Acquired Comitant Esotropia in Children and Young Adults: Clinical Characteristics, Surgical Outcomes, and Association With Presumed Intensive Near Work With Digital Displays

Risk Factors for Acute Acquired Comitant Esotropia in Children and Young Adults: A Systematic Review

Background

Acute acquired comitant esotropia (AACE) is a rare subtype of esotropia that occurs after infancy. The exact pathogenesis of AACE remains unknown with aetiologies ranging from benign conditions to serious underlying neurological diseases being reported. Given the elusive characteristic of AACE, diagnostic and management guidelines remain unclear. This systematic review aims to contribute to this field by summarising the risk factors for AACE reported thus far.

Methods

A systematic review was conducted with papers found in CINAHL, MEDLINE, Cochrane library, PubMed databases and other sources. Eligible studies investigating the risk factors for, and clinical features of, AACE in children and young adults were critically appraised before relevant data were extracted and discussed via a narrative summary.

Results

Twelve studies were included in the final review, of which six and eight papers reported on benign and non-benign risk factors for AACE respectively. Identified benign risk factors varied among studies, while non-benign risk factors were associated with intracranial pathologies, multiple sclerosis and head trauma.

Conclusion

Given the low generalisability of study findings, no definitive conclusions can be drawn on the significance of each risk factor on AACE development. Further prospective research with more objective measurements of 'near work', larger sample sizes and control groups is required to better ascertain any cause-effect relationship, refine the diagnostic criteria for each AACE subtype and advise on appropriate management guidelines for AACE.

Medial rectus insertion site in cases of acute acquired comitant esotropia associated with excessive digital device usage

PURPOSE

To compare the distance of the medial rectus muscle insertion to the limbus (DMIL) between patients with acute acquired comitant esotropia (AACE) associated with excessive digital device usage (EDDU) and exotropic patients.

STUDY DESIGN

Retrospective study.

METHODS

The medical records of 72 eyes of 44 patients with EDDU were retrospectively analyzed. The DMIL was measured from the anterior part at the midpoint of the medial rectus muscle insertion into the anterior limbus using a caliper after dissecting the medial rectus muscle with two control sutures at 12 o'clock and 6 o'clock. The DMIL in the non-fixation eye was compared between 44 patients with AACE and 23 patients with exotropia.

RESULTS

The mean daily EDDU was 6.5 ± 3.1 h. The mean cycloplegic refractive errors (spherical equivalent: SE) were - 3.18 ± 2.52 diopters (D) OD and - 3.03 ± 2.42 D OS. The mean DMIL in the 72 eyes of 44 patients with AACE associated with EDDU was 4.30 ± 0.66 mm. The difference in DMIL of non-fixation eyes between 44 AACE patients and 23 exotropic patients was significant (4.28 ± 0.65 mm vs. 5.28 ± 0.50 mm, p < 0.0001). However, the SE in 44 non-dominant eyes of AACE was - 3.08 ± 2.56 D, significantly stronger than - 1.22 ± 1.93 D in the 23 exotropic eyes (p = 0.008).

CONCLUSION

DMIL in patients with AACE associated with EDDU was significantly shorter. This anatomical anomaly may be an etiology of AACE associated with EDDU.

Clinical Characteristics and Management of Patients with Esotropia and Moderate Myopia

Although the incidence of acquired esotropia associated with moderate myopia is on the rise, there is minimal research on the clinical profile and pathophysiology of this condition. To gain deeper insights into the clinical characteristics and management of these patients, a literature search was conducted, resulting in the identification of six relevant studies. Collectively, these studies encompassed a total of 304 patients. The mean age of onset of esotropia across all studies was 37.52 years. The mean deviations for distance were not considerably larger than those reported at near, even though symptoms were reported more frequently at distance. The overall mean of the distance deviation was 25.16 prism diopters, and the overall mean of the near deviation was 20.82 prism diopters. There were very few reports of vertical deviations across all studies. Limited data suggests that increased near work may be associated with larger esodeviations. Only three articles assessed surgical management; however, it appears that surgical correction may need to be increased by approximately one-third compared to traditional surgical tables and smaller deviations may require even greater augmentation.

