The incidence, clinical features, and management of essential infantile esotropia in the United Kingdom. A British Ophthalmology Surveillance Unit (BOSU) study

BACKGROUND/OBJECTIVES

A national study was undertaken through the British ophthalmology surveillance unit (BOSU) to determine the incidence, presenting features and management of essential infantile esotropia (EIE) in the UK.

METHODS

Data from a prospective national observational study of newly diagnosed EIE presenting to clinicians in the United Kingdom over a 12-month period were collected. Cases with a confirmed diagnosis by a clinician of a constant, non-accommodative esotropia ≥20 prism dioptres (PD), presenting at ≤12 months, with no neurological or ocular abnormalities were identified through BOSU. Follow-up data were collected at 12 months.

RESULTS

A total of 57 cases were reported giving an incidence of EIE of 1 in 12,828 live births. The mean age of diagnosis and intervention were 7.05 ± 2.6 months (range 2-12) and 14.7 ± 4.9 months (range 6.5-28.1), respectively. Management was surgical in 59.6%, botulinum toxin alone in 22.8%, and 17.5% were observed. The preoperative angle of esotropia was smaller in the observation group (P = 0.04). The postoperative angle of esotropia was not statistically significant between botulinum toxin or surgery (P = 0.3), although the age of intervention was earlier in the botulinum group (P = 0.007). Early intervention (before 12 months of age) did not influence the post-intervention motor outcomes between 0 and 10 prism dioptres of esotropia (P = 0.78).

CONCLUSIONS

The incidence of EIE in the UK is considerably lower than reported in other population-based studies. The preferred method of treatment was surgical with earlier intervention in those treated with botulinum toxin. An early age of intervention (<12 months) did not influence motor outcomes.

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.

Demographic and clinical characteristics of age-related distance esotropia

BACKGROUND

Age-related distance esotropia (ARDE), is an acquired, small, comitant esodeviation that is greater at distance than at near. It occurs in older adult patients without a history of neurological event or prior strabismus. It has been observed more frequently in White adults than in other racial groups. The purpose of this study was to assess the demographic and clinical characteristics of patients with ARDE presenting at a tertiary neuro-ophthalmology clinic.

METHODS

In this retrospective study, ICD-9/10 (ICD-9 378.85 and ICD-10 H51.8) codes were used to identify all patients with ARDE from 2005 to 2020 seen in a single tertiary neuro-ophthalmology clinic. ARDE was defined as esotropia greater at distance than near with associated clinical signs of adnexal tissue laxity. Patients with history or findings compatible with other etiologies of strabismus, such as thyroid eye disease, neuromuscular disorders, sensory deviations, sudden onset of diplopia, and high myopia, as well as those with prior strabismus surgery, were excluded.

RESULTS

A total of 89 patients (59 females [66%]) met inclusion criteria. Mean patient age was 76.6 years. All patients were White except for a single patient of African descent. Mean follow-up time was 25.2 months. Mean esodeviation at distance on presentation was 6.6Δ. Of the 87 patients electing nonsurgical treatment, 80 achieved remission of diplopia symptoms with prism therapy alone. Of the 89 patients, 59 had no neuroimaging.

CONCLUSIONS

ARDE in our neuro-ophthalmology clinic population was diagnosed almost exclusively in older White adults. Prism therapy was effective for a majority of our patients.

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.

Association between Gestational Age, Birth Weight, Parental Age at Childbirth, Mode of Delivery, and Infantile Esotropia

SIGNIFICANCE

This study investigated the potential perinatal risk factors associated with infantile esotropia in a Chinese population, including advanced parental age at childbirth and mode of delivery. The findings may be significant in developing better intervention strategies for infantile esotropia.

PURPOSE

This study aimed to investigate the associations between gestational age, birth weight, parental age at childbirth, mode of delivery, family history of strabismus, and infantile esotropia in the Chinese population.

METHODS

Ninety-nine patients with infantile esotropia and 117 control subjects were enrolled between March 2018 and March 2021. Detailed questionnaires were administered to parents to collect relevant information. Univariate and multivariate logistic regression models were used to identify possible risk factors of infantile esotropia. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated.

RESULTS

Infantile esotropia was associated with low birth weight (<2500 g; OR, 4.235; 95% CI, 1.460 to 12.287; P = .008) and emergency cesarean delivery (OR, 2.230; 95% CI, 1.127 to 4.413; P = .02).

CONCLUSIONS

The findings suggest that low birth weight and emergency cesarean deliveries are risk factors for infantile esotropia, highlighting a need for collaborative care between obstetricians, pediatricians, and vision care providers.

Prevalence and clinical characteristics of age-related distance esotropia

Age-related distance esotropia (ARDET) is characterized by an esodeviation greater at distance than near in older aged patients and generally managed with prism spectacles or surgery. The purpose of this study is to describe the prevalence, clinical characteristics, and natural history of age-related distance esotropia in a defined population. The medical records of all adult (≥19 years of age) residents of Olmsted County, Minnesota, diagnosed with an esodeviation at least 2 prism diopters (PD) greater at distance than near, from 1 January 1985, through 31 December 2004, were retrospectively reviewed. Seventy-three (9.7%) of 751 new cases of adult-onset strabismus were diagnosed with age-related distance esotropia during the 20-year period. The mean age of onset was 70 years (range, 19 to 93 years) and 48 (65.8%) were female (p = .007). The mean angle of esodeviation was 7.6 (range, 2 to 20) prism diopters (PD) at distance and 0.4 (range, 10 PD of XT to 12 PD of ET) PD at near. The Kaplan-Meier rate of progression, as defined by a ≥ 6 prism diopter (PD) increase in esotropia, was 50% by 15 years after diagnosis. Half of the patients had hypertension, while one-third had coronary artery disease or other cardiac comorbidities. Age-related distance esotropia comprised 1 in 10 adults with new-onset strabismus in this population and was significantly more common among women. Hypertension and cardiovascular disease may be risk factors for this form of strabismus, and approximately half of the patients worsened over a 15-year period.

Changes in refractive status of amblyopic patients with partially refractive esotropia

PURPOSE

To investigate the changes in refractive status of amblyopic patients with partially refractive esotropia (PAET).

MATERIALS AND METHODS

Amblyopic patients with PAET were enrolled. Non-amblyopic patients with full refractive accommodative esotropia (RAET) were included in the study as a control group. Preoperative and postoperative best-corrected visual acuity (BCVA), spherical equivalent (SE), astigmatism, stereoacuity, and deviations at near and distance were evaluated and statistically compared within the study group. Mean BCVA, SE, astigmatism were compared between the two groups.

RESULTS

The patient and the control groups were composed of 58 eyes of 29 patients per group. There were statistically significant differences between pre- and postoperative mean astigmatism and SE between the patient and control groups. The mean astigmatism was higher in amblyopic eyes when compared with the eyes in the control group (P:0.009). During the follow-up period, changes in SE and astigmatism were not different between groups.

