision analysis.

METHODS

We simulated three hypothetic cohorts of children with this condition until their eighth year. Potential achievement of stereopsis, the diagnosis of dissociated vertical divergence or inferior oblique overaction, and various complications were modeled. Probability estimates were obtained from a comprehensive literature review. Analyses aimed to determine the strategy that was associated with longer time spent with aligned eyes and/or stereopsis and fewer reoperations.

RESULTS

Eight-year-old children are expected to spend 72.6 vs 58.0 vs 37.8 months with aligned eyes and 26.8 vs 9.0 vs 1.5 months with stereopsis and to receive on average 1.76 vs 1.67 vs 1.46 surgeries, if they first underwent operation at 6 vs 24 vs 48 months, respectively. Children at 8 years are expected to have stereopsis at the rate of 36.1% vs 17.2% vs 5.1%, respectively. Operation at 6 months instead of 48 months is expected to yield an additional 9% of total follow-up time in health states with eye alignment and 11% in health states with stereopsis, per 5% increase in risk for extra operations (5% and 7%, respectively, per 5% increase in risk for operation at 6 vs 24 months). Wide-range sensitivity analyses and long-term projections point to the same direction.

CONCLUSION

Given the benefit/risk tradeoffs, it is probably warranted to attempt to correct large-angle infantile esotropia as early as possible.

[Infantile esotropia: comparison of surgery results when the intervention takes place before or after 30 months of age]

OBJECTIVE

Present and compare surgery results of children with congenital or infantile esotropia, who had surgery before or after 30 months of age, in the Rouen Department of Ophthalmology between 1996 and 2000.

PATIENTS AND METHODS

A retrospective study included 37 patients, 23 females and 14 males, 19 in the first group who had surgery before 30 months at an average age of 24 months (15-30) and 18 in the second group who had surgery after 30 months at an average age of 56 months (38-81). Hypermetropia was found up to 2 diopters for 14 of 19 patients in the first group and 13 of 18 in the second. We noted the surgical procedure. We compared pre- and postoperative amblyopia as well as pre- and postoperative objective deviations at near and distance ranges. The exclusion criteria were follow-up for less than 3 months, esotropia emergence after 12 months of age, children aged more than 7 years at the first surgery, and children with central nervous system disorders. Finally, esthetic aspect, postoperative distance and near sensory results were evaluated. Success was defined by orthotropic position, esotropia less than 15 prism diopters, or consecutive exotropia less than 10 prism diopters.

RESULTS

The mean follow-up after surgery was 30 months (3-56) for the first group and 28 months (3-67) for the second. Motor results were similar between the two groups: we found 10 out of 19 successes (esotropia (E(T)) less than 15 diopters (D) or exotropia (X(T)) less than 10 D) in the first group, and 15 out of 18 successes in the second group. There were 3 out of 19 failures (E(T) more than 20 D or X(T) more than 15 D) in the first group and 3 out of 18 in the second. Hypermetropia and preoperative deviation were not significantly different for good or bad motor results (p<0.05). A second-step surgery was performed for two children in the first group and three in the second group, and one of the three children of the second group had a third step. Sensory results were very similar with 6 of 19 cases achieving binocular union in the first group and 7 of 18 in the second one. Finally, one patient from each group presented amblyopia after surgery.

CONCLUSION

In our study, as in the literature, infantile esotropia surgery can result in excellent motor alignment, while sensory results are not as good. It appears in our study that there is no significant advantage in performing surgery before 30 months for infantile esotropia. The follow-up of our patients may have been insufficient, and our definition of the semi-early surgery (before 30 months) was already too late in comparison with other studies (less than 24 months).