Clinical characteristics and treatment outcomes of myopic children and adolescents with acute acquired comitant esotropia

CLINICAL RELEVANCE

Acute acquired comitant esotropia (AACE) is becoming increasingly common in young children. Understanding clinical characteristics and treatment outcomes can inform future practice.

BACKGROUND

To evaluate clinical characteristics of myopic children and adolescents with AACE, and the outcomes of varying treatments.

METHODS

A retrospective review of medical records was conducted to identify patients diagnosed with AACE and diplopia between 2016 and 2020. The duration of smartphone use, angle of deviation, refractive error, stereopsis, and treatment options were analysed. The motor outcomes were evaluated at the earliest 6-month postoperative visit (6-30 months), and orthotropia or esodeviation ≤10 prism dioptres (PD) was defined as success. Successful sensory outcomes were defined as the elimination of diplopia in primary gaze or the presence of stereoacuity.

RESULTS

Twelve patients diagnosed with AACE were identified. Ages were between 9 and 19 years (15.6 ± 3.3 years). All patients showed convergent and comitant esotropia ranging from 12 to 40 PD at distance fixation that was nearly equivalent for distance and near fixation. The mean age at the initial visit was 15.6 ± 3.3 years. Post-treatment esodeviations were significantly lower at both distance and near compared to pretreatment (p < 0.001, for both). Eight patients required surgery and were treated with bilateral medial rectus muscle recession, two patients were treated with botulinum toxin, and two patients were followed with prismatic glasses. Nine of 10 patients (%90) treated with either surgery or botulinum toxin had successful motor and sensory outcomes.

CONCLUSIONS

Surgery is the most efficient treatment option; botulinum toxin and prismatic glasses could be useful treatment options in patients who refuse to have surgery or for whom the amount of deviation is small and variable.

Acquired comitant esotropias - comparison of surgical outcomes of accommodative vs non-accommodative types

Purpose: To compare the motor and sensory outcomes of strabismus surgery and the factors affecting surgical success in acquired acute non-accomodative esotropia (ANAET) and partially accommodative refractive esotropia (pARET). Methods: A retrospective chart review of patients with ANAET and pARET who underwent unilateral or bilateral horizontal rectus muscle surgery between January 2020 and December 2021 was conducted. Patients with postoperative follow-up of at least six weeks were included. Patients with pattern deviation, lateral incomitance, and near-distance disparity were excluded. Motor success was defined as a postoperative deviation within eight prism diopters of orthophoria. Sensory success was defined as presence of binocular single vision (BSV) for both distance and near (Worth four dot test). The effect of factors like age at onset, age at surgery, amblyopia before surgery, duration of squint before treatment, presence or absence and magnitude of vertical deviation, preoperative angle of deviation, and spherical equivalent on the motor and sensory success in each group were analyzed and compared. Results: 38 patients with ANAET and 33 patients with pARET were included. The mean age of onset of esotropia was 8.55 ± 4.65 years and 4.39 ± 2.27 years (p < .001) and the mean age at surgery was 10.62 ± 4.99 years and 7.89 ± 2.84 years (p = .006) in the ANAET and the pARET group respectively. The mean duration of the final follow-up was 38.51 weeks in the ANAET and 48.68 weeks in the pARET group (p = .089). Patients were successfully aligned for both distance and near in 81.5% of patients in the ANAET and 78.9% of patients in the pARET group at the final follow-up (p. 0.775). A BSV for both distance and near at the final follow-up was seen in 81.2% vs 66.6% of patients in the ANAET and the pARET group respectively (p = .25). A good near stereoacuity (<120 arcsecs) was seen in 60.6% and 41.9% of the ANAET and the pARET groups respectively (p = .175). The percentage of patients in the ANAET group who had orthophoria, any esodeviation, and any exodeviation for distance at the final follow-up was 63.1%, 34.2% and, 2.6%. The percentage of patients in the pARET group in similar categories was 36.3%, 42.4% and, 21.2%. None of the demographic and preoperative factors were found to affect the surgical outcomes in the two groups. Conclusions: The motor and sensory outcomes were similar in the two groups. A higher proportion of ANAET patients remained orthophoric during the follow-up. The patients in the pARET group showed a tendency toward exodrift.

Clinical presentations of acquired comitant esotropia in 5-35 years old Japanese and digital device usage: a multicenter registry data analysis study

PURPOSE

To describe clinical presentations of acquired comitant esotropia and digital device use in children, adolescents, and young adults without neurological problems.