CONCLUSION

The mean SE and astigmatism were changed in both amblyopic patients with PAET and non-amblyopic patients with RAET during the follow-up period. This suggested that neither amblyopia nor strabismus surgery has an effect on refractive status in patients with PAET.

Comparison of surgical dose response between divergence insufficiency esotropia and non-accommodative esotropia without divergence insufficiency

Background

The study compared the surgical dose-response relationship for divergence insufficiency esotropia (DIE) and non-accommodative esotropia without divergence insufficiency (non-DIE).

Methods

We carried out a retrospective review of a group of patients with DIE and non-DIE who underwent recession surgery of the medial rectus muscle in both eyes. Linear regression analysis compared surgical dose–response between the two groups.

Results

In the 15 patients with DIE, the mean preoperative ocular deviation at distant fixation was 25 prism diopters (PD), compared with 3 PD postoperatively. In the 38 non-DIE patients, the mean preoperative ocular deviation was 28 PD, compared with 3 PD postoperatively. The average surgical dose–response was 1.56 PD/mm in the DIE group and 2.91 PD/mm in the non-DIE group (p < 0.001).

Conclusions

Surgical dose–response was significantly lower in DIE patients than in non-DIE patients. Augmented MR recession surgery could be regarded as an effective treatment option for patients with DIE. Further study with a larger sample and long-term follow-up is needed to seek the proper extent of surgery in these patients.

Visual Complications of Pediatric Posterior Fossa Tumors: Analysis of Outcomes

OBJECTIVE

Visual abnormalities are common among children with posterior fossa tumors, resulting from disruption of ocular afferent and efferent systems due to the tumor or surgery. This study describes the visual complications and outcomes associated with these tumors.

METHODS

Clinical and radiographic data of patients who underwent index surgery for resection of posterior fossa tumor from 2007 to 2016 were reviewed. Descriptive statistics, univariate, and multivariate regression were performed to assess factors contributing to visual acuity and postoperative strabismus.

RESULTS

There were 182 patients who underwent posterior fossa craniotomy for neoplasm were included. Ophthalmologic symptoms were the fourth most common presenting complaint; initial ophthalmologic examination was abnormal in 40% of patients. Evaluation of visual acuity demonstrated a good outcome in 88% of patients following treatment. The most common postoperative oculomotor finding was esotropia (29%) which resolved spontaneously in more than half of patients. A good outcome was obtained in all patients who underwent surgery for esotropia. Hypertropia was noted in 14% of the cohort and less than half resolved spontaneously; less than half undergoing strabismus surgery for hypertropia had a good outcome. Multivariate analysis confirmed the association between cerebellar mutism and postoperative esotropia and hypertropia. Clinically significant pathological nystagmus was seen in 8% of the cohort.

CONCLUSIONS

Our results indicate a good visual outcome in the majority of pediatric patients undergoing resection of posterior fossa tumors. Ophthalmologic complications should be appropriately evaluated and addressed to allow for the best possible vision to survivors of posterior fossa tumors.

Prevalence of esophoria in concussed patients

PURPOSE

To assess the prevalence of esophoria at near in concussed patients in a neuro-optometric private practice setting.

METHODS

A retrospective analysis was performed involving a chart review in a neuro-optometric, private practice setting of consecutive patients with a medical diagnosis of concussion from January 1st 2016 to December 31st 2016. A total of 71 patients were included in the analysis. All received a comprehensive vision examination, with a near vision emphasis. The near horizontal phoria was assessed with the cover test and the von Graefe test.

RESULTS

Approximately 30% of the patients with a medically based diagnosis of concussion exhibited esophoria at near, with good agreement (95%) between the two tests. Mean esophoria was 5.2 (SD=2.8) prism diopters (pd), with a range from 2pd to 14pd of esophoria. Convergence excess was diagnosed in 23%.

DISCUSSION

Near esophoria was found in nearly one-third of this practice-based sample of concussed patients. Thus, it was more common than typically believed to be the case. Two proposed oculomotor-based mechanisms related to these symptomatic esophoric patients included phoria decompensation and excessive accommodative vergence.

High prevalence of strabismic visual field expansion in pediatric homonymous hemianopia

If homonymous hemianopia develops in childhood it is frequently accompanied by strabismus. In some of these cases the strabismus increases the size of the binocular visual field. We determined how prevalent visual-field-expanding strabismus is in children who have homonymous hemianopia. Medical records were examined from 103 hemianopic patients with exotropia (XT) or esotropia (ET). For each participant, we determined whether their strabismus was in a direction that resulted in visual field expansion (i.e. left exotropia with left homonymous hemianopia). Ages at which hemianopia and strabismus were first noted were compared to determine which developed first. The prevalence of XT (24%) and ET (9%) with homonymous hemianopia were both much higher than in the general population (1.5% and 5%, respectively). More strabismic eyes pointed to the blind than seeing side (62 vs 41, 60% vs. 40%, p = 0.02). Exotropic eyes were five times more likely to point to the blind side than esotropic eyes (85% vs 15%). Strabismus, especially exotropia, is much more common in pediatric homonymous hemianopia than in the general population. The strabismus is significantly more often in a visual field-expanding direction. These results support an adaptive role for the strabismus. Patients with HH and exotropia or esotropia should be aware that their visual field could be reduced by strabismus surgery.

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.

[Study of strabismus in children 0-15 years followed in Lubumbashi, Democratic Republic of Congo: Analysis of epidemiological and clinical aspects]

Introduction

Le strabisme est défini comme un syndrome à double composante: motrice et sensorielle. Le but de ce travail est de décrire les aspects épidémiologiques et cliniques du strabisme chez l'enfant congolais de 0 à 15 ans dans la ville de Lubumbashi.

Méthodes

Il s'agit d'une étude descriptive longitudinale sur les aspects épidémiologiques et cliniques du strabisme chez l'enfant congolais de 0 à 15 ans dans la ville de Lubumbashi entre Décembre 2012 à Décembre 2013. Nous avons recueilli l’âge des patients, leur sexe, leur provenance, le type de strabisme, la réfraction, le fond d'oeil, les antécédents (hérédité) ainsi que le type de la déviation strabique observé sur 70 patients.

Résultats

Nous avons observé 70 cas de strabisme manifeste dont 31 cas (44,28%) étaient dans la tranche d’âge comprise entre 0 et 5 ans. L’âge moyen de nos patients était de 6,7 ans avec une prédominance du sexe féminin, soit 51,42%. Le strabisme était convergent dans 65,71%, divergent dans 30%, et vertical dans 4,28%. Les ésotropies représentaient 65 cas (92,85%), quatre cas (5,71%) avaient un antécédent familial de strabisme au premier degré de parenté, 21 cas (30%) au second degré de parenté, 45 cas (64,28%) n'avaient pas cet antécédent. L'oeil gauche était le plus dominé dans 30% des cas. Les facteurs favorisant le strabisme étaient inconnus dans 54 cas (77,14%). Le strabisme était secondaire à l'hypermétropie chez 32 patients (42,71%).

