Cerebellar astrocytoma manifesting as isolated, comitant esotropia in childhood

Still an Unsolved Question: The Place of Cranial Magnetic Resonance Imaging in Acute Acquired Concomitant Esotropia

PURPOSE

The aim of this study was to collect further data to estimate the risk of relevant intracranial pathology and thereby better assess the need for cranial imaging in children with acute acquired comitant esotropia (AACE). To date, there is still not enough literature on this topic to enable a consensus on the diagnostic algorithm.

METHODS

We analyzed data from patients with convergent strabismus who received cranial imaging via magnetic resonance imaging (MRI). Twenty-one patients received a cranial MRI for the diagnostic evaluation of AACE. The age range was from 2 to 12 years, and the mean age at the time of diagnosis was 5.5 years. Of these patients, only one exhibited insignificant MRI findings, with no therapeutic consequences.

CONCLUSIONS

Our data add further evidence that AACE without neurological findings or other ophthalmologic anomalies might not be an indication for cranial MRI as a diagnostic screening tool.

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).

Yearly changes in cases of acute acquired comitant esotropia during a 12-year period

PURPOSE

The number of patients with acute acquired comitant esotropia (AACE) has been increasing in Japan. The purpose of this study was to investigate the changes in the number and characteristics of patients with AACE examined in our institution during a 12-year period.

METHODS

We retrospectively reviewed the medical records of patients with AACE aged < 30 years who suddenly developed diplopia or esotropia and were examined in Hyogo College of Medicine Hospital from January 2008 to December 2021. We investigated the association of the yearly changes in the number of patients with the age category, refractive error category, AACE type, esotropia type, and use or nonuse of smartphones.

RESULTS

The total number of patients with AACE was 171, and this number significantly increased each year (Pearson correlation coefficient, 0.9450; p < 0.0001). Significant increases were found among students in junior high school and beyond, patients with myopia, patients with Bielschowsky type AACE, and patients with basic esotropia (p < 0.0001 for all). We compared two age groups, elementary school students and below versus junior high school students and above, and found that the rate of increase was significantly higher in the junior high school students and above (estimate, 1.951; p < 0.0001), and the non-myopia group and myopia group and found that the rate of increase was significantly higher in the myopia group (estimate, 1.891; p < 0.0001). Excessive use of smartphones was confirmed in 82 of 133 patients, and the rate of the increase in the number of patients with AACE was significantly greater among patients with than without excessive use of smartphones (estimate, 1.098; p = 0.0009).

CONCLUSION

This study confirmed a significant increase in the number of patients with AACE in recent years. The excessive use of smartphones may be associated with the increase in AACE.

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).

Clinical characteristics and risk factors of acute acquired concomitant esotropia in last 5 years: a retrospective case-control study

OBJECTIVES

A remarkable increase in the number and proportion of surgical patients with acute acquired concomitant esotropia (AACE) has been noted in our hospital in recent years. We aimed to analyse the clinical characteristics and associated risk factors of this increasing number of strabismus in last 5 years.

METHODS

Medical information was obtained in 62 AACE patients and 73 orthotropic patients as control group completed questionnaires and examination items from March 2017 to May 2020. Data included age at onset, refractive error, angle of deviation, binocular vision, eye care habits, and optical quality of spectacles.

RESULTS

Of the 62 AACE patients, the mean ± standard deviation age at onset was 25.3 ± 8.5 years, with 47 (75.8%) cases showing myopia, 9 (14.5%) showing emmetropia, and 6 (9.7%) showing hypermetropia. Among the AACE patients, 35 (56.5%) performed >8 h of close work daily and 36 (58.1%) reported late-night use of digital devices. When compared with the control group, the risk factors identified for AACE included long durations of close work (odds ratio [OR], 11.72; 95% confidence interval [CI], 3.53-38.91; P < 0.001) and immoderate late-night use of digital devices (OR, 14.29; 95% CI, 4.10-49.72; P < 0.001).

CONCLUSION

Our study demonstrated that young adults accounted for the majority of the growing number of individuals affected by AACE in last 5 years, and excessive close visual activities and immoderate late-night use of digital devices were found to be associated with the onset of AACE.