STUDY DESIGN

Multicenter prospective observational study.

METHODS

Patients with acquired comitant esotropia, without intracranial diseases aged 5-35 years at the time of visit, who were seen at pre-registered facilities within 1 year of onset were enrolled. The duration from the onset of symptoms and the time of digital device usage approximately 1 month before onset and their lifestyles were surveyed. Visual acuity, cycloplegic refraction, and strabismus angles were measured. Data were analyzed in three age groups (Child: 5-12 years, Adolescent: 13-18 years, and Young adult: 19-35 years).

RESULTS

Between November 2019 and December 2021, 218 patients were enrolled from 55 facilities, and 194 patients (including 62 children, 69 adolescents, and 63 young adults) were analyzed. The child group spent the least amount of time using digital devices (children: 159; adolescents: 210; young adults: 267 min/work day, p < 0.05; (mean time in the same order below) 229, 338, 314 min/holiday, p < 0.05) and had the largest strabismus angle (mean strabismus angle at near: 30, 22, 18 PD, p < 0.01; at far: 28, 26, 21 PD, p<0.05).

CONCLUSION

The clinical features of acquired comitant esotropia and hand-held digital device usage differed between children aged ≤ 12 years and older patients. This report gives the current clinical characteristics of young patients with acquired esotropia and digital device usage.

The efficacy of botulinum toxin type A treatment and surgery for acute acquired comitant esotropia

Aim

To compare the long-term efficiency of botulinum toxin type A (BTXA) injection and surgery on acute acquired comitant esotropia (AACE).

Methods

This retrospective study enrolled patients with AACE from January 2020 to August 2022. The horizontal angle of deviation pre- and post-treatment was measured. Deviations in BTXA and surgical treatment were compared. The BTXA group was divided into adequate treatment (AT) and inadequate treatment (inAT) subgroup based on the deviation of no more than 4 prism diopters (at near and distance) or temporary exotropia at the 2 week follow-up. The two subgroups were compared to determine the long-term efficacy of BTXA treatment.

Results

Ninety-two patients with AACE were included. Follow-up was 6 months. The deviations of the surgery and BTXA group were significantly smaller at the 6 month follow-up than at pre-treatment (p < 0.001). The deviation before treatment in the surgery group was larger than in the BTXA groups (p < 0.001) but smaller at the 6 month follow-up (p < 0.001). The deviation was similar in the AT-BTXA and inAT-BTXA subgroups before treatment (p = 0.322 for distance and p = 0.051 for near) but smaller in the AT-BTXA subgroup at 6 month follow-up (p < 0.001 for near and distance).

Conclusion

Surgery and BTXA successfully treat AACE. Surgery has a more precise and lasting therapeutic effect than BTXA. AACE patients adequately treated with BTXA and with deviations of no more than 4 prism diopters at 2 weeks follow-up had better outcomes.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Surgical Outcomes with and without Prism Adaptation of Cases with Acute Acquired Comitant Esotropia Related to Prolonged Digital Device Use

Purpose

To analyze surgical results of 32 cases with acute acquired comitant esotropia (AACE) related to prolonged use of digital devices (DDs).

Patients and Methods

Medical records of cases with AACE related to prolonged use of DDs that had undergone surgery were retrospectively revised. Complete medical history and full ophthalmological examinations before and surgery were obtained for all cases. All cases also underwent neurological examinations using brain and orbital imaging. Motor success was considered as alignment within 10 prism diopters (Δ) at both near and distance. Sensory success was defined as stereopsis ≤60 arcsec. Nineteen cases (Group S) underwent surgery alone and 13 cases were treated with surgery and prism adaptation (Group S+P). Motor and sensory outcomes were compared between groups.

Results

Mean age at first visit was 22.0 ± 9.0 years and mean daily use of DDs use was 6.3 ± 3.4 hours. Mean angle of preoperative alignment for distance and near were 26.5 ± 13.0Δ and 24.6 ± 16.4Δ, respectively. Surgery was performed at a mean of 23.3 ±3.5 years old and mean angle of alignment at final examination for distance and near were 5.8 ± 7.7Δ and 3.5 ± 5.7Δ, respectively. Final motor and sensory success rate were 84% and 53%, respectively. No significant differences in motor or sensory outcomes were evident between groups at initial or last visit.