Conclusion

La fréquence du strabisme dans la ville de Lubumbashi chez les enfants âgés de 0 à 15 ans est de 0,50%. Comme dans la plupart des études sur le strabisme de l'enfant, c'est l’ésotropie qui est la déviation la plus commune.

Association between childhood strabismus and refractive error in Chinese preschool children

PURPOSE

To investigate the association between concomitant esotropia or concomitant exotropia and refractive error in preschool children.

METHODS

A population-based sample of 5831 children aged 3 to 6 years was selected from all kindergartens in a representative county (Yuhuatai District, Nanjing, Jiangsu Province) of Nanjing, China. Clinical examinations including ocular alignment, ocular motility, visual acuity, optometry, stereopsis screening, slit lamp examination and fundus examination were performed by trained ophthalmologists and optometrists. Odd ratios (OR) and 95% confidence intervals (95% CI) were calculated to evaluate the association of refractive error with concomitant esotropia and concomitant exotropia.

RESULTS

In multivariate logistic regression analysis, concomitant esotropia was associated independently with spherical equivalent anisometropia (OR, 3.15 for 0.50 to <1.00 diopter (D) of anisometropia, and 7.41 for > = 1.00 D of anisometropia) and hyperopia. There was a severity-dependent association of hyperopia with the development of concomitant esotropia, with ORs increasing from 9.3 for 2.00 to <3.00 D of hyperopia, to 180.82 for > = 5.00 D of hyperopia. Concomitant exotropia was associated with astigmatism (OR, 3.56 for 0.50 to 1.00 D of astigmatism, and 1.9 for <0.00 D of astigmatism), myopia (OR, 40.54 for -1.00 to <0.00 D of myopia, and 18.93 for <-1.00 D of myopia), and hyperopia (OR, 67.78 for 1.00 to <2.00 D of hyperopia, 23.13 for 2.00 to <3.00 D of hyperopia, 25.57 for 3.00 to <4.00 D of hyperopia, and 8.36 for 4.00 to <5.00 D of hyperopia).

CONCLUSIONS

This study highlights the close associations between refractive error and the prevalence of concomitant esotropia and concomitant exotropia, which should be considered when managing childhood refractive error.

Consecutive esotropia after surgery for intermittent exotropia: the clinical course and factors associated with the onset

BACKGROUND

To analyse the incidence and factors associated with the onset of consecutive esotropia after surgery for intermittent exotropia, and to investigate its clinical course.

METHODS

We retrospectively reviewed the medical records of 526 patients who had undergone exotropia surgery. We evaluated the risk factors for consecutive esotropia, defined as esodeviation ≥ 10 prism dioptres (PD) at postoperative month 1 or later. We also evaluated the clinical course of consecutive esotropia with non-surgical and surgical management.

RESULTS

Consecutive esotropia occurred in 26 (4.94%) of 526 patients. Divergence excess type of exotropia (p=0.036), amblyopia (p=0.046), bilateral lateral rectus recession (p=0.008), esodeviation of ≥ 20 PD at postoperative day 1 (p=0.000), younger age at diagnosis and surgery (p=0.010, p=0.003) and shorter duration from onset to surgery (p=0.039) showed significant association with consecutive esotropia. Among 26 patients, 15 became orthophoric with full-time patching ± Fresnel prism glasses. Eleven patients failed to show improvement of the esodeviation with non-surgical management; seven of these underwent surgery for sustained esotropia. Among these patients, five showed orthophoria at the final follow-up.

CONCLUSIONS

Divergence excess type, bilateral lateral rectus recession, amblyopia, younger age at diagnosis and surgery, shorter duration from onset to surgery and overcorrection of ≥ 20 PD at postoperative day 1 were predisposing factors for consecutive esotropia. In less than half the consecutive esotropia patients (11/26), esodeviation persisted with non-surgical management. Surgery for consecutive esotropia showed relatively favourable outcomes.

[Long-term changes in the ratio of exotropia to esotropia patients]

PURPOSE

To detect the long-term changes in the ratio of exotropia to esotropia in Japanese patients.

METHODS

The published annual reports of 3 children's hospitals in Japan were reviewed with respect to the number of new patients diagnosed with either exotropia or esotropia. The yearly ratios of exotropia to esotropia were calculated from the past 30-year data. The ratios were analyzed by using regression analysis to determine the long-term variability.

RESULTS

The ratio of exotropia to esotropia has increased in a parallel manner from less than 1.0 to nearly 2.0 in each of the 3 hospitals.

CONCLUSIONS

This gradual increase in the ratio might be attributed to the increasing number of exotropic children who consult a doctor according to the level of development in health care, or might be the result of declining occurrence of accommodative esotropia along with the decreasing number of hyperopic children. Further studies are required to determine the reason for this tendency.

Heterophoria and fusional convergence and divergence in preschool children

AIM

To determine the prevalence of heterophoria, fusional convergence and divergence values and the degree of relationship between heterophoria and fusional vergence in preschool children.

METHODS

For assessment of far and near heterophoria in 152 children aged 6-7, cover and prism cover tests were used. Far and near fusional vergences were measured by step vergence testing using prism bars.

RESULTS

Orthophoria (-tropia) with the average values of heterophoria around 0 PD (prism diopter) were most common at far, and exophoria around 2 PD at near. The average break values of far fusional convergence and divergence were 13.7 ± 4.4 PD and 7.3 ± 2.1 PD, respectively. Near fusional convergence and divergence break values were 29.6 ± 6.6 PD and 16.2 ± 4.1 PD, respectively. The recovery values were from 1/3 to 1/2 lower than the break values. The correlation between heterophoria at far and far fusional convergence and heterohoria at near and near fusional convergence and divergence was weak, yet significant (r = 0.18 - 0.26; p less than 0.05).

CONCLUSION

In preschool children the prevalence of heterophoria, and values of fusional vergence were in the ranges of values for elementary school children and adults cited in the literature. Heterophoria and fusional convergence at far, and heterophoria and fusional vergences at near have shown a weak relationship.

The management of childhood esotropia with hyperopia

PURPOSE

Esotropia, especially accommodative estropia (AE), is often seen in patients with hyperopia. In this paper, the authors aim to report the management methods of different types of esotropia in children with hypermetropia and to show the feasibility and efficacy of prismatic correction in the management of small angle of residual esotropia in accommodative estropia.

