Acquired esotropia as initial manifestation of Arnold-Chiari malformation

Risk of serious intracranial pathology in children presenting with acute acquired comitant esotropia

OBJECTIVE

Acute acquired comitant esotropia (AACE) is defined as a sudden-onset constant nonaccommodative esodeviation. The purpose of this study was to determine the risk of serious intracranial pathology in children presenting with AACE.

DESIGN

Retrospective observational cohort study.

SETTING

Tertiary care pediatric hospital.

METHODS

The study included consecutive children who met the diagnostic criteria for AACE and had neuroimaging at a tertiary care pediatric hospital between 2000 and 2020. Patients were identified by searching the radiology database for all children who underwent neuroimaging for esotropia. The primary outcome measure was the proportion of patients with serious intracranial pathology. Secondary outcomes included risk factors for finding likely causative intracranial pathology and the proportion of patients with incidental findings.

RESULTS

A total of 107 patients met the inclusion criteria. Most of the patients (75.7%) had normal neuroimaging. The next most common result was an incidental finding unrelated to the esotropia (18.7%). Five patients (4.7%) had findings with uncertain contribution to esotropia, including 3 cases of type I Chiari malformation. A serious intracranial pathology was found in 1 patient (0.9%) who had a cerebellar medulloblastoma.

CONCLUSION

In this large series of pediatric patients with AACE who underwent neuroimaging, there was a small but nontrivial risk of serious intracranial pathology. In these patients, it is advisable either to obtain neuroimaging or to monitor closely for the development of concerning signs or symptoms.

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).

Acute acquired comitant esotropia of childhood: a classification based on 48 children

PURPOSE

To identify characteristics of pediatric patients who develop acute acquired comitant esotropia (AACE) with and without intracranial disease.

METHODS

We reviewed the charts of 48 children consecutively referred to the hospital with AACE during a 13-year period. Inclusion criteria were acute onset of comitant esotropia, available data on ophthalmologic, orthoptic and neurologic examinations. Children with neurological signs, AACE recurrence or hyperopia <+3 dioptres (D) underwent brain computed tomography or magnetic resonance imaging. Patients without imaging were followed.

RESULTS

In all, 48 cases were recorded. The mean age at onset was 4.7 years, being significantly higher among children with intracranial disease. Seven cause-specific types of AACE in childhood were identified: The acute accommodative (n = 15, 31%), decompensated monofixation syndrome or esophoria (n = 13, 27%), idiopathic (n = 9, 19%), intracranial disease (n = 3, 6%), occlusion related (n = 3, 6%), AACE secondary to different aetiologic disease (n = 3, 6%) and cyclic AACE (n = 2, 4%). Intracranial disease included hydrocephalus, pontine and thalamic glioma. Of the children with intracranial disease, 2 of 3 had no obvious neurological signs at onset. Four significant risk factors for intracranial disease were identified as follows: larger esodeviation at distance, recurrence of AACE, neuro signs (papilledema) and older age at onset (>6 years).

CONCLUSION

In a large case series of children with AACE and by review of literature, we identified seven cause-specific types of AACE. Intracranial disease was present in 6%, and four risk factors were identified to guide clinicians when to perform brain imaging. Findings suggest AACE of childhood to be differentiated from AACE of adulthood.

Neuro-ophthalmology of type 1 Chiari malformation

Chiari malformation is a congenital deformity leading to herniation of cerebellar tonsils. Headache is a typical symptom of this condition, but patients with Chiari malformation often present with double vision and vertigo. Examination of eye movements in such patients often reveals nystagmus and strabismus. Eye movement deficits in the context of typical symptomatic presentation are critical clinical markers for the diagnosis of Chiari malformation. We will review eye movement deficits that seen in patients with type 1 Chiari malformation. We will then discuss the underlying pathophysiology and therapeutic options for such deficits.

Long-term follow-up of children with acute acquired concomitant esotropia

PURPOSE

To study the clinical features and surgical outcome of type 2 (Burian-Franceschetti) acute acquired concomitant esotropia (AACE).

METHODS

Retrospective analysis of children with AACE type 2. All patients underwent strabismus surgery to restore ocular alignment. All children underwent a complete assessment including medical history and pre- and postoperative ophthalmological and orthoptic examinations. Postoperative follow-up was at least 12 months in all cases.

