Weaning children with accommodative esotropia out of spectacles: a pilot study

Comparison of photorefraction by Plusoptix A12 and cycloplegic autorefraction in children

BACKGROUND

Plusoptix photoscreeners are capable of measuring refractive errors of children from 1 meter distance, without cyloplegia. We aimed to compare refractive data obtained from the newest version of Plusoptix (model 12) with cycloplegic autorefraction.

METHODS

We examined 111 consecutive children aged 3-7 years first by Plusoptix A12C under manifest condition and subsequently for cycloplegic refraction by Topcon KR-1 tabletop autorefractometer. Sphere, spherical equivalent, cylinder and axis of astigmatism measured by the two methods were analyzed to determine correlation, agreement and differences.

RESULTS

Binocular examination of 111 children aged 4.86±1.27 years revealed good agreement between refractive data obtained by Plusoptix and cycloautorefraction, according to Bland-Altman plots. Significant (p < 0.001) and strong correlation was found between all refractive measurements (Pearson's r value of 0.707 for sphere, 0.756 for pherical equivalent, and 0.863 for cylinder). Plusoptix mean sphere, spherical equivalent and cylinder were 1.22, 0.56, and -1.32 D, respectively. Corresponding values for cycloautorefraction were 1.63, 1.00, and -1.26 D. The difference between axis of cylinder measured by the two methods was < 10° in 144 eyes (64.9%).

CONCLUSIONS

Considering the significant agreement and correlation between Plusoptix photoscreener and cycloplegic autorefraction, the need for cycloplegic drops in refractive examination of children may be obviated. The mean difference between cylinder measurements are considerably trivial (0.06 D), but sphere is approximately 0.4 D underestimated by Plusoptix compared to cycloautorefraction, on average.

Accommodative esotropia: An outcome analysis from a tertiary center in Oman

AIM

The aim of this study is to determine the outcome of accommodative esotropia (ET) and influencing factors in young Omani children.

SUBJECTS AND METHODS

In this retrospective cohort, children diagnosed with accommodative ET who had followed up in a tertiary hospital from 2006 to 2011 were identified. Parameters studied included cycloplegic refraction and its change with time, ocular alignment, binocularity, visual acuity (VA), amblyopia, and requirement for surgery.

RESULTS

A total of 51 patients were identified. Twenty-four patients were diagnosed with fully accommodative ET (FAET) and 27 with partially accommodative ET (PAET). The mean (± standard deviation [SD]) age of onset and reporting were 2.6 (±1.58) and 3.2 (±1.84) years in the two groups, respectively. The mean (SD) cycloplegic refraction at presentation was 4.50 (±1.66) in the FAET group and 3.65 (±1.67) in the PAET group. Anisometropia was present in 28% of patients. The mean follow-up period was 4.9 years. The following were detected in the final visit. A reduction in amblyopia from 43% to 6% of patients, binocularity in 75% of patients, and a mean increase of 0.64 (±1.3) D in cycloplegic refraction from the first visit (P = 0.005). The mean angle of deviation at near and distance was 29.86 (±15.21) and 17.80 (±10.14) prism diopters, respectively, in FAET patients and 30.15 (±14.83) and 29.53 (±15.53), respectively, in PAET patients. Thirty-seven percent of the PAET patients underwent surgery within 5 years from diagnosis. All participants in this cohort continued to wear glasses in the last follow-up visit.

CONCLUSION

Most children with refractive accommodative ET have an excellent outcome in terms of VA and binocular vision. The PAET group was characterized by delayed reporting, the presence of anisometropia, and lower hypermetropia. Further study is required to determine the possibility of weaning glasses in FAET patients.

Diagnosis and management of accommodative esotropia

BACKGROUND

Accommodative esotropia is the most common form of childhood strabismus presenting to optometric practice. Functional and cosmetic outcomes are often excellent but depend on accurate diagnosis, urgent and correct initial management and careful follow-up.

