The effect of optical correction on refractive development in children with accommodative esotropia

Comparison of Longitudinal Changes in Refractive Error of Hyperopic Children with or without Refractive Accommodative Esotropia

We investigated longitudinal changes in the spherical equivalent refractive error (SE) in hyperopic children with or without refractive accommodative esotropia (AccET). A total of 456 patients met the inclusion criteria: 190 (41.7%) in the hyperopic control group and 266 (58.3%) in the AccET group. All patients received at least 3 years of follow-up after spectacle prescription. Subgroups were divided according to age when spectacles were prescribed, presence of amblyopia, or initial SE. Longitudinal changes in SE in children with hyperopia showed a gradual decrease, although SE of younger children with AccET increased over the first 4 years and then decreased thereafter. SE in eye with higher SE was tended to decrease significantly in patient with Acc ET than hyperopic control group (group × time p = 0.015). Amblyopic eyes showed a greater decreased in SE compared with non-amblyopic eyes, but it was not statistically significant (p = 0.07). SE was significantly decreased in children with more hyperopia (≥ 3 D) compared with children with less hyperopia (<3 D) (p = 0.008). Emmetropization of hyperopia was faster in hyperopic patients without AccET and could be affected by the age of the initial spectacles prescription, initial amount of SE, or presence of amblyopia.

Long-term development of refractive error in refractive, nonrefractive and partially accommodative esotropia

Accommodative esotropia (AE) is a convergent deviation due to an excess of the convergence linked to the innervational stimulus for accommodation and it is usually associated to the presence of hyperopia. The development of hyperopia over time has been widely described but the lack of comparative analysis among accommodative esotropia subtypes, does not allow to verify the existence of different developmental patterns. In this study we aimed to describe the long term changes of refractive error in patients affected by accommodative esotropia as a function of the strabismus type: refractive (RAE), non-refractive (NRAE) and partially accommodative esotropia (PAE). The medical records of 66 patients (24 RAE, 22 PAE, 20 NRAE), who wore the full correction of their cycloplegic refraction error during the entire follow up period, were retrospectively reviewed. Mean outcome was the analysis of the variations, among groups, of refractive error over time; differences between mild (≤3.00D) and high (≥5.00D) hyperopia, effects of amblyopia and relationship with AC/A ratio were also investigated. All patients were followed up from approximately 4 years of age to 20, with mean follow up of 16.06±0.29 years. Our results described similar non-linear trend of refractive error development among groups. The initial increase of hyperopia (up to 7–8 years) was followed by a decreasing trend persisting up to adulthood (approximately 20 years of age). During this period, spherical equivalent decreased at a lower mean annual rate in patients affected by RAE (-0.07D) compared to other groups (NRAE -0.11D, p = 0.003 and PAE 0.13D, p = 0.002). In all groups, however, significant amount of hyperopia was found at last examination; indeed the observed difference in SE values from baseline to the end of follow up, was not significant (RAE: +0.27D, 95% C.I. -0.49 to +1.04D, p = 0.472; PAE: -0.69D, 95% C.I. -1.67 to +0.28D, p = 0.154; NRAE: -0.39D, 95% C.I. -1.11 to +0.34D, p = 0.278). AC/A ratio, amblyopia and amount of initial hyperopia appeared to have no significant role in longitudinal change of the refractive error. In conclusion, this study provides a complete overview, from childhood to adulthood, of refractive error development in different form of accommodative esotropia.

The effects of partial and full correction of refractive errors on sensorial and motor outcomes in children with refractive accommodative esotropia

PURPOSE

To investigate the effects of partial and full correction of refractive errors on sensorial and motor outcomes in children with refractive accommodative esotropia (RAE).

METHODS

The records of pediatric cases with full RAE were reviewed; their first and last sensorial and motor findings were evaluated in two groups, classified as partial (Group 1) and full correction (Group 2) of refractive errors.