METHODS

A total of 82 esotropes with hyperopia treated during a 2-year period from 2007 to 2009 were reviewed retrospectively. Data were collected from the medical records.

RESULTS

A total of 25 patients showed pure accommodative esotropes, whereas 45 had partial AE and 12 non-AE. All 25 pure AE patients were corrected fully using glasses alone, and all 12 non-AE patients received surgery. Among the 45 partial AE cases, 35 patients with residual esodeviation of ≤30 PD received prismatic correction, with a success rate of 71.4% (25 of the 35 patients). The remaining 10 children who were not successfully treated with prismatic correction and the other 10 partial AE with residual esodeviation of >30 PD received surgery. The most recent follow-up examination indicated that all the non-surgical children were orthotropia or esophoria or had residual esotropia ≤10 PD. Among the surgical patients, 5 patients (5 in 32 or 15.6%) exhibited unstable alignment during the postoperative follow-up period, and 10 patients (10 in 32 or 31.25%) underwent additional surgery for residual esotropia.

CONCLUSIONS

Treatment of estropia in children with hyperopia includes wearing glasses, glasses combined with prism glasses and surgery. Prismatic correction in the treatment of small angle of residual esotropia in partial AE was feasible and efficacious. Since the follow-up lasted only a year, a long-term follow-up is needed in future studies to investigate the efficiency of the treatments.

Longitudinal follow-up of hypermetropic children identified during preschool vision screening

PURPOSE

Early childhood hypermetropia is an important risk factor for the development of amblyopia and esotropia. Understanding the natural history of these complications aids in management decisions.

METHODS

A retrospective observational review was undertaken of 149 patients referred from a preschool photoscreening program who were determined to have hypermetropia of >or=+3.75 D spherical equivalent on criterion standard examination and were treated/followed by one group of academic pediatric ophthalmologists. The prevalence and incidence of accommodative esotropia and amblyopia were determined.

RESULTS

At presentation 19% of hypermetropic children had amblyopia, 32% had esotropia, and 13% had both. Follow-up data of 108 patients during a mean of 40 months showed that 20 (24%) of 83 initially nonamblyopic patients developed amblyopia and that 22 (33%) of 67 initially nonstrabismic patients developed accommodative esotropia. Of patients initially managed with observation, 38% (6 of 16) developed amblyopia, and 31% (5 of 16) developed accommodative esotropia as compared with 21% (14 of 67) and 33% (17 of 51), respectively, for those given full or partial refractive correction. For patients without amblyopia or strabismus at presentation, only 20% developed amblyopia and 35% esotropia. Strabismic patients responded well to treatment, with no cases developing partially accommodative strabismus requiring surgery during follow-up.

CONCLUSIONS

In this case series we found a high prevalence of amblyopia and strabismus. The results support the importance of early preschool vision screening and spectacle correction of moderate to high hypermetropia (>+3.50 D) to reduce the risk of amblyopia, although more research is needed.

Prevalence and pattern of strabismus in Ilorin

BACKGROUND

There is a paucity of studies devoted exclusively to strabismus in children.

OBJECTIVE

To determine the prevalence, and pattern of presentation of strabismus among a group of Nigerian school children.

METHODS

A cross sectional survey was carried out among primary school children in Ilorin South Local Government Area in Nigeria. Twenty-one public primary schools grouped into three zones of seven schools each were selected for screening using a cluster random sampling technique.

RESULTS

A total 7,288 children were screened (3766 boys and 3522 girls). This yielded 32 cases of strabismus (19 males and 13 females). Their age ranged from two to sixteen years (mean, 9.5 + or - 6.0 years). The prevalence of esotropia 0.14%. (95% CI, 0.029%-0.31%) and that of exotropia 0.14%. (95% CI, 0.13%-0.15%). Congenital estropia and accommodative esotropia constituted 50.0% and 18.8% of cases respectively while, exotropia constituted 31.3%.

CONCLUSION

The prevalence of strabismus is low in the study population as has been found in other studied. Like most studies on strabismus; estropia is the most common variety seen.

Consecutive esotropia in intermittent exotropia patients with immediate postoperative overcorrection more than 17 prism diopters

Purpose

To report the incidence and the factors of consecutive esotropia (ET) in patients with immediate postoperative overcorrection of at least 17 prism diopters (PD) after surgery for intermittent exotropia (X(T)).

Methods

Four-hundred-five patients under the age of 18 were included in this study. They underwent bilateral lateral rectus recession (LROU-rec) or unilateral recession-resection (R&R) for X(T). On postoperative day one, the patients with at least 17 PD overcorrection were classified as group 1 and those with less than 17 PD as group 2. Age, refractive error, type of surgery, lateral incomitancy, and the incidence of consecutive ET were analyzed for each group.

Results

Group 1 consisted of 116 patients (28.6%) and group 2 consisted of 289 (71.4%). At the six-month follow-up visit, consecutive ET had developed in 16 patients (13.8%) in group 1, and in five patients (1.7%) in group 2 (p<0.001). The occurrence of consecutive ET was not related to age at the time of surgery (p=0.46 in group 1 ; p=0.54 in group 2), refractive error (p=0.18 in group 1 ; p=0.08 in group 2), or the type of surgery (p=0.69 in group 1 ; p=1.00 in group 2). The incidence in group 1 was 23.8% in patients with lateral incomitancy and 8.1% in patients without lateral incomitancy (p<0.05). In group 2, the incidence was 4.4% in patients with lateral incomitancy and 0.5% in patients without lateral incomitancy (p=0.04).

Conclusions

Consecutive ET developed in 13.8% of patients with immediate overcorrection of at least 17 PD. Lateral incomitancy was the most important risk factor.

[Ophthalmologic findings in multiple handicapped patients]

PURPOSE

To report the visual findings in patients with multiple handicaps.

METHODS

Two hundred and seventy-four patients cared for at the Pediatric and Strabismus Ophthalmology Department of the "Fundação Altino Ventura" - Brazilian National Health System, were examined from June to September 2004. Age varied from 0.1 to 20 years with a median of 5.

RESULTS

The majority of the patients (61.3%) presented good visual acuity; however low visual acuity (< 20/80) was observed in 38.7% of the patients. Heterotropias were observed in 66 patients (24.0%); astigmatism (53.2%) and hyperopia (29.0%) were more frequent.

CONCLUSION

Children with multiple handicaps need an early ophthalmologic diagnosis and treatment for better global development. The integration of a multidisciplinary team with pediatricians, pediatric ophthalmologists and specialists in low vision, may assure a better visual rehabilitation.

The clinical course of consecutive esotropia after surgical correction

PURPOSE

To investigate the clinical course in patients who underwent surgical correction of consecutive esotropia.