Conclusion

Favorable motor and sensory outcomes were achieved with surgical intervention with and without prism adaptation for AACT related to prolonged use of DDs.

Epidemiology, clinical features, and surgical outcomes of acute acquired concomitant esotropia associated with myopia

PURPOSE

To analyze epidemiology, clinical features, and surgical outcomes of type III acute acquired concomitant esotropia (Bielschowsky esotropia (BE)).

METHODS

The medical charts of patients diagnosed with acquired concomitant esotropia between 2013 and 2021 were reviewed. Assessed data were age, gender, age at diplopia onset, age at the diagnosis, refraction, visual acuity, neuroimaging, diplopia onset, angle of deviation, stereopsis, surgical procedure, amount of surgery, and relapse of diplopia after surgery. Moreover, we investigated the correlation between the use of electronic devices and the onset of diplopia.

RESULTS

One hundred seventeen patients (mean age 35.07 ± 15.81 years) were included in the study. The mean delay to the diagnosis was 3.29 ± 3.62 years. Myopia range was 0 to 17 diopters spherical equivalent. 66,3% spent more than 4 hours a day using laptops, tablets, or smartphones at the onset of diplopia, and 90,6% presented a subacute onset. None showed neurologic signs or symptoms. Patients who underwent surgery were ninety-three, with a rate of surgical success of 93.6%, and a relapse rate of 17.2%. A negative correlation resulted between pre-operative deviation and age at diagnosis (ρ = -0.261; p<0.05), whereas factors associated with surgical failure were older age at diplopia onset (p = 0.042) and longer delay between onset and diagnosis (p = 0.002).

CONCLUSION

We registered an outstanding increase in prevalence of BE, which could be related to the exponential increase in the use of electronic devices for professional, educational, and recreational purposes. A prompt diagnosis and an augmented dose of surgery allows good motor and sensory results.

Prism adaptation response and surgical outcomes of acquired nonaccommodative comitant esotropia

PURPOSE

To investigate the clinical factors influencing the prism adaptation response of acquired non-accommodative comitant esotropia (ANAET) and evaluate the surgical outcomes.

STUDY DESIGN

Retrospective observational study.

METHODS

This study assessed patients with ANAET who underwent strabismus surgery based on the results of a short prism adaptation test (PAT). Patients wore Fresnel trial prisms based on alternate prism cover tests in outpatient clinics. The cover test was then performed after 15-20 minutes; if the deviation increased, the power of the prism was increased to neutralize the angle. The test was repeated until the angle was stable. Patients were classified as either prism builders (angle increased by ≥ 10 prism diopters [PD] compared with the entry angle) or prism non-builders (angle increased by < 10 PD). The following clinical characteristics were noted: age at onset, age at surgery, duration of esotropia, refractive error, angle of deviation, presence or absence of intermittent esotropia at near, and pre- and postoperative sensory status.

RESULTS

A total of 41 patients (median age, 15.4 years) were evaluated. The mean (standard deviation) spherical equivalent refractions were -3.03 (3.33) diopters (D) and -3.05 (3.23) D in the right and left eyes, respectively. Twenty-seven (66%) patients were prism builders. The prism builders had greater myopia (builders vs. non- builders, right eye: -3.97 [2.97] vs. -1.22 [3.33] D, P = .01; left eye: -4.08 [2.78] vs. -1.07 [3.20] D; P = .003), lower angle of deviation at near (median [interquartile range] 30.0 [20.0, 35.0] vs. 42.5 [35.0, 49.4] PD; P = .009), much more preoperative intermittent esotropia or esophoria at near (44% vs. 7%, P = .03) and diplopia (96% vs. 64%, P = .01), and better postoperative stereoacuity (50 [40, 110] vs. 100 [60, 400] arcsec, P = .02) than the prism non-builders. The overall success rate was 83%, without a significant difference between the two groups (builders vs. non-builders, 89% vs. 71%, P = .21).

CONCLUSION

In cases of myopic refractive error, a small entry angle with intermittency at near, and good binocularity, it is recommended that surgery is performed based on prism-adapted angle to prevent under-correction.

