Recurrence of cyclic esotropia after surgical correction

A Conservative Approach by Unilateral Maximal Single-Muscle Recession Surgery for the Treatment of Cyclic Esotropia

Purpose

Cyclic esotropia (alternate-day squint) is a poorly understood form of strabismus that mostly occurs at younger pediatric ages. It demonstrates classically a 48-hour cycle with 24 hours of manifest esotropia and 24 hours of orthotropia, which is conventionally managed by bilateral or unilateral 2-muscle surgery. We aimed to report a child with cyclic esotropia who was surgically treated by a conservative unilateral 1-muscle approach.

Methods

Case report.

Results

A 3.5-year-old girl presented to the strabismus department with an intermittent esodeviation for 2 years that became cyclic in the last 3 months. The diagnosis of primary classical cyclic esotropia was made after seeing her multiple times on different days. The girl was emmetropic bilaterally, had normal visual acuities in both eyes, and high-angle right esodeviation (45-50 ^Δ ) with normal laboratory and MRI results. Unilateral maximal single-muscle recession of the right medial rectus was performed, and the child was followed up for 9 months. The girl developed excellent alignment after the surgery both at distance and near without cyclic pattern, and near-normal stereopsis (by animals: 100 sec. of arc) with binocularity was reached. The girl did not experience under- or overcorrection nor have a recurrence postoperatively.

Conclusion

This is the first report of "one eye single-muscle" surgery for high-angle cyclic esotropia. Conservative unilateral medial rectus recession seems to be sufficient to permanently block the circadian rhythm and restore binocular fusion and stereopsis.

Cyclic strabismus: what measured angle of strabismus should guide surgery?

Purpose: Here we aimed to describe seven pediatric patients with cyclic strabismus and report the outcome of their surgical treatment.Methods: Seven children with acquired esotropia manifesting in a 48-h cycle were included in the study. Four of them were boys, and three of them were girls. All cases had a large angle of deviation and associated suppression on the esotropic day and small angle of deviation with fusion on the other day. A complete ocular motility examination was performed for seven consecutive days. For all cases, we planned strabismus surgery according to the amount of deviation on the strabismic day. Postoperatively, the deviation angles were recorded at the first week, first month, and third month. Later, the patients were examined at 3-month intervals.Results: The mean age at presentation was 4.42 ± 3.69 years (1-12 years). The mean angle of esotropia at near fixation preoperatively was 36.4 ± 14.9 pd (prism dioptre) (20-60 pd) on the esotropic day. The mean angle of esotropia on the esotropic day at distance fixation was 32.1 ± 6.9 pd (20-40 pd). The mean follow-up period was 18.4 ± 5.5 months (12-25 months). The mean duration of esotropia before surgery was 11.1 ± 9.4 months (3-29 months). Following surgery, orthophoria within 10 pd was achieved and maintained in all cases.Conclusion: When treating children with cyclic strabismus, the best surgical results can be achieved when surgery is planned according to the amount of deviation on the strabismic day.

Role of Botulinum Toxin Type A in Cyclic Esotropia: A Long-Term Follow-up

PURPOSE

To describe two patients with childhood cyclic esotropia 8 and 9 years after they underwent botulinum toxin type A treatment to report its long-term outcome.

METHODS

Two patients with sudden onset cyclic esotropia aged 2 and 4 years were included. Botulinum toxin type A injections were performed on the appropriate muscles.

RESULTS

The first patient was a 2-year-old boy with left dominant alternating esotropia on a cyclic basis. His strabismus ranged from 25 to 45 prism diopters (PD) at near and distance. A botulinum toxin type A injection into the left medial rectus muscle revealed orthotropia at near and distance with a stereopsis of 60 seconds of arc (arcsec). During the 9 years of follow-up, he remained stable. The second patient was a 4-year-old girl who complained of double vision and strabismus. Her deviation was 40 PD at near and 35 PD at distance on a cyclic pattern. She became orthotropic with glasses after a bimedial botulinum toxin A injection. During the 8 years of follow-up, she remained stable with a stereo-acuity of 120 arcsec.