Amblyopia characterization, treatment, and prophylaxis

Amblyopia has a 1.6-3.6% prevalence, higher in the medically underserved. It is more complex than simply visual acuity loss and the better eye has sub-clinical deficits. Functional limitations appear more extensive and loss of vision in the better eye of amblyopes more prevalent than previously thought. Amblyopia screening and treatment are efficacious, but cost-effectiveness concerns remain. Refractive correction alone may successfully treat anisometropic amblyopia and it, minimal occlusion, and/or catecholamine treatment can provide initial vision improvement that may improve compliance with subsequent long-duration treatment. Atropine penalization appears as effective as occlusion for moderate amblyopia, with limited-day penalization as effective as full-time. Cytidin-5'-diphosphocholine may hold promise as a medical treatment. Interpretation of much of the amblyopia literature is made difficult by: inaccurate visual acuity measurement at initial visit, lack of adequate refractive correction prior to and during treatment, and lack of long-term follow-up results. Successful treatment can be achieved in at most 63-83% of patients. Treatment outcome is a function of initial visual acuity and type of amblyopia, and a reciprocal product of treatment efficacy, duration, and compliance. Age at treatment onset is not predictive of outcome in many studies but detection under versus over 2-3 years of age may be. Multiple screenings prior to that age, and prompt treatment, reduce prevalence. Would a single early cycloplegic photoscreening be as, or more, successful at detection or prediction than the multiple screenings, and more cost-effective? Penalization and occlusion have minimal incidence of reverse amblyopia and/or side-effects, no significant influence on emmetropization, and no consistent effect on sign or size of post-treatment changes in strabismic deviation. There may be a physiologic basis for better age-indifferent outcome than tapped by current treatment methodologies. Infant refractive correction substantially reduces accommodative esotropia and amblyopia incidence without interference with emmetropization. Compensatory prism, alone or post-operatively, and/or minus lens treatment, and/or wide-field fusional amplitude training, may reduce risk of early onset esotropia. Multivariate screening using continuous-scale measurements may be more effective than traditional single-test dichotomous pass/fail measures. Pigmentation may be one parameter because Caucasians are at higher risk for esotropia than non-whites.

Horizontal rectus muscle tenotomy in children with infantile nystagmus syndrome: a pilot study

PURPOSE

We wished to determine the effectiveness of horizontal rectus tenotomy in changing the nystagmus of children with infantile nystagmus syndrome.

DESIGN

This was a prospective, noncomparative, interventional case series in five children with varied sensory and oculographic subtypes of congenital nystagmus (including asymmetric (a)periodic alternating nystagmus) and no nystagmus treatment options. Simple tenotomy of all four horizontal recti with reattachment at the original insertion was accomplished. Search-coil and infrared eye movement recordings and clinical examinations were performed before and 1, 6, 26, and 52 weeks after surgery. Outcome measures included masked pre- and postoperative expanded nystagmus acuity function (NAFX), foveation time obtained directly from ocular motility recordings, and masked measures of visual acuity.

RESULTS

At 1 year after tenotomy and under binocular conditions, two of the three patients for whom the NAFX could be measured had persistent, significant postoperative increases in the NAFX of their fixating eye. Average foveation times increased in these patients' fixating eyes. Measured binocular visual acuity increased in four patients; the remaining patient had retinal dystrophy. There were no adverse events due to surgery.

CONCLUSIONS

In the two children who could fixate the targets for several seconds and for whom we could obtain accurate measurements of their infantile nystagmus, tenotomy resulted in significant improvements in nystagmus foveation measures. In those patients plus two others (four of five), measured visual function improved.

Pre-operative stability of infantile esotropia and post-operative outcome

PURPOSE

To define the prevalence and time course of significant changes in angle of deviation during the first months after the diagnosis of infantile esotropia and to determine whether long-term alignment and sensory outcomes differ when surgical alignment is performed on infants with stable vs unstable angles of deviation.

DESIGN

Prospective cohort study.

METHODS

setting: Institutional and clinical practice. patient population: Newly diagnosed patients with infantile esotropia (N = 208). observation procedure: Preoperative measurements of the angle of deviation on the initial visit and at approximate six-week intervals until surgery was performed. main outcome measures: Ocular alignment at six weeks, one year, and four years postoperative and stereoacuity at age five to nine years.