Fusional Vergence Dysfunctions in Acute Acquired Concomitant Esotropia of Adulthood with Myopia

INTRODUCTION

Acute acquired concomitant esotropia (AACE) has been increasing dramatically in myopia. The aim of this study was to clarify whether fusional vergence dysfunctions exist in AACE with myopia and to explore the relationship between fusional vergence and myopia in AACE.

METHODS

This is a prospective clinical study. Adult AACE patients as well as controls (aged ≥18 years) both with myopia were prospectively recruited from October 2016 to August 2021. Refractive error and fusional divergence and convergence amplitude at distance were measured, as determined with a comprehensive refractor. The main outcome measures were the real value of the fusional divergence amplitude (calculated by subtracting the break point value from the angle of deviation) and the real value of the fusional convergence amplitude (calculated by subtracting the angle of deviation from the break point value). Two-sided p value of less than 0.05 was considered to indicate statistical significance.

RESULTS

Fusional vergence consisting of fusional divergence and fusional convergence in patients with AACE of adulthood was different from the controls (p < 0.001), with fusional convergence decreased and fusional divergence increased. In the linear regression analysis, spherical equivalents were significantly negatively correlated with fusional convergence (right eyes, p < 0.001; left eyes, p < 0.001) in patients with AACE of adulthood but not in controls. There was a significant difference in fusional convergence amplitude among different degrees of spherical equivalents (p < 0.001).

CONCLUSIONS

Fusional vergence dysfunction exists in AACE of adulthood, which may be attributed to self-adaptation based on concomitant esotropia to maintain fusion in AACE. Fusional convergence was associated with degrees of myopia, implying the adaption would be weakened as the degree of myopia becomes serious.

Surgical outcomes of acquired acute comitant esotropia. Causes and classification

PURPOSE

To study the results of surgical treatment of acquired concomitant esotropia and its posible causes.

METHODS

Retrospective study of the patients with acute acquired esotropia that were operated on since 2017. Distance and near horizontal deviation, spherical equivalent and the excessive use of the tablets and smartphones were analyzed. A good sensorial outcome was considered when stereopsis was recovered and good motor outcome if horizontal deviation was ≤10 prism diopters at the end of the follow-up.

RESULTS

A total of 15 cases were included (60% women), mean age: 29.07 years (86.66% ≥16 years). Mean time since the beginning of the symptoms to the surgery was 23.3 months. Mean horizontal preoperative deviation was 19.73 ± 7.2 pd at near and 22.93 ± 7.3 dp at distance decreasing to 3.33 ± 3.8 pd at near and 3.86 ± 3.9 pd at distance (P < .001). The 66.6% had diplopía. The 46.66% had decompensated esophoria or microesotropia, 86,66 % myopia and the 33.33% referred excesive use of the tablets and smartphones. The medial rectus recession were done in 10 cases. A good motor outcome was obtained in the 93.33% of the cases and sensorial outcome in the 53.3% without diplopía.

CONCLUSION

Surgery was an excellent treatment to resolve the deviation and diplopia. The esophorias and microesotropias represented near the half of the cases and the excesive use of the tablets and smartphones were the third part of the sample. Most of the patients had myopia.

The effects of topical cycloplegics in acute acquired comitant esotropia induced by excessive digital device usage

Background

Acute acquired comitant esotropia induced by excessive digital device usage, especially smartphones (SAACE), has been increasing over the past few years. One suggested mechanism is convergence spasm induced by excessive near work, with refraining from digital device use considered to be an effective method for decreasing the degree of esodeviation. However, if symptoms persist and are untreated over time, recovery becomes more difficult. The present study evaluated the effects of topical cycloplegics on persistent SAACE untreated for over 1 year.

Methods

Patients with sustained SAACE that was untreated for over 1 year were evaluated. Digital device usage was discouraged and a topical cycloplegic, 0.4% tropicamide, was prescribed at bedtime. After obtaining informed consent, the 14 out of 23 enrolled patients who agreed to eye drop administration were defined as the study group, with the others serving as the controls. After a 3-month follow-up, patients who elected to undergo surgery were analyzed as the surgery group. Changes in esotropia angles, stereoacuity and diplopia complaints were evaluated after a 3-month follow-up.