CASE REPORTS

We present several cases that highlight important aspects of the clinical care of accommodative esotropia. The first patient was mismanaged by undercorrection of hypermetropia, but was later accurately diagnosed to have accommodative esotropia and was subsequently managed successfully with full hypermetropic correction alone. The second patient had an accommodative esotropia with amblyopia. The third patient used a near addition to correct a residual near esotropia.

CONCLUSIONS

The published evidence and these cases make several points regarding assessment, diagnosis and management of esotropia. Assessment must aim to reach a diagnosis based on aetiology, as the aetiology of esotropia has a significant impact on management decisions and prognosis.

Assessment of Refractive Error Changes and Factors for Decompensation in Patients With Fully Accommodative Esotropia

PURPOSE

To determine the factors affecting the risk of deterioration and evaluate the refractive error change in patients with fully accommodative esotropia.

METHODS

Patients diagnosed as having fully accommodative esotropia (esotropic deviation that started before 7 years of age and less than 8 to 10 prism diopters [PD] of esotropia with full hyperopic correction and/or bifocals) were included in this retrospective population-based cohort study. Refractive error changes were recorded. For comparisons, patients were divided into two groups: nondecompensated fully accommodative esotropia group and decompen-sated fully accommodative esotropia group.

RESULTS

Two hundred and twenty-three patients met the inclusion criteria. The mean follow-up time was 5.94 ± 0.31 years (range: 5 to 8 years). The changes in spherical equivalent in the younger than 7 years, 7 to 12 years, and 12 to 17 years groups were statistically significant (P < .001). The decrease of hypermetropia was 0.13 diopters/year between 7 and 12 years and 0.06 diopters/year between 12 and 17 years. Forty-one of 223 patients (18.4%) discontinued spectacle therapy during the follow-up period. Hyperopic error and presence of amblyopia were lower, whereas visual acuity level and presence of near-distance disparity were higher in the spectacle discontinuation group (P < .001, .007, .01, and 0.01, respectively). Deterioration of fully accommodative esotropia occurred in 30 of 223 patients (13.5%). Boys were more likely to require strabismus surgery (P = .32). The mean age at presentation, esotropia angle with and without refractive correction at both near and distance fixation, near distance disparity, and inferior oblique overaction were significantly higher in patients with decompensated fully accommodative esotropia.

CONCLUSIONS

Hyperopic error increased from the initial level until 7 years of age, followed by a myopic shift thereafter. Few children had resolution of fully accommodative esotropia and could discontinue spectacle therapy. Children with male gender, higher esotropia angle, older age at presentation, near-distance disparity, and inferior oblique overaction experienced a greater deterioration of the fully accommodative esotropia. [J Pediatr Ophthalmol Strabismus. 2020;57(4):217-223.].

Esodeviation without correction for tapering hyperopia in refractive accommodative esotropia

OBJECTIVE

To investigate clinical features for prescription of tapered hyperopia in patients with refractive accommodative esotropia (RAET).

METHODS

The clinical features in patients with RAET who began tapering of hyperopia were analyzed. Within a range that can sustain corrected visual acuity and stereoacuity, patients were prescribed for tapered hyperopic correction by 0.25-diopters (D) interval, up to a maximum of 1.0 D. At every visit, visual acuity and esodeviation with and without correction, amount of tapered hyperopia, and near stereoacuity were measured.

RESULTS

One hundred and six patients were enrolled in this study. The follow-up period was 3.1 ± 0.2 years and frequency of visits was 6.3 ± 0.6. Tapering hyperopia was initiated at 6.1 ± 2.9 years, and baseline refraction was 7.6 ± 1.5 D. The esodeviation without correction was 24.3 ± 8.5 prism diopters (PD), and median near stereoacuity was 400 arc sec. The median amount of tapered hyperopia at visit was 0.5 D. At the final visit, there were no significant deteriorations in visual acuity, esodeviation with correction, or near stereoacuity (p > 0.05, all). The amount of tapered hyperopia was positively correlated with correction and the reduced esodeviation without correction (p = 0.03).

CONCLUSIONS

Esodeviation without correction should be considered for tapering hyperopia for patients with RAET. Esodeviation without correction can be easily measured, and its decline may be used as a clinical indicator for tapering hyperopia.