CONCLUSIONS

Considering the consecutive and recurrent deviations with surgical treatment in previous reports, botulinum toxin type A is an appropriate first-line option for the treatment of cyclic deviations, despite its limitations. The results suggest that botulinum toxin type A is an effective method to break the cycle in cyclic esotropia permanently. [J Pediatr Ophthalmol Strabismus. 2019;56(6):360-364.].

A Cluster of Cyclic Esotropia: White Matter Changes on MRI and Surgical Outcomes

PURPOSE

To report a series of patients with cyclic esotropia, their surgical outcomes, and incidental findings.

METHODS

The medical records of five patients with cyclic esotropia presenting over 17 months were reviewed. Age at onset, ocular and motility examinations, brain magnetic resonance imaging (MRI), acetylcholine receptor antibodies, thyroid hormone levels and antibodies, calendars documenting phases, surgical treatments, postoperative alignment, and fusion were documented.

RESULTS

Three boys and two girls presented at 3 to 4 years old in 2015-2016. Typical periodicity followed a 48-hour cycle. Duration of cycling varied from 1 to 9 weeks. Mean maximum deviation was 37 prism diopters (PD) of esotropia (range: 35 to 40 PD of esotropia). All patients had normal laboratory studies. MRIs showed an abnormal white matter signal in the frontal lobes in 2 patients and were normal in the others. Bilateral medial rectus recessions for the maximum angle were successful in 4 patients at a minimum follow-up of 13 months; the other patient required reoperation for a residual esotropia. Fusion was present in 4 patients preoperatively and all postoperatively. Stereopsis was stable or improved in all postoperatively.

CONCLUSIONS

This is the first report of frontal white matter changes occurring in the setting of cyclic esotropia. MRI with attention to frontal lobe white matter might be considered in the work-up of cyclic esotropia to determine if this is a common finding. Bilateral medial rectus recessions can restore fusion in these patients. [J Pediatr Ophthalmol Strabismus. 2019;56(3):178-182.].

Cyclic esotropia with development of a high accommodative convergence to accommodation ratio after surgery for intermittent exotropia

PURPOSE

To report a patient with cyclic esotropia with a high accommodative convergence to accommodation (AC/A) ratio after surgical correction of intermittent exotropia who was found to have bilateral anomalous medial rectus muscle insertion sites.

METHOD

A 5-year-old girl developed intermittent esotropia on alternating days after undergoing bilateral lateral rectus recessions for correction of intermittent exotropia. Alternate prism and cover measurement of ocular alignment and binocular function was assessed on consecutive days. Surgical correction was performed for the full amount measured on a "crossed" day.

RESULT

On "straight" days, her eyes were orthotropic with normal binocular vision. Examination on "crossed" days revealed a left esotropia of 75 prism diopters (PD) at near fixation and 40 PD at distance fixation in primary gaze without fusion or stereopsis. The patient underwent bilateral medial rectus recessions in conjunction with posterior fixation sutures (MRP). During surgery, the distance from the limbus to the medial rectus muscle insertion was 3.5 mm bilaterally. Postoperatively, the cycle was broken, and the esotropia disappeared with no recurrence at the latest follow-up at 12 months.

CONCLUSION

MRP is an effective procedure for correction of cyclic esotropia with a high AC/A ratio. Strabismus surgeons should design surgical strategies based on preoperative measurement of deviations at all distances and the anatomy of muscle insertions in patients with cyclic esotropia.

Accommodative esotropia decompensated to cyclic esotropia in a 6-year-old boy

Cyclic esotropia, characterized by alternating intervals of esotropia and orthotropia, is associated with decreased vision, trauma, strabismus surgery, or central nervous system disease. We report a 6-year-old boy who developed cyclic esotropia after 3 years of successful control of accommodative esotropia with full hyperopic correction. After bilateral medial rectus recession, he remained esophoric with good binocular function and stereoacuity. To our knowledge, this is the first report of accommodative esotropia decompensating into a cyclic esotropia.