RESULTS

A total of 25 consecutive patients were included. All but 2 patients (92%) were aligned within 8(∆) or less of orthotropia. Of the 25, 15 (60%) regained normal stereovision. In 6 additional cases (24%) some level of binocular vision (Titmus test, 200'' to 3000'') was demonstrated. All of the patients who finally achieved normal stereopsis had lower levels of binocularity on the first postoperative day. The mean interval between surgery and first occurrence of full stereovision was 18 months (range, 2 to 58 months).

CONCLUSIONS

General features of AACE type 2 are concomitance of strabismus, absence of an accommodative component even in the presence of hyperopic refractive errors, and no neurological pathology. The potential for normal binocular vision plays a key role in defining this entity. The reemergence of full stereopsis may take several years.

Acute comitant esotropia in a child with a cerebellar tumor

We report a case of acute comitant esotropia in a child with a cerebellar tumor. A 3-year-old boy was referred for management of a 9 month history of acute acquired comitant esotropia. On first presentation, the patient's angle of esodeviation was 50 prism-diopters (PD) at distance and near fixation without any lateral incomitance. The cycloplegic refraction revealed +0.75 diopters in both eyes. Very mild bilateral papilledema was found on the fundus examination, but the neurological examination did not reveal any other pathological findings. Brain MRI showed a 5 cm mass located in the midline of the cerebellum as well as hydrocephalus. The mass was completely excised and histological examination confirmed the diagnosis of pilocytic astrocytoma. Despite neurosurgery, the patient's strabismus remained unresolved. One year after neurosurgery, both medial rectus muscles were surgically recessed by 6 mm, resulting in esotropia of 8PD at distant and near fixation without restoration of bifoveal fusion at follow-up 2 years after the eye muscle surgery. Therefore, acute onset comitant esotropia in a child can be the first sign of a cerebellar tumor, even without any other neurological signs and symptoms.

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.

Bilateral abducens palsies and facial weakness as initial manifestations of a Chiari 1 malformation

PURPOSE

Chiari I malformations are rare, congenital anomalies involving the caudal herniation of the cerebellar tonsils into the upper cervical spinal canal. Osseous abnormalities of the skull permit the extension of the hindbrain below the foramen magnum and engender syringohydromyelia formation. Neuroophthalmic manifestations are not uncommon; nevertheless, this is the first report of concomitant bilateral abducens palsies and facial nerve impairment as presenting manifestations of a Chiari I malformation.

CASE REPORT

A 30-year-old black female presented with a recent history of blurred vision and binocular diplopia in both left and right gazes. Headaches, dizziness, and orofacial sensorimotor impairments were noted in conjunction with the onset of her diplopia. No history of surgery, trauma, or systemic illness was elicited. Extraocular motility testing confirmed a complete bilateral abduction deficit. Additional cranial nerve testing revealed bilateral facial nerve weakness and tactile hypesthesia in the perioral region. No taste disturbances were reported. Nuclear magnetic resonance imaging studies revealed a Chiari I malformation with a syringohydromyelia formation in the vicinity of the patient's sixth cervical vertebrae. Foramen magnum decompression surgery was performed. Two months after surgery, abduction capacity was restored along with resolution of symptoms of perioral numbness and signs of facial weakness.

CONCLUSION

Bilateral sixth nerve palsies are rare clinical commodities especially when they do not occur in isolation. Intracranial neoplams, trauma, subarachnoid hemorrhaging, demyelinating disease, and meningeal infarcts have all been shown to induce mixed cranial neuropathies. The concomitant bilateral abducens palsy and concomitant facial nerve weakness reported in this case represents an atypical and previously unreported presentation of a Chiari I malformation.

Resolution of periodic alternating nystagmus after decompression for Chiari malformation

CASE REPORT

A 20-year-old female presented with horizontal jerk nystagmus, blurred vision, severe headaches, unsteady gait, and paresthesia. Magnetic resonance imaging revealed Chiari malformation I. Symptoms resolved after decompression of the posterior cranial fossa and removal of the right cerebellar tonsil.

COMMENTS

Conditions associated with acquired periodic alternating nystagmus and ocular disorders associated with Chiari malformation are discussed. To our knowledge, this case is the first to report the resolution of periodic alternating nystagmus after neurosurgical decompression.