RESULTS

The mean age at first admission was 5.84 ± 3.62 years in Group 1 (n = 35) and 6.35 ± 3.26 years in Group 2 (n = 46) (p = 0.335). Mean change in best corrected visual acuity (BCVA) was 0.24 ± 0.17 logarithm of the minimum angle of resolution (logMAR) in Group 1 and 0.13 ± 0.16 logMAR in Group 2 (p = 0.001). Duration of deviation, baseline refraction and amount of reduced refraction showed significant effects on change in BCVA (p < 0.05). Significant correlation was determined between binocular vision (BOV), duration of deviation and uncorrected baseline amount of deviation (p < 0.05). The baseline BOV rates were significantly high in fully corrected Group 2, and also were found to have increased in Group 1 (p < 0.05). Change in refraction was - 0.09 ± 1.08 and + 0.35 ± 0.76 diopters in Groups 1 and 2, respectively (p = 0.005). Duration of deviation, baseline refraction and the amount of reduced refraction had significant effects on change in refraction (p < 0.05). Change in deviation without refractive correction was - 0.74 ± 7.22 prism diopters in Group 1 and - 3.24 ± 10.41 prism diopters in Group 2 (p = 0.472). Duration of follow-up and uncorrected baseline deviation showed significant effects on change in deviation (p < 0.05).

CONCLUSIONS

Although the BOV rates and BCVA were initially high in fully corrected patients, they finally improved significantly in both the fully and partially corrected patients. Full hypermetropic correction may also cause an increase in the refractive error with a possible negative effect on emmetropization. The negative effect of the duration of deviation on BOV and BCVA demonstrates the significance of early treatment in RAE cases.

Accommodative ET-High AC/A Ratio Esotropia: The Case for Glasses

BACKGROUND AND PURPOSE

There is a continuing debate as to whether the patient optically correctable at distance to within 8 prism diopters of perfect alignment requires treatment for persisting overconvergence at near, and if treatment is indicated, what it should be.

PATIENTS AND METHODS

For the patient whose misalignment at distance is reduced to 8 or fewer prism diopters, my preference is for the full cycloplegic correction plus a bifocal in the first prescription, to discourage virtually all accommodation initially, with pull back later.

RESULTS

Review of several reports indicates a continued lack of consensus on whether this causes disuse weakening of accommodation and premature presbyopia. Recent studies found that prolonged convergence tone at near can result in anatomic and physiologic alterations in the medial rectus muscles that threaten a satisfactory distance alignment as well, despite relief of the accommodative demand. Hypoaccommodative esotropia resembles the high AC/A variety.

CONCLUSION

Spontaneously improving over-convergence at near is not likely to occur in the hypoaccommodating patient either with observation alone or with surgery. I reserve surgery for the over-convergence at near for the unusual case of an extremely high distance-near disparity, and for the teenager or adult not showing likelihood that the condition will resolve.

Treatment of Amblyopia and Amblyopia Risk Factors Based on Current Evidence

PURPOSE

Amblyopia is a leading cause of low vision and warrants timely management during childhood. We performed a literature review of the management of amblyopia and potential risk factors for amblyopia.

METHODS

Literature review of the management of amblyopia and risk factors for amblyopia.

RESULTS

Common amblyopia risk factors include anisometropic or high refractive error, strabismus, cataract, and ptosis. Often a conservative approach with spectacles is enough to prevent amblyopia. However, surgery may be necessary to clear the visual axis or align the eyes.

CONCLUSION

Amblyopia risk factors should be managed early. Though amblyopia treatment is more likely to be successful at a younger age, those who are older but treatment-naïve may still respond to treatment. Promoting binocular or dichoptic experiences may be the future direction of amblyopia management.

Prognostic factors for stereopsis in refractive accommodative esotropia

OBJECTIVE

To determine the prognostic factors affecting stereoacuity in patients with refractive accommodative esotropia (RAE) according to the results of long follow- up period.

METHODS

We reviewed the charts of 70 patients with RAE between the years 1985-2014. Patients were classified into three groups. G-1: Stereoacuity score 40 second/arc. G-2: Stereoacuity score >40 second/arc (50-3000). G-3: No binocular vision. Initiation age of RAE, duration of deviation, refractive error, amblyopia, amblyopia treatment, anisometropia, visual acuity, family history, angle of deviation for distance and near at each group and the prognostic factors affecting stereoacuity were analyzed.