Cyclic (alternate day) vertical deviation--possible forme fruste of ocular neuromyotonia

PURPOSE

Cyclic ocular deviations are relatively uncommon and are seldom seen in adults. We report 3 adult patients with cyclic hypotropia that has clinical characteristics similar to neuromyotonia, suggesting a possible common etiology.

METHODS

Three consecutive patients with 48-hour cyclic hypotropia underwent full neuro-ophthalmologic, oculoplastics, and orthoptic evaluations as well as appropriate medical and neurologic studies. Examinations were arranged on consecutive days on multiple visits to document the cyclic pattern.

RESULTS

All 3 patients had sustained contraction of a vertically acting extraocular muscle lasting 24 hours and demonstrated characteristics of ocular neuromyotonia. The contraction was absent for the next 24 hours. Two of the patients had thyroid eye disease; the third patient had unilateral ophthalmoparesis and had subsequent frameless robotic radiosurgery for a cavernous sinus schwannoma. Regular cycles lasting 6, 9, or 14 months were documented by all 3 patients. In 2 patients, treatment with carbamazepine and gabapentin effectively reduced or eliminated the cycle. The cyclic deviation in the third patient resolved spontaneously.

CONCLUSIONS

On the basis of the response of these patients to membrane-stabilizing medications and the behavior noted as the cycle broke each day, we propose that cyclic vertical strabismus and ocular neuromyotonia may be related conditions with similar underlying physiology.

Consecutive cyclic exotropia after surgery for adult-onset cyclic esotropia

Cyclic esotropia--periods of esotropia alternating with periods of orthotropia, most commonly on a 48-hour cycle--is a rare condition seen mostly in children. Surgical correction of the maximum deviation generally corrects the esotropia without resulting in alternating periods of exotropia, as might be expected if the periodicity continued postoperatively. Unlike cyclic esotropia in children, the few reported adult cases have often been associated with severe acquired monocular visual impairment; however, the response to surgical treatment is reported to be the same as that in children. We report here an exception, in which an adult patient developed cyclic exotropia after surgical correction of her acquired cyclic esotropia.

Consecutive exotropia following surgically corrected cyclic esotropia

INTRODUCTION

Cyclic esotropia is a rare form of strabismus consisting of regular intervals of esotropia alternating with periods of orthophoria in a rhythmic/cyclic manner. In the vast majority of cases, surgery appears to permanently correct the esotropia, with no sequelae after years of follow-up. We report a case of consecutive exotropia in a patient five years after bilateral medial rectus recessions for cyclic esotropia.

METHODS

A case report involving review of a clinical chart.

RESULTS

A two-year-old male presented with right esotropia and mild amblyopia. He was treated with patching and following resolution of the amblyopia he developed a cyclic esotropia. Surgical correction was performed for the full amount measured on a "manifest" day. Following the surgery, he was orthophoric and demonstrated binocular vision. He remained stable for five years, and then returned with occasional diplopia and an intermittent exotropia.

CONCLUSION

Cyclic esotropia is a rare disorder of ocular motility that spontaneously appears and disappears at regular intervals. After surgical correction, the deviation disappears and recurrence of esotropia is very infrequent. We present the first reported case of consecutive exotropia following surgical correction of a cyclic esotropia.

Cyclic exotropia associated with retinitis pigmentosa

PURPOSE

To report the occurrence of cyclic exotropia in a patient with retinitis pigmentosa.

METHODS

A 31-year-old man presented with cyclic exotropia of the left eye of 4 years duration that alternated every 24 h. A detailed ophthalmologic examination was performed.

RESULTS

The patient showed an orthotropia and a comitant left exotropia of 30 prism diopters at distance and 25 prism diopters at near in the primary position on an exotropic day with a cycle of 48 h. A fundoscopic examination showed bone spicule formation and arteriolar narrowing, and electroretinography showed no response in either eye. A Goldmann visual field examination showed a central island in both eyes.

CONCLUSIONS

Cyclic exotropia may occur in patients with retinitis pigmentosa, an association that to the best of our knowledge has not been previously reported in the English ophthalmic literature. Cyclic exotropia is an unusual association with retinitis pigmentosa.