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.

Clinical characteristics and risk factors of acute acquired concomitant esotropia in last 5 years: a retrospective case-control study

OBJECTIVES

A remarkable increase in the number and proportion of surgical patients with acute acquired concomitant esotropia (AACE) has been noted in our hospital in recent years. We aimed to analyse the clinical characteristics and associated risk factors of this increasing number of strabismus in last 5 years.

METHODS

Medical information was obtained in 62 AACE patients and 73 orthotropic patients as control group completed questionnaires and examination items from March 2017 to May 2020. Data included age at onset, refractive error, angle of deviation, binocular vision, eye care habits, and optical quality of spectacles.

RESULTS

Of the 62 AACE patients, the mean ± standard deviation age at onset was 25.3 ± 8.5 years, with 47 (75.8%) cases showing myopia, 9 (14.5%) showing emmetropia, and 6 (9.7%) showing hypermetropia. Among the AACE patients, 35 (56.5%) performed >8 h of close work daily and 36 (58.1%) reported late-night use of digital devices. When compared with the control group, the risk factors identified for AACE included long durations of close work (odds ratio [OR], 11.72; 95% confidence interval [CI], 3.53-38.91; P < 0.001) and immoderate late-night use of digital devices (OR, 14.29; 95% CI, 4.10-49.72; P < 0.001).

CONCLUSION

Our study demonstrated that young adults accounted for the majority of the growing number of individuals affected by AACE in last 5 years, and excessive close visual activities and immoderate late-night use of digital devices were found to be associated with the onset of AACE.

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.

Acquired, Comitant, Non-Accommodative Esotropia (ANAET): Evaluation, Treatment, and Prognosis

Children presenting in later childhood with isolated, acquired, comitant non-accommodative esotropia (ANAET) form an unusual clinical group whose evaluation, treatment, and prognosis are unclear. We identified 9 such patients with no evidence of intracranial pathology whose outcomes following standard bilateral medial rectus recessions were excellent.

Visual and ocular motor outcomes in children with posterior fossa tumors

PURPOSE

To describe the clinical characteristics and visual and ocular motor outcomes of a large cohort of pediatric patients treated for tumors of the posterior cranial fossa.

METHODS

The medical records of all patients with posterior fossa tumors evaluated by the ophthalmology services at two large tertiary care academic hospitals between 2005 and 2011 were reviewed retrospectively. Data abstracted for each study patient included demographic information, presenting signs and symptoms, pathologic diagnosis, and results of the most recent ophthalmology examination.

RESULTS

A total of 139 patients were included. Visual outcomes were categorized as "good" (bilateral acuity of 20/20-20/40) in 101 patients (72.7%), "fair" (<20/40-20/200 in one or both eyes) in 12 patients (8.6%), or "poor" (<20/200 in one or both eyes) in 9 patients (6.5%). Patients with medulloblastoma and ependymoma had a significantly greater risk of a poor or fair visual outcome than those with juvenile pilocytic astrocytoma (both P < 0.05), independent of age and sex. Thirty-two patients (23.0%) developed nystagmus, and 59 patients (42.4%) developed strabismus. Twenty-four patients (17.3%) underwent eye muscle surgery for persistent strabismus.

CONCLUSIONS

The majority of patients had good visual outcomes, although ocular motor abnormalities were common. Tumor type was a significant risk factor for permanent vision loss.

Outcomes after the surgery for acquired nonaccommodative esotropia

Background

To analyze the surgical outcomes for patients diagnosed with acquired nonaccommodative esotropia (ANAET).

Methods

In this retrospective study, the medical records of 35 patients who had undergone the surgery for ANAET with a postoperative follow-up period of 6 months or more were reviewed. The main outcome measures were postoperative esodeviation angle, final success rate, and factors affecting surgical outcome. Surgical success was considered to be an alignment within 8 prism diopters (PD) at distance and near.