RESULTS

Overall, 57% of infants had an esodeviation on the second visit that was within 10 prism diopters (p.d.) of the deviation measured on the initial visit (stable group), 33% had an increase of 10 p.d. or more (unstable group), and 11% had a decrease of 10 p.d. or more. Among the 127 patients with additional preoperative visits, many switched between the stable and unstable categories during follow-up. Long-term, stable and unstable preoperative alignment groups had similar postoperative motor alignment, re-operation rates, rates of prescription of hyperopic, or bifocal spectacle correction and stereoacuity.

CONCLUSIONS

It may not be necessary to wait for a "stable" angle of esodeviation before surgery since both alignment and sensory outcomes were similar for stable and unstable groups.

Long-term results of bilateral medial rectus recession for congenital esotropia

PURPOSE

This study assessed the long-term results of orthophoria obtained with bilateral medial rectus recession for congenital esotropia.

PATIENTS AND METHODS

The medical records of 214 patients who underwent bilateral medial rectus muscle recession between January 1995 and January 2000 were reviewed. Patients were excluded if neurological abnormalities or developmental delays were documented and if structural eye abnormalities were present. Mean follow up was 54.2 months (range, 36 to 96 months). Rates of reoperation for residual esotropia, consecutive exotropia, oblique muscle overaction, or dissociated vertical deviation were determined.

RESULTS

Forty-five (21%) patients underwent surgery for residual esotropia, 32 (15%) underwent surgery for consecutive exotropia or dissociated horizontal deviation, and 39 (18%) underwent surgery for oblique muscle overaction and dissociated vertical deviation.

CONCLUSION

To maintain long-term alignment of congenital esotropia, additional surgical procedures may be required. The success rate of bilateral medial rectus recession for ocular realignment with one operation is approximately 50%. This method is quicker, simpler, and less traumatic than three or four muscle operations. In addition, the lateral rectus and oblique muscle are left unoperated for future surgeries if necessary.

Surgery and botulinum toxin in congenital esotropia

BACKGROUND

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

METHODS

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

RESULTS

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

INTERPRETATION

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

Stereopsis and long-term stability of alignment in esotropia

PURPOSE

Recent studies of infantile and accommodative esotropia (ET) have focused on stereoacuity as a final outcome measurement for judging the success or failure of treatment. The purpose of the present study was to extend this approach by evaluating whether the presence of stereopsis developing immediately after surgical alignment or optical correction plays a role in maintenance of long-term alignment.

METHODS

Random-dot stereoacuity was assessed within 3 months of initial surgical alignment in 70 children with infantile ET and within 3 months of initial optical correction in 66 children with accommodative ET. At > or = 5 years of age, adverse outcomes were assessed including loss of alignment, amblyopia, and nil stereopsis. Risk-factor analysis was used to evaluate whether early nil stereopsis increased the risk for subsequent adverse outcomes.

RESULTS

In the infantile ET cohort, early nil stereopsis was associated with a 3.6 times (95% confidence interval [CI] 2.4 to 4.1) greater risk of surgery for recurrent ET or consecutive exotropia and a 4.2 times (95% CI 3.3 to 4.4) greater risk for nil stereopsis at > or = 5 years of age. In the accommodative ET cohort, early nil stereopsis was associated with a 17.4 times (95% CI 3.3 to 32.2) greater risk of surgery for ET and a 32.2 times (95% CI 15.8 to 35.6) greater risk for nil stereopsis at > or = 5 years of age.

CONCLUSION

Treatment protocols designed to optimize stereoacuity outcomes promote long-term stability of alignment.

A cost-utility analysis of therapy for amblyopia

OBJECTIVE

Evaluation of the incremental cost-effectiveness of therapy for amblyopia.

DESIGN

Cost-utility reference-case analysis.

METHODS

A cost-utility analysis was performed from a third-party insurer perspective by using decision analysis, evidence-based data from the literature, and patient preference-based time trade-off utility values.

DATABASE

Patient-derived time trade-off ocular utility values and the American Academy of Ophthalmology Preferred Practice Pattern guidelines for the treatment of amblyopia.

INTERVENTION

Treatment of childhood amblyopia using medical and surgical therapies per the American Academy of Ophthalmology Preferred Practice Pattern.

MAIN OUTCOME MEASURE

Dollars (year 2001 nominal U.S. dollars) expended per quality-adjusted life-year ($/QALY) gained.