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.

The Effect of Hyperopic Laser in Situ Keratomileusis on Refractive Accommodative Esotropia

PURPOSE

To evaluate the efficacy of laser in situ keratomileusis (LASIK) for discarding spectacles and simultaneously correcting ocular alignment in patients with refractive accommodative esotropia.

METHODS

LASIK was performed on 20 eyes of 10 patients (mean age, 24.3 years; range, 11 to 43 years) using a Technolas 217C excimer laser. The target refraction was emmetropia. Visual acuity (uncorrected and best-corrected), refractive error, and ocular alignment were recorded before and after LASIK. Minimum follow-up was 12 months.

RESULTS

The mean preoperative uncorrected and corrected angle of deviation was 37.1 prism diopters (PD) (range, 17 to 80; standard deviation (SD), 19.8)) and 14.74 PD (range, 0 to 50; SD, 12.9) of esotropia, respectively, which changed to 7.2 PD (range, 0 to 50; SD, 15.78) without correction postoperatively (p=0.005). Of 20 eyes, 15% lost one line of best-corrected visual acuity, 10% gained two lines, and 75% showed no change.

CONCLUSIONS

LASIK could be considered an alternative treatment for patients with refractive accommodative esotropia with intolerance to glasses and contact lenses.

Changes in refractive error in patients with accommodative esotropia after being weaned from hyperopic correction

BACKGROUND

To determine the long-term changes in refractive error and ocular alignment in patients with accommodative esotropia (AET) who were able to discontinue wearing hyperopic glasses because of emmetropisation.

METHODS

Forty-seven patients with refractive AET who achieved emmetropisation and orthotropia without hyperopic glasses and were followed up for at least 3 years were enrolled. All of the patients had been prescribed the weakest possible glasses for best corrected vision. Refractive error and ocular alignment were analysed after the cessation of hyperopic glasses use.

RESULTS

The mean length of follow-up was 5.7±3.21 years after successful weaning from hyperoptic glasses. The mean spherical equivalent (SE) of the refractive error was -1.01±1.53 dioptres (D), and the mean esotropia (ET) was 1.0±8.70 Δ at the final visit. Myopia developed in 55.3% of all patients. The mean myopic progression rate per year was -0.19±0.23 D/year. Forty-one patients (87.2%) showed orthotropia; in addition, three of the patients (6.4%) developed ET, and three (6.4%) developed exotropia (XT). The six patients who had ET or XT all showed myopia. Two of the three patients who developed ET underwent surgery. Both patients initially had a low degree of hyperopia and a high ratio of accommodative convergence to accommodation (AC/A). The initial hyperopia correlated with the SE refractive error at the final follow-up (p<0.001).

CONCLUSIONS

When emmetropisation occurs early in patients with AET, it is necessary to note the development of myopia and the deterioration of ocular alignment.

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.

The maximal tolerable reduction in hyperopic correction in patients with refractive accommodative esotropia: a 6-month follow-up study

PURPOSE

To investigate the optimal amount of safe under-correction in patients with refractive accommodative esotropia.

DESIGN

Prospective noncomparative interventional case series.

METHODS

Patients with refractive accommodative esotropia wore trial glasses based on cycloplegic refraction, then -0.25 diopters (D) of minus sphere lenses were placed on both lenses of the trial glasses and the deviation was measured. Minus spheres of -0.25 D were continuously added until the angle of deviation increased; the minus spheres added just before the deviation increase were defined as the maximal tolerable amount of under-correction. A total of 38 patients were prescribed under-corrected spectacles up to -1.5 D and followed for 6 months.

RESULTS

Thirty-one patients underwent the maximal tolerable amount of under-correction and 7 underwent -1.5 D of under-correction. A mean -0.89 D of under-correction was performed. We observed no deterioration in visual acuity, stereoacuity, or fusional ability during the follow-up period in any of the patients. Small increase in the angle of deviation of 2 prism diopters was noted in 2 patients. The mean spherical equivalent refractive error of both eyes (P = .012) and age of onset (P = .006) showed strong positive correlations with the maximal tolerable amount of under-correction.