Results

Esotropia angles decreased and stereoacuity improved after a 3-month treatment in the study group (P < 0.01). Diplopia disappeared in 13 patients (92.9%, totally disappeared or disappeared when using glasses with built-in prisms). Among 11 patients with untreated esotropia ranging from 1–3 years, decreases in esotropia angles were correlated to untreated esotropia duration (near: R = -0.6; distance: R = 0.7; both P < 0.05). Esotropia angles in the control group exhibited a tendency to increase while stereoacuity tended to deteriorate after the 3-month follow-up. As diplopia did not disappear in any patients, 7 elected to undergo surgery and were enrolled as the surgery group. While esotropia angles decreased in the study group, they were lower than the surgery group (P < 0.01), but higher than the control group (P < 0.01). Stereoacuity was worse in the control versus the study and surgery groups (both P < 0.05).

Conclusion

Results suggest short-acting topical cycloplegics are effective in SAACE patients with long untreated periods. Decreases in esotropia angles were negatively correlated to untreated esotropia duration, which suggests the necessity of early treatment.

Clinical features and treatment of near-work-related acquired esotropia

AIM

To investigate the characteristics of near-work-related esotropia and the clinical efficacy of botulinum toxin type A (BTXA) injection therapy on it.

METHODS

A total of 107 patients aged 15-57y with near-work-related esotropia were taken as the BTXA-treated group, and 30 other peers without near-work-related esotropia were included in the control group. All participants were refractive corrected to analyse the clinical characteristics of near-work-related esotropia. All subjects were examined including Worth4 spot examination, stereoscopic vision, strabismus angle, accommodative convergence to accommodation ratio (AC/A), far and near positive and negative convergence, positive and negative fusion range, positive and negative relative accommodation. Clinical efficacy was evaluated at a period of 10mo follow-up.

RESULTS

The distant and near stereopsis were found in 84.9% and 77.5% of patients in the BTXA-treated group, respectively. In the control group, all patients had distant and near stereopsis. The incidence of taking off one's glasses to see close objects was significantly higher in the BTXA-treated group than in the control group (P<0.05). The BTXA-treated group showed a smaller range of in-fusion (9.84±5.72)° than the control group (22.04±8.71)° (P<0.05). The near esotropia angle of the BTXA-treated group (17.08±11.98)^Δ was significantly smaller than the distant esotropia angle (19.07±11.68)^Δ (P<0.05). Ten months after injection, the diplopia and esotropia of most patients underwent improvements after treatment (P<0.05).

CONCLUSION

This study reveals that the accommodation function and the habit of near work without wearing spectacles are associated with near-work-related esotropia, while the length of time for near work and the onset time are independent of near-work-related esotropia. Additionally, BTXA injection therapy plays a vital role in relieving diplopia and restoring eye position.

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.].

Series of cases of acute acquired comitant esotropia in children associated with excessive online classes on smartphone during COVID-19 pandemic; digital eye strain among kids (DESK) study-3

Extra time of sitting in front of a digital device is required for e-learning by children during Corona virus (COVID-19) pandemic which can lead to many ocular problems including digital eye strain (DES). In view of increased incidence of DES in children, multiple studies had been conducted in central India to assess the eye strain in children due to excessive online classes as a research project named "Digital eye strain among kids (DESK) study." This study DESK-3 aimed to report series of cases of acute acquired comitant esotropia (AACE) in children attending online classes during COVID-19 pandemic. Children aged 6-18 years with recent onset of esotropia of < 1-month duration without any similar history in past presented in month of July-August 2020 at a tertiary children eye care hospital were evaluated. Data collection included age and gender of child, presence or absence of diplopia, visual acuity, duration of smartphone use, duration of online classes, angle of deviation for near and distance and cycloplegic refraction. Total eight children of AACE were included in the study. The mean age of children was 12.5 ± 4.2 years. All eight were males. The mean duration of smartphone use was 4.6 + 0.7 hours per day. All children were attending online classes > 4 hours per day on smartphone of average size 5.5 inches. Five children were emmetropic, one myopic, one pseudomyopic and one hyperopic. The angle of deviation for near and distance were 48.1 ± 16.4 PD and 49.3 ± 15.9 PD respectively with normal ocular motility. Seven children complained of horizontal diplopia in all gazes. Neurological examination and CT scan of brain and orbit was normal in all patients.  Two months before the lockdown only one case was identified as compared to eight during the lockdown. Prolonged near work during smart phone use for e-learning might lead to the development of AACE in children.