METHODS

The medical records of 13 patients who underwent surgical correction of consecutive esotropia were reviewed retrospectively. The authors investigated the deviation and surgical method at the time of exotropia surgery. During the follow up period, the authors also studied incidence of amblyopia development, the effect of occlusion therapy, surgical methods for consecutive esotropia, and postoperative change of deviation.

RESULTS

The average exodeviation was 27.1 prism diopter (PD). Bilateral lateral rectus muscle recession was performed in all patients. In all patients, alternate occlusion was tried from 2 weeks after development of consecutive esotropia. However, there was no effect on 7 patients. None of the patients developed amblyopia. Surgery for consecutive esotropia was performed on the average 15.3 months after exotropia surgery. The average esodeviation was 21.1PD. Medial rectus muscle recession was performed in 10 patients and lateral rectus muscle advancement in 3 patients. The average deviation of the subject group immediately after surgery was 1.2PD esodeviation, 0.9PD esodeviation one month after surgery, 2.4PD exodeviation 6 months after surgery, and 4.7PD exodeviation at the last follow up, and it showed a tendency to progress to exodeviation as the follow up period increased. Ten patients (76.9%) showed deviation within 8PD at the last follow up.

CONCLUSIONS

The success rate of surgical correction for consecutive esotropia was a favorable outcome. But, careful decisions of the surgical method and amount is needed because the conversion of exodeviation during long-term follow-up is possible.

Variables associated with the incidence of infantile esotropia

PURPOSE

Infantile esotropia (manifesting from birth to 6 months) is a common type of strabismus, accounting for 28% to 54% of all esotropias and with an incidence of 1% of the general population. The purpose of this cohort study was to evaluate risk factors for infantile esotropia. Such information may aid in early intervention to prevent manifestation of infantile esotropia.

METHODS

A retrospective chart review of 5,347 records (October 1, 1993, to September 30, 2003) of birth mothers and infants at the W.W. Hastings Indian Health Science Hospital in Tahlequah, Oklahoma, was performed to identify children with varying degrees of Native American blood who had infantile esotropia. A nonstrabismic birth cohort control group was also identified. Twenty-three medical records indicating a diagnosis of infantile esotropia that were complete enough to be used in analysis were identified. Normal infants were compared with infants with esotropia.

RESULTS

Infantile esotropia in this preliminary study was associated with 24 factors including prematurity, family ocular history, cardiovascular disease, systemic disease, pregnancy-associated hypertension and low birth weight (<2,500 g) among others.

CONCLUSIONS

Prematurity, family history or secondary ocular history, perinatal or gestational complications, systemic disorders, use of supplemental oxygen as a neonate, use of systemic medications, and male sex were found to be significant risk factors for infantile esotropia. Our results provide additional evidence that might help facilitate early detection and intervention in cases in which these risk factors are identified.

Age at strabismus diagnosis in an incidence cohort of children

PURPOSE

To compare the age at diagnosis of children with esotropia, exotropia, and hypertropia.

DESIGN

Retrospective, population-based cohort study.

METHODS

The medical records of all Olmsted County, Minnesota, residents < 19 years diagnosed with esotropia, exotropia, or hypertropia from January 1, 1985 through December 31, 1994 were reviewed.

RESULTS

The median age at diagnosis of esotropia (n = 380), exotropia (n = 205), and hypertropia (n = 42) was 3.1 years, 7.2 years, and 6.1 years, respectively (P = .001). In the first six years of life, esotropia had the highest incidence and was more likely to occur than either exotropia or hypertropia; exotropia predominated between age seven and 12 years; and each form was similarly likely to occur between 13 and 18 years of age (P = .001).

CONCLUSIONS

The age at diagnosis was significantly different for the various forms of strabismus in this population. Esotropia is the most common form in the first six years of life; beyond this age exotropia predominates until the teenage years when the three forms have a similar but decreased incidence.

Common forms of childhood strabismus in an incidence cohort

PURPOSE

To report the prevalent forms of childhood strabismus.

DESIGN

Retrospective, population-based cohort study.

METHODS

The medical records of all Olmsted County, Minnesota, residents younger than 19 years diagnosed with esotropia, exotropia, or hypertropia from January 1, 1985 through December 31, 1994, were reviewed.

RESULTS

Six hundred twenty-seven new cases of childhood strabismus were identified during the 10-year study period, including 380 (60.1%) with esotropia, 205 (32.7%) with exotropia, and 42 (6.7%) with hypertropia. The five most common forms of strabismus included accommodative esotropia (27.9%), intermittent exotropia (16.9%), acquired nonaccommodative esotropia (10.2%), esotropia in children with an abnormal central nervous system (7.0%), and convergence insufficiency (6.4%).

CONCLUSIONS

This study provides population-based data on the most prevalent forms of childhood strabismus. Accommodative esotropia, intermittent exotropia, and acquired nonaccommodative esotropia were the predominant forms of strabismus in this Western population.

Clinical characteristics of spontaneous late-onset comitant acute nonaccommodative esotropia in children

PURPOSE

To describe the clinical characteristics of spontaneous, late-onset comitant acute, nonaccommodative esotropia (ANAET) in children.

MATERIALS AND METHODS

Clinical characteristics of a cohort of patients under 16 years of age with ANAET were studied retrospectively.

RESULTS

Of 15 patients eight were females. Mean age was 7.15 years (range 2.5-13, SD 3.34). Mean age of the onset of deviation was 3.2 years (range 1.5-9, SD 2.26). Mean duration of strabismus was 36 months (range 3-132, SD 43). History of a precipitating event was present in five patients (33.3%). Mean cycloplegic refraction was 1.84 diopter sphere (range -5.75 to +7.25, SD 3.55). Mean esodeviation for near and distance fixation was 40 prism diopter (range 15-90, SD 23.9). None had near/distance disparity of more than 5 prism diopter. Amblyopia was present in 13 cases (87%). Strabismus surgery was performed for eight patients. Five patients had orthophoria and three were aligned within 8 prisms esodeviation.

CONCLUSION

ANAET is more common than previously reported, has a variable time of onset and high incidence of amblyopia. Timely management would avert emergence of amblyopia and vertical incomitance thereby promising better binocular outcome.

Comitant horizontal strabismus: an Asian perspective

AIM

Recent studies suggest that Asian strabismus patterns are different from those in the West. This study aims to determine the profile of children with comitant horizontal strabismus in Singapore.

METHOD

682 children aged <or=16 years presenting with strabismus for the first time between 2000 and 2002 were included in this study. The type and size of the squint, visual acuity, refractive error and stereopsis were noted.

RESULTS

493 children (72%) were exotropic, the majority (92%) of whom had intermittent exotropia, X(T). The divergence excess type X(T) was most common (59.5%), followed by basic (29.0%) and convergence-weakness (11.5%). Children with X(T) demonstrated stereopsis for near in 92% and distance in 50%. Esotropia was present in 191 (28%) children (23% infantile and 53% accommodative). Children with infantile esotropia presented significantly younger (2.8 years vs 4.5 years), had larger squint size (35D vs 26D) and were less hyperopic (+0.78D vs +2.79D). Amblyopia or ocular preference was noted in 50% of children with infantile esotropia, and 43% with accommodative esotropia.