CONCLUSIONS

A reduction in hyperopic correction by the maximal tolerable amount of under-correction was performed without notable short-term side effects. The spherical equivalent refractive error and age of onset appear to be useful clinical indices in determining the appropriate amount of under-correction.

Longitudinal changes in refractive error of children with infantile esotropia

Aim

The aim of this study was to quantify changes in refractive status over time in children with infantile esotropia and to analyse a number of clinical factors associated with infantile esotropia to determine how they may affect emmetropisation.

Methods

Longitudinal cycloplegic refraction data were collected for 5-12 years from 143 consecutive children enrolled in a prospective study of infantile esotropia by 6 months of age. Changes in refractive error with age were summarized with descriptive statistics and the influence of amblyopia, undercorrection of hypermetropia, accommodation, and binocular factors on emmetropisation were evaluated by ANOVA and t-tests.

Results

Most had low to moderate hypermetropia on the initial visit (55% had <+3.00 D). While the initial refractive error is similar to normative data, the rapid decrease in hypermetropia that characterizes normal development during the first 9 months of life is absent in children with infantile esotropia. After 9 months of age, children with infantile esotropia follow a developmental course that is similar to the normative course; there is little change in hypermetropia during years 1-7, followed by a decline of approximately -0.5 D/yr beginning at age 8 years. None of the clinical factors examined had a statistically significant effect on the course of refractive changes with age.

Conclusions

Children with infantile esotropia exhibit a different pattern of refractive development than that seen in normative cohorts. The long term changes in refraction observed in children with infantile esotropia suggest that there is a need for long-term clinical follow-up of these children.

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

PURPOSE

To compare the effects of partial or full hyperopic optical correction on refractive development in children with accommodative esotropia.

METHODS

Children with accommodative esotropia and hyperopia >3 D were enrolled in this prospective, nonrandomized study. All children underwent an ophthalmologic examination, including refraction, keratometry, and axial length. Subjects were divided into either full- or partial-correction groups according to their tolerance of the full hyperopic correction. Routine follow-up examinations were performed for at least 3 years. The main outcome measure was cycloplegic spherical equivalent at the end of the study period.

RESULTS

A total of 120 children were enrolled. The mean cycloplegic spherical equivalent, corneal radius, and axial length were significantly (p < 0.05) different between the first and last visits in both groups. However, when all the measurements were adjusted for the age difference between groups, only the difference in axial length between the first and last visits was statistically significant (p < 0.05). Partial or full optical correction in age-adjusted cohorts with accommodative esotropia did not result in a significant change in refraction, keratometry, or axial length between the first and last visits.

CONCLUSIONS

Partial or full optical correction of hyperopia had similar effects on refractive development of the eye in children with accommodative esotropia. Treatment of accommodative esotropia in children older than age 5 did not appear to impair refractive development.

Longitudinal changes in the cylinder power of children with accommodative esotropia

PURPOSE

To assess the longitudinal changes in the cylindrical refractive errors of children with accommodative esotropia according to the age when glasses were prescribed.

METHODS

Refractive errors were followed longitudinally for 120 children with accommodative esotropia for a mean of 4.4 +/- 2.5 years. Cycloplegic refractions were performed using an autorefractor. The refractive data were analyzed for three groups of children based on their age at the time spectacles were prescribed.

RESULTS

In all three age groups, the mean cylinder power was initially about 1.0 D. Over time, the mean cylinder power in the two younger age groups gradually increased by about 0.5 D. In the oldest age group, the mean cylinder power remained relatively unchanged with some suggestion of a decrease in the later years. A regression model demonstrated the statistical significance of both the age when spectacles were prescribed (p < 0.0001) and the interaction of age and time after spectacles were prescribed (p = 0.0034).

CONCLUSIONS

Longitudinal changes in cylinder power for children with accommodative esotropia vary according to their age when spectacle wear is initiated. The greatest increase in cylinder developed in the children who were youngest when initially treated.