Results

The preoperative mean esodeviation angles were 37.3 ± 13.7 PD at distance and 38.6 ± 16.6 PD at near. The postoperative mean esodeviation angles at distance were as follows: 4.2 PD at day 1, 4.0 PD at month 1, 3.9 PD at month 3, 4.9 PD at month 6, 4.7 PD at year 1, and 4.8 PD at final follow-up. There was no statistically significant difference in angle of esodeviation between the initial postoperative period (day 1 to month 6) and the final follow-up day (p > 0.05). The surgical success rate at final follow-up was 65.7% (23/35). Among the 12 patients for whom the surgery failed, 9 (24.3%) showed esotropia and 3 (8.1%) exotropia of more than 8 PD. Six patients (16.2%) underwent reoperation (4 for esotropia and 2 for exotropia). There was no factor influencing surgical outcome (p > 0.05).

Conclusions

The surgical outcome in patients with ANAET was relatively favorable: the final success rate was 65.7% and the reoperation rate was 17.1%.

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.

Acute Acquired Concomitant Esotropia: Clinical features, Classification, and Etiology

Acute acquired concomitant esotropia (AACE) is a rare, distinct subtype of esotropia. The purpose of this retrospective study was to describe the clinical characteristics and discuss the classification and etiology of AACE.Charts from 47 patients with AACE referred to our institute between October 2010 and November 2014 were reviewed. All participants underwent a complete medical history, ophthalmologic and orthoptic examinations, and brain and orbital imaging.Mean age at onset was 26.6 ± 12.2 years. Of the 18 cases with deviations ≤ 20 PD, 16 presented with diplopia at distance and fusion at near vision at the onset of deviation; differences between distance and near deviations were < 8 PD; all cases except one were treated with prism and diplopia resolved. Of the 29 cases with deviations > 20 PD, 5 were mild hypermetropic with age at onset between 5 and 19 years, 16 were myopic, and 8 were emmetropic with age at onset > 12 years; 24 were surgically treated and 5 cases remained under observation; all 24 cases achieved normal retinal correspondence or fusion or stereopsis on postoperative day 1 in synoptophore; in 23 cases diplopia or visual confusion resolved postoperatively. Of the 47 cases, brain and orbital imaging in 2 cases revealed a tumor in the cerebellopontine angle and 1 case involved spinocerebellar ataxia as revealed by genetic testing.AACE in this study was characterized by a sudden onset of concomitant nonaccommodative esotropia with diplopia or visual confusion at 5 years of age or older and the potential for normal binocular vision. We suggest that AACE can be divided into 2 subgroups consisting of patients with relatively small versus large angle deviations. Coexisting or underlying neurological diseases were infrequent in AACE.

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.

Esophoria or esotropia in adulthood: a sign of cerebellar dysfunction?

Convergent strabismus is a common diagnosis in early childhood, when it is mostly considered benign. If it develops later in life, strabismus can, however, be a sign of neurological disease. In these cases the underlying pathophysiological mechanisms are largely unknown. In this retrospective case-control study we analyzed the neuro-ophthalmological examination reports of 400 adult patients who presented at the German Center for Vertigo and Balance Disorders to determine an association between ocular misalignment and cerebellar dysfunction. Patients with cerebellar signs (i.e., cerebellar ataxia and/or cerebellar ocular motor signs) had a 4.49 (95 % CI [1.60; 13.78]) times higher frequency of ocular misalignment and specifically a 13.3 (95 % CI [3.80; 55.73]) times increased frequency of esophoria/esotropia (ESO) during distant gaze than patients without cerebellar dysfunction. ESO when looking into the distance was associated with saccadic smooth pursuit, dysmetria of saccades, and downbeat nystagmus (DBN) (χ (2) test, p < 0.0001 for all associations). Patients with cerebellar dysfunction also showed mildly impaired eye abduction (χ (2) test, left eye and right eye: p < 0.0001), associated with horizontal gaze-evoked nystagmus (χ (2) test, p < 0.0001). The association of ESO and DBN implicates a pathophysiological involvement of the cerebellar flocculus, while the association with dysmetric saccades suggests involvement of the oculomotor vermis. This is compatible with animal studies showing that the pathways of the flocculus/posterior interposed nucleus and vermis/nucleus fastigii are both involved in vergence movements and static binocular alignment. From a clinical point of view, a newly diagnosed esophoria/esotropia only during distant gaze may be a sign of a cerebellar disease.