CONCLUSION

Twice as many Singaporean children presented with exotropia than esotropia. However, within the exotropia and esotropia groups, the distribution and characteristics of various strabismus subtypes bore similar characteristics to those described in the West.

Incidence and types of childhood esotropia: a population-based study

OBJECTIVE

To describe the incidence and types of childhood esotropia in a defined population.

DESIGN

Retrospective population-based cohort.

PARTICIPANTS

All pediatric (<19 years of age) residents of Olmsted County, Minnesota, diagnosed with an esodeviation (> or =10 prism diopters) from January 1, 1985, through 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 and types of childhood esotropia.

RESULTS

Three hundred eighty-five cases of childhood esotropia were identified during the 10-year period, yielding an annual age- and gender-adjusted incidence of 111.0 (95% confidence interval, 99.9-122.1) per 100,000 patients younger than 19 years of age. This rate corresponds to a cumulative prevalence of approximately 2.0% of all children younger than 6 years, with a significant decrease in older ages (P<0.0001). Of the 385 study children, the specific forms and percentages of esotropia diagnosed were as follows: fully accommodative, 140 (36.4%); acquired nonaccommodative, 64 (16.6%); esotropia associated with an abnormal central nervous system, 44 (11.4%); partially accommodative, 39 (10.1%); congenital, 31 (8.1%); sensory, 25 (6.5%); paralytic, 25 (6.5%); undetermined, 13 (3.4%); and other, 4 (1.0%).

CONCLUSIONS

The incidence of childhood esotropia from this self-referred population-based study is comparable with prevalence rates reported among Western populations. Esotropia is most common during the first decade of life, with the accommodative and acquired nonaccommodative forms occurring most frequently. The congenital, sensory, and paralytic forms of childhood esotropia were less common in this population.

[Torticollis in a group of strabismic patients in Cameroon]

PURPOSE

Our aim was to study the characteristics of torticollis in a group of strabismic patients in Cameroon.

PATIENTS AND METHODS

This was a prospective study carried out in the ophthalmology service of the General Hospital, Douala from January 1991 to December 2004. All strabismic patients followed up in our service were included in this study and they all had a complete strabologic and ophthalmological examination. Torticollis was analysed using photographs and classified according to its configuration, degree and variability.

RESULTS

We examined 379 strabismic patients of which 227 were divergent (59.9%) and 152 convergent (40.1%). We found 166 cases of torticollis (43.8%). This pathology was found in 52.6% of patients with esotropia versus 37.9% in exotropia. Torticollis was classified as severe in 14.5% of patients, moderate in 45.8% and mild in 39.7%. Two out of three early esotropias had alternating torticollis. In congenital monophthalmus syndrome, torticollis was found in 68.4% of cases and in 100% of cases with the alphabetic syndrome. Moreover 63.8% of strabismics with torticollis have astigmatism.

CONCLUSION

Torticollis in strabismic patients is a cause for concern as it is frequent and its functional consequences are severe.

Risk factors for accommodative esotropia among hypermetropic children

PURPOSE

Identification of risk factors for accommodative esotropia may help to determine which children with hyperopia may benefit from early spectacle correction or preventive therapy.

METHODS

Participants in the family history study were 95 consecutive patients, aged 18 to 60 months, with accommodative esotropia. Participants in the binocular sensory function study were a subgroup of 41 children enrolled in the family history study within 1 month of onset, while the esodeviation was still intermittent. Participants in the hypermetropia study were 345 consecutive patients, ages 12 months to 8 years, with refractive error of +2.00 D or greater and no esodeviation before age 12 months.

RESULTS

In the family history study, 23% of children with accommodative esotropia had an affected first-degree relative, and 91% had at least one affected relative. In the binocular sensory function study, random-dot stereoacuity was abnormal in 41% of children, whereas an abnormal motion VEP, Worth 4-dot, or positive 4-PD base-out prism responses were present in 4% or less of the children. In the hypermetropia study, patients with a mean spherical equivalent of < +3.00 D and significant anisometropia had a 7.8-fold increased risk for accommodative esotropia over nonanisometropic patients.

CONCLUSIONS

A positive family history, subnormal random-dot stereopsis, and hypermetropic anisometropia each pose a significant risk for the development of accommodative esotropia. Assessment of these risk factors in conjunction with refractive screening should help to identify those children who are most likely to benefit from early spectacle correction or preventive treatment.

Why is squint surgery in children in decline?

BACKGROUND

/aims: Paediatric squint surgery appears to be declining. This study aims to identify if this is so and, if so, why.

METHODS

Retrospective review of (1) episodes of paediatric squint surgery in Scotland and Tayside, 1986-2001, (2) presentations to orthoptists (Tayside) during 1986 and 1996.

RESULTS

(1) Overall, a 58% fall in surgery in Scotland and 59% in Tayside. For esotropia, a reduction of 63% (Scotland) and 69% (Tayside). (2) Incidence of esotropia was unchanged; surgery for these esotropes fell (from 55% to 30%) (p = 0.013). More children received maximum hypermetropic correction (p <0.001) and more developed stereopsis (p = 0.003).

CONCLUSION

Childhood strabismus surgery, particularly for esotropia, is declining. The maximum hypermetropic correction has improved the functional results.

Long-term study of accommodative esotropia

PURPOSE

Previous studies of accommodative esotropia have been hampered by bias-prone methods of data collection and analysis and by small sample size. The studies have conflicting conclusions, causing uncertain results. This study aims to determine long-term results of standard treatment of accommodative esotropia and identify predictors of outcome, while minimizing bias in data collection and analysis, using the largest possible sample size.

METHODS

A research assistant collected data from all files of a large, long-established pediatric ophthalmology practice (M.M.P.). The assistant was given standardized collection forms that allowed inclusion of all patient data points over all visits. The assistant was masked as to study goals. She was instructed to include any patient with esotropia who had been prescribed glasses during treatment. Descriptive terms were converted to code numbers. A second, similarly masked research assistant entered data into a computerized database. Criteria for patient inclusion were designed to conform to earlier studies by I.H.L. and M.M.P. and were implemented by computer.

RESULTS

The database totaled 1,307 patients (747,717 data points). Of these, 354 qualified for this analysis. A greater difference between near and distance esodeviation (AC/A relationship) correlated with a higher rate of deterioration of accommodative esotropia control (P<.0001). Deterioration also positively correlated with earlier age at onset, inferior oblique overaction, and amblyopia.