RESULTS

The mean initiation age of RAE was 2.7±1.5 years, the mean age at first visit was 6.4±4.2 years. The mean follow up time was 7.3±4.4 years. Seven patients had 40 second/arc, 48 patients had 50 to 3000 second/arc stereoacuity, 15 patients had no binocular vision. Mean deviation for near was statistically higher in group 2 and 3. Visual acuity levels were higher in group 1 and 2 and was statistically significant. Low visual acuity (p=0.001, 0.008), higher angle of deviation at near (p=0.01), increased duration of deviation (p=0.01), presence of amblyopia (p=0.001) and irregularity of amblyopia treatment (p=0.01) were significantly related with poor stereoacuity.

CONCLUSION

According to the prognostic factors low stereoacuity was mostly related with amblyopia as a result the late presentation of the patients in seeking care. Appropriate treatment as full refractive correction and amblyopia treatment during the RAE is important for development of good stereopsis. Also angle of deviation at near and duration of deviation can be a useful predictor for poor stereoacuity levels.

Accommodative esotropia who needs spectacles for good ocular alignment after refractive shift below +2.00 diopters

Purpose

The aim of this study is to investigate the clinical characteristics of patients diagnosed with refractive accommodative esotropia (RAE) whose refractive errors were gradually reduced to below +2.00 diopters (D) during follow-up but use of spectacles was still required for maintenance of good ocular alignment.

Methods

We conducted a retrospective review of the medical records of patients diagnosed with RAE from 1995 to 2011. Patients were divided into 2 groups according to their ocular alignment at the last visit. Inclusion criteria were hyperopia ≥+2.00 D detected with cycloplegic refraction at the initial visit, which then became mild hyperopia (<+2.00 D) or myopia during follow-up, with more than 5 years of follow-up.

Results

A total of 92 patients met the inclusion criteria. Twenty-six patients showed persistent esotropia (≥10 prism diopters [PD]) without spectacles (group A) and 66 patients showed good ocular alignment (<10 PD) without spectacles (group B) at the last visit. No statistically significant differences in the spherical equivalent of the refractive errors at the initial and last visit were observed between the two groups. A significantly lower number of positive responses on the Lang I stereotest was observed in group A (n = 1, 3.8%) compared to group B (n = 22, 33.3%) (p = 0.003). There were increasing trends toward group A with worsening stereoacuity measured by the Stereo Fly Stereotest between the two groups (p = 0.016, linear by linear association). The results of the Lang I test, Stereo Fly Stereotest, and duration between the onset of esotropia and prescribing spectacles showed a significant association with the discontinuation of spectacles in the univariate logistic analysis.

Conclusions

Stereoacuity showed more significant associations than refractive errors in RAE with refractive error <+2.00 D but still required spectacles for maintenance of good ocular alignment. The prompt treatment of accommodative esotropia at the onset of esotropia is important for the discontinuation of spectacles.

Relationship between lenticular power and refractive error in children with hyperopia

Objectives

To evaluate the contribution of axial length, and lenticular and corneal power to the spherical equivalent refractive error in children with hyperopia between 3 and 13 years of age, using noncontact optical biometry.

Methods

There were 62 children between 3 and 13 years of age with hyperopia (+2 diopters [D] or more) who underwent automated refraction measurement with cycloplegia, to measure spherical equivalent refractive error and corneal power. Axial length was measured using an optic biometer that does not require contact with the cornea. The refractive power of the lens was calculated using the Sanders-Retzlaff-Kraff formula. Single regression analysis was used to evaluate the correlation among the optical parameters.

Results

There was a significant positive correlation between age and axial length (P = 0.0014); however, the degree of hyperopia did not decrease with aging (P = 0.59). There was a significant negative correlation between age and the refractive power of the lens (P = 0.0001) but not that of the cornea (P = 0.43). A significant negative correlation was observed between the degree of hyperopia and lenticular power (P < 0.0001).

Conclusion

Although this study is small scale and cross sectional, the analysis, using noncontact biometry, showed that lenticular power was negatively correlated with refractive error and age, indicating that lower lens power may contribute to the degree of hyperopia.