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).

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).

Clinical Profile, Neuroimaging Characteristics, and Surgical Outcomes of Patients With Acute Acquired Non-accommodative Comitant Esotropia

PURPOSE

To report the clinical presentations, neuroimaging findings, and surgical outcomes in patients with acute acquired non-accommodative comitant esotropia (AACE).

METHODS

A retrospective review of records of all patients diagnosed as having AACE between January 2011 and December 2019 across three tertiary eye care centers was done. Cases with AACE onset after age 1 year were included. Patients were divided into two groups based on age of onset of esotropia: childhood (16 years or younger) and adult (older than 16 years). Surgical success was defined as postoperative horizontal deviation of 8 prism diopters (PD) or less at the last follow-up visit.

RESULTS

A total of 338 patients (220 males and 119 females; mean age at presentation: 12.60 ± 9.8 years) met the study criteria. The mean age at onset of esotropia in the childhood and adult onset groups was 3.61 ± 1.1 and 26.6 ± 8.7 years, respectively. There were significantly more individuals with myopia (30%) in the adult onset group compared to the childhood onset group (6%) (P = .004). Thirty-seven (16%) had positive neuroimaging findings (16.4% adult onset vs 9.4% childhood onset). A total of 148 (44%) patients underwent surgery for esotropia, and the overall success rate was 73%. Mean preoperative esotropia was comparable in either group (P = .20), but surgical success was better in the adult onset group (75.6% vs 66.3% in the childhood onset group). Mean duration of follow-up postoperatively was 13.6 ± 12 months.

CONCLUSIONS

Two-thirds of the patients had childhood onset of AACE. Intracranial pathology was found in 1 of 6 patients. Surgical success was better in the adult onset group, which was not influenced by preoperative esotropia, neuroimaging findings, or refractive status, but was dependent on age at onset of esotropia and duration between onset and intervention. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XX-XX.].

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.

Functional acute acquired comitant esotropia: clinical characteristics and efficacy of single Botulinum toxin type A injection

Background

To examine the clinical features of acute acquired comitant esotropia (AACE) and to evaluate the clinical effectiveness of a single injection of botulinum toxin type A (BTXA) on binocular visual function (BVF).

Methods

This retrospective, observational case series study enrolled patients with AACE examined from October 2018–May 2019. BTXA was injected into the both medial rectus muscles. The refractive error, best-corrected visual acuity (BCVA), stereoacuity, vergence, accommodation, the horizontal angle of deviation, and the gradient accommodative convergence/accommodation (AC/A) ratio were measured pre- and post-BTXA injection. Data pre- and postinjection were compared by the Wilcoxon signed-rank test. A Spearman correlation coefficient was calculated to explore the relationships between demographic characteristics and BVF.

Results

Twenty-two AACE cases were included. Compared with preinjection deviation, the postinjection deviation in the primary position was smaller for near (p < 0.001) and distance (p < 0.001) fixation at 3 months after injection (BTXA). Furthermore, convergence was better for near (p = 0.003) and distance (p < 0.001) fixation, divergence was better for near (p = 0.021) and distance (p < 0.001) fixation, accommodation was better in the right (p = 0.011) and left (p = 0.004) eyes, and the gradient AC/A ratio was better at the third month after injection (p = 0.001). Stereoacuity was improved in 11 (50%), unchanged in 5 (22.73%) and decreased in 6 (27.27%) patients. The preinjection stereoacuity (p = 0.013, r = 0.522) and preinjection deviation for near (p = 0.015 r, = − 0.512) and distance (p = 0.009, r = − 0.541) were significantly associated with patient age.

Conclusions

AACE is characterized by a high AC/A ratio and low accommodation. A single injection of BTXA is effective for AACE. Deviation, stereoacuity, and the therapeutic effect of BTXA may be correlated with patient age.

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.

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.

Varied aetiology of acute acquired comitant esotropia: A case series

This is an observational case series of five cases of acute acquired comitant esotropia (AACE) with diplopia, aged between 5 and 12 years. The duration of presenting complaints ranged from 4 days to 2 months. A detailed ophthalmic evaluation and neuroimaging were done on all patients. Three patients were found to have intracranial pathology. Two patients had pontine glioma and one patient had benign intracranial hypertension. One patient was diagnosed as accommodative spasm and one patient was diagnosed as having Type 2 AACE.We would like to conclude that AACE can be of a varied aetiology ranging from convergence spasm to those harboring serious intracranial diseases. We reiterate that AACE has a small but significant association with intracranial disorders. Neuroimaging is a definite need in cases which cannot be proved to be either Type 1 or 2.