Bilateral phakic hypermetropic epikeratoplasty for accommodative esotropia

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hyperopic laser in situ keratomileusis for refractive accommodative esotropia

PURPOSE

To assess the efficacy of hyperopic laser in situ keratomileusis (LASIK) in creating orthophoria without optical correction in adult patients with refractive accommodative esotropia (RAE).

SETTING

Instituto Oftalmológico de Sabadell, Sabadell, Barcelona, Spain.

METHODS

This prospective single-center clinical trial studied 9 eyes (18 patients) with RAE having hyperopic LASIK. The mean follow-up was 20 months (range 12 to 24 months). The mean preoperative refraction was +5.01 diopters (D) and the mean deviation angle without optical correction, 36 prism diopters. The intervention was hyperopic LASIK using the Automated Corneal Shaper microkeratome (Bausch & Lomb) and the Apollo broad-beam excimer laser using a 5.5 mm optical zone and an 8.0 mm transition zone; astigmatism was treated by steepening the flattest meridian.

RESULTS

All patients achieved orthophoria or the preoperative microtropia without optical correction immediately after surgery. This was maintained throughout the follow-up. Fifty-six percent of all cases were within +/-0.5 D of emmetropia, and 89% were within +/-1.0 D. The uncorrected visual acuity improved significantly (P <.005), especially at near, and the mean best corrected visual acuity (BCVA) was maintained, although 4 eyes (22%) lost 1 line of BCVA. There were no significant complications.

CONCLUSIONS

In adult patients with RAE, treatment of the refractive error using hyperopic LASIK was safe and effective and corrected the esodeviation. Further studies in younger patients will help determine the age at which this intervention may be indicated.