Long-term follow-up of acquired nonaccommodative esotropia in a population-based cohort

PURPOSE

To describe the clinical characteristics and long-term outcomes of children diagnosed over a 30-year period with acquired nonaccommodative esotropia (ANAET).

DESIGN

Retrospective chart review of a population-based cohort.

PARTICIPANTS

All pediatric (<19 years of age) residents of Olmsted County, Minnesota, who were diagnosed with ANAET from January 1, 1965, to December 31, 1994.

METHODS

The medical records of all potential patients identified by the resources of the Rochester Epidemiology Project were reviewed.

MAIN OUTCOME MEASURES

Incidence, clinical characteristics, and long-term motor and sensory outcomes of children with ANAET.

RESULTS

A total of 174 children were diagnosed during the 30-year period, yielding an incidence of 1 in 287 live births. The median age at diagnosis for the 174 patients was 4.0 years (range, 10 months to 18.2 years), and 61% (107) were male (P = 0.009). Although 11% (8/75) of those queried were diplopic, none of the 174 was subsequently diagnosed with an intracranial lesion. During a mean follow-up of 10.9 years (range, 0 days to 37 years), 127 patients (73%) underwent strabismus surgery (mean, 1 surgery; range, 0-3 surgeries). Among the 127 patients who underwent surgery, the median final stereoacuity was 3000 seconds of arc, including 8 patients (6.3%) with ≥ 50 seconds of arc. Patients who were older (>44 months) at ANAET diagnosis (P = 0.005) and without amblyopia at their initial examination (P < 0.001) were more likely to achieve excellent final stereopsis.

CONCLUSIONS

In this population-based cohort, ANAET occurred in 1 in 287 children and was more prevalent among male children. Although diplopia was relatively common, none of the children were found to have an intracranial malignancy. Most patients achieved good motor and sensory outcomes, with the best results among those with a later onset of their deviation and no amblyopia.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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.

Double Vision Worth a Double Take

An 18-year-old girl presented with an acute acquired comitant esotropia. Investigation showed a brainstem glioma. Discussion of types of acute acquired comitant esotropia, differential diagnosis and neurologic work-up is given. Review of the literature involving acute acquired comitant esotropia is provided.

Acute onset concomitant esotropia: sensorial evaluation, prism adaptation test, and surgery planning

BACKGROUND AND OBJECTIVE

Acute acquired concomitant esotropia is a rare form of strabismus that usually presents during infancy or early childhood with diplopia and minimal refractive error. The aim of this study was to evaluate the response to the prism adaptation test in a group of normosensorial patients with acute acquired concomitant esotropia and to determine its predictive value for surgical outcome.

PATIENTS AND METHODS

Six patients (median age, 11 .5 years) with acute acquired concomitant esotropia underwent the prism adaptation test by applications of Fresnel press-on and prismatic lenses. The sensorial condition of each patient had been evaluated with theTNO stereopsis test, the Irvine test, Bagolini striated glasses, and the Worth four-dot test during the prism adaptation test, when maximum compensation angle was achieved, and after surgery. In all patients, surgery was performed based on the angle of the squint after the prism adaptation test. Patients were observed 1 day, 3 months, 6 months, and 1 year after surgery.

RESULTS

An increase in the angle of the squint occurred in all patients during prism adaptation. The maximum value was obtained in the same amount of time whether with prisms of increasing power or by direct application of the final value of the prisms. The final prismatic value (target angle) was always the same.

CONCLUSIONS

The accuracy of the patients' selection confirmed the existence of highly reproducible compensational movements to the prismatic correction in not only patients with anomalous retinal correspondence but also normosensorial patients. Prism adaptation test results were useful in these patients because of their high predictive value for the surgical treatment.