La malformation de Chiari de type 1 à l’ère de l’imagerie par résonance magnétique

The Chiari type 1 malformation is common. Unlike the Chiari type 2 and 3 malformations, it may remain latent for a long time, becoming symptomatic only in adulthood. The introduction of MRI has resulted in an increased number of diagnoses of this malformation in pediatric patients. It appears to be related to underdevelopment of the posterior cranial fossa. It must be differentiated from acquired tonsillar herniation, particularly when herniation results from intracranial hypotension; these cases are sometimes reported as acquired Chiari I malformation with spontaneous resolution. Tonsillar ectopia may cause symptoms by its direct effect on any or all of the medulla and the cerebellar and upper spinal cord. The most suggestive of the oculomotor disturbances is oscillopsia with downbeat nystagmus. Dysphonia and dysphagia are common. Potentially serious autonomic disturbances are also frequent: sleep apnea, respiratory failure, syncope and even sudden death. Another risk is syrinx formation, resulting from obstruction of CSF circulation in the cisterna magna. Syringomyelia is detected in 32 to 74% of patients with Chiari I malformation. Treatment is surgical. Posterior fossa decompression is achieved by suboccipital craniectomy combined with laminectomy of the upper cervical segments. Surgical intervention is indicated when the malformation is symptomatic and there is no doubt that it is the cause of the symptoms. When a Chiari I malformation is identified fortuitously on MRI, long-term monitoring is essential. The risk of developing symptoms increases over time. Patients should be advised not to participate in contact sports.

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.

Isolated comitant esotropia and Chiari I malformation

PURPOSE

To report four patients with isolated comitant esotropia and Chiari I malformation and discuss the most appropriate management.

METHODS

Case reports and literature review.

RESULTS

All four patients (5, 14, 16, and 37 years of age) presented with an isolated comitant esotropia that led to the diagnosis of Chiari I malformation. The first two patients underwent uncomplicated neurosurgical decompression of their malformation, followed by complete resolution of their esotropia. The third patient underwent strabismus surgery and experienced initial resolution of the esotropia, but eventual recurrence resulted in the strabismus surgery being repeated 5 years later. The fourth patient had strabismus surgery with resolution of the esotropia but only 2 months of follow-up.

CONCLUSION

Although management of patients with Chiari I malformation and severe neurologic findings typically includes surgical decompression, management is less straightforward in cases with subtle findings or in which ocular findings are isolated. The decision to perform neurosurgical decompression or strabismus surgery should still be made on a case-by-case basis, with the understanding that strabismus surgery may provide only temporary ocular alignment.

Oculographic and clinical characterization of thirty-seven children with anomalous head postures, nystagmus, and strabismus: the basis of a clinical algorithm

BACKGROUND AND PURPOSE

We studied children with nystagmus who also had anomalous head postures and strabismus to determine the etiology of the conditions and present a diagnostic clinical algorithm.

METHODS

The patients for this study were among the 560 patients evaluated in the ocular motor neurophysiology laboratory between the years 1991 and 1997. Clinical characteristics, infrared oculography data, and medical and surgical treatments were entered into a database for analysis. Oculography was performed on all patients according to a standard protocol, and data were stored and analyzed off-line. Etiology of anomalous head posture was determined with both clinical and oculography information.

RESULTS

Thirty-seven children are the subjects of this report. The etiology of anomalous head posture was a "gaze null" due to congenital nystagmus in 23 (62%) patients, an "adduction null" due to manifest latent nystagmus in 12 (32%) patients, spasmus nutans in 1 (3%) patient, and strabismus in 1 (3%) patient. The patients' ages ranged from 9 months to 12 years and averaged 4.4 years. Sixty-nine percent were male patients. Nineteen (63%) of 30 patients had abnormal recognition (linear optotype) acuity in at least 1 eye on monocular cover; the recognition remained abnormal in 5 (17%) of 30 patients under binocular conditions. Thirty percent of patients had amblyopia, 16% had some structural disease of the eyes, 22% had some systemic syndrome or abnormality, 57% had a significant refractive error, and 27% had some ability to fuse.

CONCLUSIONS

The major etiology for anomalous head posture in these patients was to adopt a gaze null due to congenital nystagmus (62% of patients) regardless of the direction of their anomalous head posture or type of strabismus. Moving the fixing eye as the first step for the anomalous head posture, combined with moving the nonfixing eye for the resulting strabismus may help treat these patients.

Treatment of acute comitant esotropia in Chiari I malformation

PURPOSE

To explore the appropriate treatment of acute comitant esotropia in patients with Chiari I malformation.

DESIGN

Interventional case reports and literature review.

PARTICIPANTS

Two patients with Chiari I malformation presenting with acute comitant esotropia are described.

INTERVENTION

Strabismus surgery, then neurosurgical decompression of the Chiari I malformation was performed.

MAIN OUTCOME MEASURE

Both patients were evaluated for resolution of esotropia and other ocular motility problems.

RESULTS

After initially successful strabismus surgery, both patients developed recurrent esotropia with diplopia, which resolved on suboccipital decompression.