Longitudinal changes in the spherical equivalent refractive error of children with accommodative esotropia

AIM

To assess the longitudinal changes in the spherical equivalent (SE) refractive errors of children with accommodative esotropia as a function of the age when glasses were prescribed.

METHODS

Refractive errors were followed longitudinally for 126 children with accommodative esotropia for a mean of 4.4 (SD 2.5) years. Cycloplegic refractions were performed using an autorefractor for older children and retinoscopy for younger children. The refractive data were analysed for three groups of children based on their age at the time spectacles were prescribed.

RESULTS

The initial SE refractive error was age dependent (<2 years, 5.1 (1.9) D; 2-<4 years, 4.2 (1.9) D; 4-8 years, 3.8 (1.7) D). Children in all age groups had an initial increase in their SE refractive error, followed by a later decrease; however, the greatest decrease occurred in the patients in the oldest age group. The SE refractive error peaked 1 year after spectacles were prescribed for the children 4-8 years of age versus 6 years after spectacles were prescribed for the children less than 2 years of age.

CONCLUSION

Longitudinal changes in SE refractive error for children with accommodative esotropia vary as a function of their age when spectacle wear is initiated.

Amblyopia characterization, treatment, and prophylaxis

Amblyopia has a 1.6-3.6% prevalence, higher in the medically underserved. It is more complex than simply visual acuity loss and the better eye has sub-clinical deficits. Functional limitations appear more extensive and loss of vision in the better eye of amblyopes more prevalent than previously thought. Amblyopia screening and treatment are efficacious, but cost-effectiveness concerns remain. Refractive correction alone may successfully treat anisometropic amblyopia and it, minimal occlusion, and/or catecholamine treatment can provide initial vision improvement that may improve compliance with subsequent long-duration treatment. Atropine penalization appears as effective as occlusion for moderate amblyopia, with limited-day penalization as effective as full-time. Cytidin-5'-diphosphocholine may hold promise as a medical treatment. Interpretation of much of the amblyopia literature is made difficult by: inaccurate visual acuity measurement at initial visit, lack of adequate refractive correction prior to and during treatment, and lack of long-term follow-up results. Successful treatment can be achieved in at most 63-83% of patients. Treatment outcome is a function of initial visual acuity and type of amblyopia, and a reciprocal product of treatment efficacy, duration, and compliance. Age at treatment onset is not predictive of outcome in many studies but detection under versus over 2-3 years of age may be. Multiple screenings prior to that age, and prompt treatment, reduce prevalence. Would a single early cycloplegic photoscreening be as, or more, successful at detection or prediction than the multiple screenings, and more cost-effective? Penalization and occlusion have minimal incidence of reverse amblyopia and/or side-effects, no significant influence on emmetropization, and no consistent effect on sign or size of post-treatment changes in strabismic deviation. There may be a physiologic basis for better age-indifferent outcome than tapped by current treatment methodologies. Infant refractive correction substantially reduces accommodative esotropia and amblyopia incidence without interference with emmetropization. Compensatory prism, alone or post-operatively, and/or minus lens treatment, and/or wide-field fusional amplitude training, may reduce risk of early onset esotropia. Multivariate screening using continuous-scale measurements may be more effective than traditional single-test dichotomous pass/fail measures. Pigmentation may be one parameter because Caucasians are at higher risk for esotropia than non-whites.

Childhood esotropia

PURPOSE

To review the most recent studies on childhood esotropia, and to summarize recent changes in treatment approach.

RECENT FINDINGS

Constant, large-angle esotropia present in the first few months of life may be suitable for early surgery. Earlier surgical intervention, within the first several months of onset, is associated with better sensory outcomes. Similar findings are true for accommodative esotropia; children treated within the first 4 months of constant esotropia have better outcomes. Refractive surgery has been used successfully in adult patients to treat accommodative esotropia.

SUMMARY

New developments pertaining to infantile esotropia have helped clarify the pathophysiology of the condition and the best treatment approaches. Abnormal binocular visual input early in life contributes to poor outcomes in both infantile and accommodative esotropia.