CONCLUSIONS

This study agrees with our previous findings that a high AC/A relationship increases the likelihood of deterioration of accommodative esotropia, thus confirming the integrity of the database. This unique, unbiased dataset will be used for future analyses of esotropia.

[The Faden operation in strabismus surgery]

PURPOSE

Is to evaluate the indications of Faden operation and the postoperative results.

MATERIAL AND METHOD

We studied a number of 32 patients with convergent strabismus operated in the Universitary Eye Hospital from Cluj, during 1998-2000 at whom we performed Faden operation with conventional surgery on the medial rectus. The anAestesia was with ketamine i.v.

RESULTS

The majority of patients where females (62.50%) with ages between 0-14 years. We performed surgery in cases of convergent strabismus with spasm of fixation. The postoperative results were promising; in 23 cases we obtained ortHophory, in 8 cases a remaining deviation angle (5-10 D P), and in 1 case a deviation angle above 5-10 D P.

CONCLUSIONS

1. Faden operations is indicated to correct the spatical component of the deviation angle. 2. The postoperative good results are depending on the aSsociations of Faden operation with conventional surgery. 3. Under or above correction of the strabismus is linked with a deficiency of the conventional surgery associated.

Changing patterns of strabismus: a decade of experience in Hong Kong

BACKGROUND/AIMS

Racial variation in the pattern of strabismus is known, but few large scale studies on non-white populations are available. Furthermore, longitudinal change in this pattern within a local setting has not been well documented in the past. This study aims to support the clinical impression that exotropia is more common in Chinese patients, and that the proportion of patients with exotropia has been increasing in the past decade.

METHODS

A total of 2704 consecutive patients with the diagnosis of primary horizontal strabismus, seen in the strabismus clinic of the Hong Kong Eye Hospital, were retrospectively analysed to determine the relative prevalence of esotropia and exotropia. Characteristics recorded include patient demographics, type of strabismus, and whether the nature of the squint was constant or intermittent.

RESULTS

742 (27.4%) patients were found to have esotropia, 548 (20.3%) had constant exotropia, 1213 (44.9%) had intermittent exotropia, and 201 (7.4%) had microtropia. The proportion of exotropic to esotropic patients was shown to increase steadily throughout the past decade (p<0.0001). This was mainly accounted for by an increase in the number of patients with intermittent exotropia, and a corresponding decrease in the number of patients with esotropia.

CONCLUSION

Exotropia was shown to be more prevalent than esotropia in a Hong Kong Chinese population. Furthermore, the proportion of patients with intermittent exotropia appears to be increasing, in contrast with esotropic patients. The exact nature of this trend, and possible aetiological factors will require further study.

Sensory strabismus--eso or exo?

PURPOSE

The type of horizontal strabismus from loss or impairment of vision is thought to depend on patient age at the time of vision loss. Association between the age at onset of vision loss and development of esotropia vs exotropia will be determined.

METHODS

Patients with a diagnosis of sensory strabismus and visual acuity of 20/40 or poorer were reviewed as well as patients with diagnoses consistent with the development of sensory strabismus. Parameters considered were age at onset of vision loss and type of strabismus. Patients were excluded if the age at onset was not clear.

RESULTS

Of 123 patients with sensory strabismus reviewed: 82 (67%) had unilateral vision loss; 41 (33%) had bilateral vision loss; 75 (61%) had congenital vision loss; 50 (67%) developed esotropia; 25 (33%) developed exotropia; 48 (39%) had acquired vision loss; 5 (10%) developed esotropia; and 43 (90%) developed exotropia. A significant difference was noted between age at onset and type of horizontal strabismus (X2= 37.44; P <.0001).

CONCLUSION

Of patients with congenital vision loss, 67% developed sensory esotropia and 33% developed sensory exotropia. Of those with acquired vision loss, 10% developed sensory esotropia and 90% developed sensory exotropia. Patients with congenital vision loss are significantly more likely to develop esotropia, P <.005, and those with acquired vision loss are significantly more likely to develop exotropia, P <.001.

[Hereditary factors in strabismus]

This retrospective study took place in the Ophthalmology Department of Douala General Hospital. The aim was to determine the importance of hereditary factors in a group of strabismic Cameroonians. In a series of 275 patients with strabismus, we found 79 familial cases (28.72%). Among them, 22.78% had more than one relative with squint and 75% had the same type of strabismus as their relative. There was no significant difference in the percentage of familial cases with regard to the type of strabismus, the sex, the mode of fixation and the impairment of ductions. As far as ametropias are concerned, only myopia showed a hereditary tendency in our series. The authors agree with the literature in that there is a significant hereditary component in the cause of strabismus, but its genetic sites are yet to be identified. There is strong hope in this direction with the decoding of the human genom and the advances in molecular biology. However, the study of familial cases is important since it allows high risk groups to be defined and screened. It thus makes it possible to successfully fight amblyopia through early detection and treatment.

Common forms of childhood esotropia

OBJECTIVE

To determine the most common forms of childhood esotropia.

DESIGN

Prospective, consecutive, observational case series.

PARTICIPANTS

All esotropic children younger than 11 years of age from a predominantly rural Appalachian region evaluated from August 1, 1995 through July 31, 1998.

METHODS

Demographic and clinical data were collected for all patients.

MAIN OUTCOME MEASURES

The percentage ratio of the various forms of childhood esotropia.

RESULTS

Two hundred twenty-one consecutive children without prior surgical treatment were evaluated for esotropia. One hundred seventeen (52.9%) of the 221 children had some form of accommodative esotropia, 38 (17.2%) were associated with congenital or acquired abnormalities of the central nervous system, 23 (10.4%) displayed acquired nonaccommodative esotropia, 15 (6.8%) resulted from ocular sensory defects, 12 (5.4%) had confirmed congenital esotropia, seven (3.2%) had paralytic esotropia, and an unverified age at onset prevented an accurate categorization in the remaining nine (4.1%).

CONCLUSIONS

Children with accommodative esotropia accounted for more than half of the study patients and were diagnosed nearly 10 times more frequently than children with congenital esotropia. Esotropic patients with central nervous system defects or with an acquired nonaccommodative deviation were also more common than children with congenital esotropia. Children with congenital esotropia or with a paralytic or sensory cause of their deviation were relatively uncommon.

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.

[Sensory heterotropias: epidemiological aspects at Douala General Hospital (Cameroon)]

The aim of this retrospective study was to determine the epidemiological characteristics of the sensory heterotropia cases seen in the Opthamology Department of Douala General Hospital between November 1991 and November 1999. Sensory heterotropia accounted for 22.5% of the cases of strabismus reported. Onset was before the age of one year in 80.4% of cases and after the age of one year in 19.6% of cases. All cases of esotropia were apparent before the age of one year. Sensory heterotropia was associated with amblyopia in 89.3% of cases, with eccentric fixation in 78.6% of cases and with nystagmus in 53.6% of cases. Etiology was diverse, the most frequent causes being: albinism (19.6%), chorioretinal scars (16.1%), unilateral cataracts (16.1%), atrophy of the optic nerve (16.1%) and ametropia (8.9%). We recommend preventive measures for some etiologies.