Cerebellar astrocytoma presenting with acute esotropia in a 5 year-old girl. Case report

We encountered a 5-year-old girl with acute onset of alternating, comitant esotropia in the absence of diplopia and other neurologic findings. She did not have any refractive error and seen bilateral papilledemas in fundus examination, magnetic resonance imaging (MRI) of the head was performed. A large cerebellar astrocytoma and moderate hydrocephalus was identified and successfully resected. The onset of comitant esotropia in a child can be the first sign of a cerebellar tumor without any other neurologic signs and symptoms.

Acquired nonaccommodative esotropia in childhood

PURPOSE

Acquired nonaccommodative esotropia (ANAET) in childhood is reported to occur infrequently and is often associated with an underlying neurologic or neoplastic disorder. The primary objective of this study was to ascertain the prevalence and clinical characteristics of this form of childhood esotropia.

METHODS

A cohort of all children younger than 11 years with esotropia from a predominantly rural Appalachian region was prospectively identified from August 1, 1995, through July 31, 1998. The age at onset, family history of strabismus, perinatal and medical history, ophthalmologic findings, and surgical results were reviewed for all patients with ANAET.

RESULTS

Twenty-three (10.4%) of 221 consecutive children with esotropia were diagnosed with ANAET compared with 12 (5.4%) diagnosed with congenital esotropia. The median age at esotropia onset for the 23 children with ANAET was 31.4 months (range, 8-63 months) with a mean initial angle of esotropia of 24 PD. Although at least 2 children presented with diplopia, none of the 23 patients were known to have harbored intracranial tumors or other lesions of the central nervous system during the follow-up period. Fourteen of the 19 patients who underwent surgery attended follow-up visits for at least 6 months after their last surgical procedure: 13 were within 8 PD or less of orthotropia, whereas the final patient had persistent esotropia. Twelve of the 13 patients within 8 PD of orthotropia demonstrated some level of stereopsis, including 2 children with bifoveal fixation. Two (10.5 %) of the 19 operated patients later required a low hyperopic spectacle correction to control their deviation.

CONCLUSIONS

ANAET was more prevalent than congenital esotropia in this cohort of children with esotropia. This clinically distinct form of strabismus typically begins between 1 and 5 years of age and appears to be infrequently associated with underlying disease. The angle of deviation is relatively small and early surgical correction is more likely to achieve bifoveal fixation for these patients than for those with congenital esotropia.

Acute acquired comitant esotropia: a prospective study

PURPOSE

To define the clinical characteristics of patients presenting with acute onset esotropia and features suggestive of possible underlying central nervous system pathology. To assess the prognosis for the return of binocular function and to consider the most appropriate management.

METHODS

A prospective clinical study was carried out of all patients presenting to the department of paediatric ophthalmology at a university teaching hospital over the period January 1994 to April 1997. Each patient underwent a full ophthalmological examination (including assessment of sensory status). All patients were referred to a paediatric neurologist for examination and CT and/or MRI scan.

RESULTS

Ten patients presented during the study period. Uncorrected hypermetropia and/or decompensated monofixation syndrome were the commonest aetiological factors. One patient was found to have a cerebellar tumour. In 5 patients prescription of the full hypermetropic correction alone was sufficient to restore binocularity. Five patients required bilateral medial rectus recession. Binocular function was restored in all cases--in 5 cases with bifoveal fusion.

CONCLUSION

Decompensation of a pre-existing phoria or monofixation syndrome appears the commonest aetiology. Prescription of the full hypermetropic correction found at cycloplegic refraction forms an essential part of initial management. No single clinical sign can reliably indicate the rare patient harbouring a tumour. A high index of suspicion should be maintained and neuro-imaging considered in the absence of expected findings such as hypermetropia or fusion potential or in the presence of atypical features or neurological signs.

Acquired binocular horizontal diplopia

Binocular horizontal diplopia is an important symptom that may foretell or help localize and characterize various neurologic and neuromuscular disorders. An appropriate evaluation requires a careful and complete neuro-ophthalmic history and examination. This review focuses on the differential diagnosis of binocular horizontal diplopia.

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.