CONCLUSION

Comitant esotropia may recur and other eye movement disorders may develop after initially successful strabismus surgery in patients with Chiari I malformation. The data suggest that the appropriate sequence of treatment should first be suboccipital decompression, then strabismus surgery if spontaneous realignment does not occur, but further studies are needed to confirm this impression.

Comitant esodeviation resulting from neurologic insult in children

PURPOSE

Our purpose was to establish whether comitance was a common or uncommon finding in children with esodeviation associated with a neurologic insult.

METHODS

A retrospective chart review was performed of children with acquired esodeviation associated with an identifiable neurologic insult.

RESULTS

Examinations of 30 children seen over a 2-year period were analyzed. Twenty-two (73%) had brain tumors. Twelve (40%) had comitant esodeviation, and the other 18 (60%) had incomitant measurements. Of the patients with comitant esodeviation, 6 had normal abduction OU (two after recovery from bilateral sixth nerve palsies), and 6 had mild or minimal abduction deficits. Moderate or severe abduction deficits were associated with incomitant measurements.

CONCLUSIONS

Comitant esodeviation can be common in children with identifiable neurologic insults.

Etiology and prognosis of acute, late-onset esotropia

OBJECTIVE

The purpose of the study is to review etiologies and outcomes of sudden, late-onset esotropia.

DESIGN

The authors reviewed charts of patients in whom acute, comitant, constant esotropia developed after 5 years of age.

MAIN OUTCOME MEASURES

The authors evaluated final ocular alignment, treatment, fusion, apparent etiologies, and associated neurologic conditions.

RESULTS

Ten patients met entry criteria with documentation of previous orthotropia. Ages ranged from 5 to 35 years. Esotropia at near ranged from 16 to 70 prism diopters. In seven patients, the esotropia improved partially or completely with correction of hypermetropia. Eight patients required surgery. In only one patient were neuroimaging studies positive, associated ophthalmic and systemic findings identified, and underlying neurologic disease diagnosed.

CONCLUSIONS

Sudden, late-onset esotropia may be caused by an uncorrected refractive error. If no other neurologic signs are present, underlying intracranial disease is unlikely.

Neuro-ophthalmological evaluation of patients with myelomeningocele and Chiari malformations

Twenty-eight patients (14 females and 14 males aged between four and 34 years) with myelomeningocele and Chiari malformations were examined neuro-ophthalmologically. All patients had been under proper neurosurgical care and no reduction of visual function was found that could be related to optic atrophy or other changes in the visual pathways. However, ocular motility disorders, including strabismus, were common, although no case of down-beat nystagmus was observed. Manifest strabismus was found in 11 patients. Esotropia with or without A-pattern was seen in nine patients. Spontaneous or gaze-related nystagmus and abnormal optokinetic nystagmus represented the most common disturbances of ocular motility. Abnormalities of horizontal eye-movements were more common than those of vertical eye-movements. Strabismus of the manifest type was combined with other ocular motility disturbances in most cases.

Chiari type I malformation in children

We reviewed the recent experience at Texas Children's Hospital by examining the records of 11 children who underwent suboccipital decompression for symptomatic Chiari type I malformation. Presenting complaints included neck pain (1 child), scoliosis (4 children), back pain (1 child), torticollis (1), motor dysfunction (1), and apnea (3 children). Neurologic findings were normal in 7 of the 11 children. The craniocervical junction and medulla were studied by magnetic resonance imaging, which revealed anatomy consistent with Chiari type I malformation in all cases. At surgery, all patients had tonsillar herniation to the first cervical vertebra or below. Three patients had syringomyelia. Postoperatively, either the patients were symptom free or, in the cases of scoliosis and torticollis, there was no progression. Our experience suggests that Chiari type I malformation may occur in childhood with varied and unusual clinical findings. Magnetic resonance imaging was essential to the diagnosis; the presence of tonsillar herniation was confirmed at surgery. The results of suboccipital decompression were favorable in this series.

Exercise induced esotropia

A case of unusual intermittent esotropia and diplopia is reported. A 13-year-old boy experienced diplopia during vigorous exercise that resolved within 30 minutes after stopping the exercise. The symptoms had been present unchanged since age 6. Examination revealed orthophoria. After vigorous exercise an esotropia of 14 prism diopters in the distance developed, which gradually resolved over 30 minutes. Neurologic evaluation, CT scan, and magnetic resonance imaging scan have been normal. The symptoms have continued unchanged for 11 years. To my knowledge, no other similar case of exercise induced esotropia has been reported.