RESULTS

Treatment for amblyopia resulted in a $/QALY gained of $2281 with a discount rate of 3% for costs and outcomes. Sensitivity analysis, varying costs and utility values by 10%, resulted in a $/QALY gained range from $2053 to $2509.

CONCLUSIONS

When compared with other interventions in health care, therapy for amblyopia seems to be highly cost-effective. This information is increasingly important for health care policy makers.

Binocular visual function in congenital esotropia after bilateral medial rectus recession with loop suture

PURPOSE

Our aim was to evaluate the binocular visual function in congenital esotropia after bimedial rectus recession with loop suture and to address the factors that could take part in the attainment of binocular function.

SUBJECTS AND METHODS

Forty children with congenital esotropia who were operated on between 12 and 48 months of age were included in the study group. Postoperative follow-up ranged from 2 to 10 years. In order to determine the factors affecting the sensory results in congenital esotropia, we classified our patients into two groups according to their fusion status. We compared the preoperative and postoperative characteristics of patients in these two groups.

RESULTS

Twenty-one of 40 patients (52.5%) fused the Worth four-dot at near (Group 1), 19 patients (47.5%) did not (Group 2) at the final examination. No patient showed evidence of stereopsis. We found significant differences between these two groups in respect to the final angle of vertical deviation, the age at surgery, the presence of postoperative inferior oblique overaction, dissociated vertical deviation and abnormal head position. Correlation analysis revealed that early alignment of the eyes and the absence of postoperative vertical deviation were associated with increased incidence of achieving some degree of binocular vision.

CONCLUSION

In congenital esotropia, not all infants may have the potential for normal binocular function owing to yet unknown constitutional factors. We determined that achieving some degree of binocular function may be related to early alignment of the eyes. Additionally, close follow-up and precise treatment of the accompanying vertical deviation, especially inferior oblique overaction and dissociated vertical deviation, in a timely manner may enhance the attainment of binocular sensory function.

Outcome study of stereopsis in relation to duration of misalignment in congenital esotropia

PURPOSE

A recent outcome study of Randot stereopsis in congenital esotropia reported early surgical alignment is associated with a higher percentage of patients with stereopsis and a higher quality of stereopsis because early surgery minimized the duration of misalignment. We compared the Titmus stereopsis with the duration of misalignment and the age of alignment for a group of patients who were surgically aligned by 24 months of age.

METHODS

The data previously obtained in a study of 90 patients aligned by 2 years of age, examined in a masked, independent evaluation for binocularity was analyzed. The age of alignment and duration of misalignment was correlated with the percentage of patients with stereopsis and quality of the stereopsis result as determined by the Titmus vectograph overlay.

RESULTS

Patients aligned by 6 or 12 months of age or within 6 or 12 months of duration of misalignment did not differ in percentage with stereopsis. However, patients aligned after 12 months of age did show a decrease percentage with stereopsis (P <.05, power 0.8). The quality of the stereopsis that was established was similar for those aligned by 6 or 12 months (P >.05, power 0.8). The quality of stereopsis, however, was decreased for patients with duration of misalignment greater than 12 months (P <.001, power 0.8).

CONCLUSION

Alignment within 1 year of age or within 12 months of misalignment favorably affects the percentage of patients who develop stereopsis in the treatment of congenital esotropia. The quality of the stereopsis result is affected by the duration of the misalignment, rather, than the age of alignment per se.

Spontaneous resolution of early-onset esotropia: experience of the Congenital Esotropia Observational Study

PURPOSE

To determine the probability of spontaneous resolution of esotropia with onset in early infancy.

DESIGN

Prospective multicenter cohort study.

METHODS

Eligibility criteria included age at enrollment 4 to < 20 weeks and an esotropia measuring at least 20 prism diopters (pd). The primary outcome measure was ocular alignment at 28 to 32 weeks of age. The esotropia was classified as resolved when there was a misalignment of 0 to 8 pd at the outcome examination either with or without spectacle correction.