Binocular Accommodation and Vergence Dysfunction in Children Attending Online Classes During the COVID-19 Pandemic: Digital Eye Strain in Kids (DESK) Study-2

PURPOSE

To subjectively evaluate the degree of visual fatigue in children attending online classes during the coronavirus 2019 (COVID-19) pandemic and objectively evaluate accommodation and vergence dysfunction in these children.

METHODS

Children aged between 10 and 17 years with recent onset of asthenopia symptoms were included. Symptoms were evaluated using the Convergence Insufficiency Symptom Survey (CISS) questionnaire. A CISS score of 16 or greater was considered symptomatic. Binocular vergence and accommodation parameters were objectively evaluated. For ease of comparison, children were divided into two groups: children using digital devices for less than 4 hours/day and children using digital devices for 4 hours/day or more.

RESULTS

A total of 46 children with a mean age of 14.47 ± 1.95 years were evaluated. The mean duration of online classes during the COVID-19 pandemic was 3.08 ± 1.68 hours/day, which is higher than before the COVID-19 pandemic (0.58 ± 0.71 hours/day, P < .00001). The mean CISS scores were 21.73 ± 12.81 for children using digital devices less than 4 hours/day and 30.34 ± 13.0 for children using digital devices for 4 hours/day or more (P = .019). Mean near exophoria (P = .03), negative fusional vergence (P = .02), negative relative accommodation (P = .057), and accommodation amplitude (P = .002) were different between the two groups. The Spearman correlation between the symptomatic CISS score and the duration of online classes showed a linear association (coefficient r_s = 0.39; P = .007). In the multivariate analysis, only the duration of online classes longer than 4 hours was a significant risk factor (P = .07) for the symptomatic CISS score.

CONCLUSIONS

Online classes longer than 4 hours were more detrimental to abnormal binocular vergence and accommodation parameters than online classes shorter than 4 hours. [J Pediatr Ophthalmol Strabismus. 2021;58(4):224-231.].

Clinical Classification of Acquired Concomitant Esotropia

BACKGROUND

Classification and management of acquired concomitant esotropia is controversial. We sought to establish a simple clinical classification in order to determine in which cases further investigations in search of underlying pathologies are necessary.

PATIENTS AND METHODS

Observational retrospective study of the files of 175 consecutive patients examined in our unit between 2009 and 2018 for acute convergent strabismus. One hundred and nine patients were selected, after exclusion of infantile, incomitant, or mechanical esotropias, residual esotropias, and patients examined on a single occasion. All patients received a complete orthoptic and ophthalmological examination. We grouped the patients according to their common characteristics.

RESULTS

We established the following categories: 1. Acute esotropia of large angle (20 to 45 prism diopters [PD]), accompanied by mild hyperopia (mean 1.2 D) in children (n = 16) and moderate myopia (mean 3.7 D) in adolescents and adults (n = 13). 2. Decompensated micro-esotropia, which is distinguished from the other categories by the presence of abnormal retinal correspondence (n = 33). 3. Decompensated esophoria, with intermittent deviations of 5 to 30 PD, esotropia being compensated part of the time (n = 25). 4. Esotropia present only at a distance in patients over 50 years of age (n = 20). 5. Small-angle esotropia (< 15 PD) greater at a distance, associated with oculomotor cerebellar syndrome (n = 2). Complementary examinations (MRI or CT scan) were performed on 21 patients, leading to the discovery of a posterior fossa astrocytoma in a 4-year-old boy.

CONCLUSIONS

The recognition of decompensated micro-esotropia and esophoria, as well as distance esotropia of the elderly, avoids unnecessary additional investigations, which are indicated in any type of acute comitant strabismus if associated with any neurological sign or symptom (e.g., headaches, nausea, vertigo, imbalance, poor coordination, nystagmus, or papilledema). In the absence of neurological findings, there is no consensus about the indication of neuroimaging in large-angle acquired concomitant esotropia, but long-term follow-up of patients that do not undergo neuroimaging is strongly recommended in order to identify later occurring intracranial diseases. This is of particular importance with children.