Infantile esotropia in very low birth weight (VLBW) children

VLBW children are known to have a high frequency of early onset strabismus, which is related to the high prevalence of pre- and perinatal cerebral disturbances reported in these children. It is unknown if the early onset strabismus in VLBW children has the characteristics of infantile esotropia. If so, then (acquired) cerebral damage may play an important role in the origin of this type of strabismus. For this reason, the charts of 265 VLBW children were retrospectively reviewed. Strabismus was present in 55 (20.7%) children. Mean follow-up was 75 weeks, with 29.8% of the children having a follow-up of less then 6 months. Only 5 children (1.9%) with characteristics of infantile esotropia could be identified. Another 8 children (3.0%) possibly had infantile esotropia, but follow-up had been too infrequent during the first year of life to determine the time of onset of strabismus precisely. The other 42 children with strabismus all had ophthalmological disorders (i.e. ROP, optic nerve atrophy, cortical blindness) explaining early disruption of binocular visual development. Therefore, VLBW children are at risk for early onset strabismus. However, infantile esotropia is not typical for VLBW children and may be an indication that early acquired cerebral damage does not play an important role in the pathogenesis of infantile esotropia.

Early-onset accommodative esotropia

PURPOSE

To determine the frequency of accommodative esotropia with onset by 6 months of age; to determine if the presence or absence of characteristics usually associated with infantile esotropia can help in the diagnosis; and to determine if antiaccommodative therapy is adequate treatment for the esotropia.

METHODS

The charts of 100 patients with infantile esotropia, seen over a 2-year period (September 1995 to September 1997), were reviewed. We identified those with at least 2.25 diopters (D) of hyperopia and determined the presence of large angle esotropia (> 30 to 40 prism diopters [delta]), amblyopia, inferior oblique overaction, dissociated vertical deviation, latent nystagmus, and cross-fixation. The success of antiaccommodative therapy, if attempted, was also evaluated.

RESULTS

Of 100 patients with infantile esotropia, 15 (15%) were found to have at least +2.25 D. This represented 8% of all patients with accommodative esotropia seen over the same time period. The average age at initial examination was 21 months, although the reported age of onset in all cases was 6 months or less. Two had surgery before presenting to our institute. Eleven of 13 (84%) had 40 delta or less. Six (40%) of the 15 had amblyopia, 5 (33%) had inferior oblique overaction, 3 (20%) had dissociated vertical deviation, 1 (7%) had latent nystagmus, and 4 (27%) had cross-fixation. Of the 13, 7 were given glasses initially, with 3 being fully corrected. Six were not given glasses, all had surgery, and all were given glasses postoperatively for a residual esotropia.

CONCLUSION

Fifteen percent of infantile esotropia patients and 8% of accommodative esotropia patients have infantile accommodative esotropia. Other characteristics of infantile esotropia may be present, but are less frequent, and at least 40% are fully corrected with spectacles indicating that when the hyperopia is 2.25 D or greater, antiaccommodative therapy should be instituted before surgery.

Congenital esotropia in Olmsted County, Minnesota

OBJECTIVE

To determine the birth prevalence of and risk factors associated with congenital esotropia.

DESIGN

Population-based prevalence study with nested case-control study.

PARTICIPANTS

All residents of Olmsted County, Minnesota who were diagnosed with congenital esotropia and born between January 1, 1980 and December 31, 1989 (n = 47). Control subjects were chosen by selecting the next two sequential births to parents residing in Olmsted County, Minnesota (n = 94).

METHODS

Cases were identified through the Medical Diagnostic Index of Mayo and the Rochester Epidemiology Project. The community medical records were reviewed to confirm case status and ascertain risk factor information.

MAIN OUTCOME MEASURE

Birth prevalence of congenital esotropia.

RESULTS

Forty-seven cases were identified from 17,536 live births, for a birth prevalence of 27 per 10,000 (95% confidence interval [CI], 20-35). Congenital esotropia was associated with prematurity (odds ratio [OR], 11.5; 95% CI, 3.4-39.2), a birth weight less than 2500 grams (OR, 4.6; 95% CI, 1.7-12.9), a low Apgar score at 1 minute (OR, 4.3; 95% CI, 1.7-11.2) and at 5 minutes (OR, 6.3; 95% CI, 1.3-30.7), and a family history of strabismus (OR, 3.5; 95% CI, 1.5-8.3).

CONCLUSIONS

The birth prevalence of congenital esotropia in Olmsted County, Minnesota is lower than previous estimates. Prematurity, low birth weight, low Apgar scores, and a family history of strabismus are significant risk factors for congenital esotropia.

Effective medical examination of VDT workers using a new testing method of ocular alignment

To investigate the relationship between asthenopia of VDT workers and the ocular alignment, we measured far and near alignment of 407 subjects (74 VDT workers with asthenopia, 137 VDT workers without asthenopia, and 196 non-VDT workers) using Total Vision tester (VT-500). There was no relationship between the asthenopia and the records of far alignment test. On the other hand, the incidence of exophoria and convergence insufficiency type in near alignment test was significantly high in the group of VDT workers with asthenopia. From these results, we speculate that cases who have exophoria or show incomplete fusional response measured under the near testing distance (50 cm) tend to complain of asthenopia.

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.

Associations between siblings for esotropia and exotropia

OBJECTIVE

To quantify familial aggregation of esotropia and exotropia in children examined in a large multicenter study.

METHODS

Pregnant women and their children were examined in the Collaborative Perinatal Project of the National Institute of Neurological Disorders and Stroke, Bethesda, Md. Strabismus was evaluated in the children during follow-up examinations up to the age of 7 years. The second-order generalized estimating equations approach to logistic regression was used to estimate familial aggregation of esotropia and exotropia.

RESULTS

For any pair of siblings, the odds for one sibling having esotropia more than doubled when the other sibling had esotropia. For exotropia, there were differences in sibling associations based on birth relationships. In particular, there was no statistically significant association between siblings from separate single births. On the other hand, for the pairs of siblings from multiple births (ie, twins, triplets, and quadruplets), the odds for exotropia in one sibling were increased by at least a factor of 17 when the other sibling from that birth also had exotropia. For both esotropia and exotropia, adjustment for previously identified risk factors only somewhat reduced the magnitudes of the observed associations. Limited data on zygosity showed a stronger association between monozygotic twins than between dizygotic twins.

CONCLUSIONS

There is a significant familial component in the cause of strabismus. Furthermore, there are important contributions to this familial aggregation beyond those associated with known risk factors for strabismus.