RESULTS

Outcome data were available for 170 of the 175 enrolled patients. The esotropia was classified as resolved in 46 of the 170 patients (27%, 95% confidence interval = 21% to 34%). Most of the resolved cases had an intermittent or variable deviation at enrollment. Resolution occurred in only one of 42 cases that had a constant esotropia > or = 40 pd on both the baseline and first follow-up examination and had a refractive error < or = + 3.00 diopters. In another patient, who had an esotropia of 35 pd at baseline and 40 pd at the outcome examination, the esotropia resolved subsequent to the outcome examination.

CONCLUSIONS

Esotropia with onset in early infancy frequently resolves in patients first examined at less than 20 weeks of age when the deviation is < 40 pd in size and is intermittent or variable. Cases with a constant deviation > or = 40 pd presenting after 10 weeks of age have a low likelihood of spontaneous resolution. Our results can be used to define a clinical profile for which persistence of the esotropia is sufficiently likely that surgical correction at 3 to 4 months of age could reasonably be considered.

Relationship of dissociated vertical deviation and the timing of initial surgery for congenital esotropia

PURPOSE

To clarify the incidence of dissociated vertical deviation (DVD) among patients with congenital esotropia and to identify any relationship between the time when patients undergo their initial strabismus surgery and the time when they may subsequently have DVD develop.

DESIGN

Noncomparative case series.

PARTICIPANTS

One hundred five consecutive patients undergoing surgery for congenital esotropia over a 10-year period.

METHODS

All patients underwent bimedial rectus recession before 24 months of age.

MAIN OUTCOME MEASURES

Patients were followed postoperatively to note the age at onset of clinically evident DVD.

RESULTS

By 6 years of age, 92% of available patients had DVD. The mean age at onset was 2.81 +/- 1.37 years. There was no significant difference between patients surgically aligned before 6 months of age compared with those aligned between 6 and 12 or 12 and 24 months of age.

CONCLUSIONS

DVD occurs in almost all patients with surgically treated congenital esotropia, and its development is unrelated to the timing of surgical intervention during the first 24 months of life.

Critical age of botulinum toxin treatment in essential infantile esotropia

PURPOSE

To assess the results of botulinum toxin treatment in 60 consecutive children with essential infantile esotropia.

METHODS

Bilateral simultaneous injection of botulinum toxin into the medial rectus muscle was performed in 60 patients under direct visualization with an "open sky" technique. Fluothane/sevoflurane insufflation anesthesia was used. Each patient underwent a single bilateral botulinum toxin injection. Patient age at the time of injection ranged from 5-8 months.

RESULTS

Mean patient age at the time of treatment for the 88% of patients who gained a good alignment (within +10 prism diopters [delta] of residual esotropia) was 6.5 months, while mean patient age at time of injection for the 12% of patients who were undercorrected or the deviation relapsed was 7.8 months. Follow-up averaged 5.2 years (range: 2-9 years, SD 2). No variation of the angle of strabismus was observed after 6 months from injection. In some patients with hyperopic refraction, plus lens corrections were prescribed during follow-up to stabilize the alignment.

CONCLUSION

Botulinum toxin can be effective in essential infantile esotropia when children are treated by age 7 months.

Comitant strabismus

A review of the literature on comitant strabismus of the period from April 1999 until April 2000 is presented. A rather new and increasingly important issue is the psychosocial aspect of strabismus. Two studies have demonstrated that strabismus creates a significant negative social prejudice on the patients and that it can significantly reduce an applicant's ability to obtain employment. Subsequently, strabismus surgery can no longer be called "cosmetic". Concerning the timing of surgery in congenital esotropia, it was reported that early surgery does not ensure continued alignment, but frequently requires additional operations. The increased risk of early-onset strabismus in prematurely born children was confirmed by several studies, and the importance of regular ophthalmologic controls of all preterm infants screened for retinopathy of prematurity was stressed. It was reported that risk factors are cicatricial retinopathy of prematurity, refractive error, family history of strabismus, and poor neurodevelopmental outcome, rather than low gestational age and regressed acute retinopathy of prematurity. A number of other aspects of interest concerning exotropia, esotropia, and dissociated vertical deviation are presented in this review.