Changes in Hypermetropic Spectacle Correction after Surgery in Partially Accommodative Esotropia

PURPOSE: To investigate the characteristics of successfully weaning patients off of glasses and the change in hypermetropic spectacle correction required for maintaining orthotropia using an analysis of surgery results of patients with partially accommodative esotropia. METHODS: We reviewed the medical records of 104 patients who underwent standard surgery for correcting partially accommodative esotropia. In total, 64 patients who had follow-up periods of at least 2 years were included. The patients were divided into 2 groups: 28 patients who were asked to discontinue their hyperopic glasses (glasses-discontinued group) and 36 patients who still needed hyperopic glasses (glasses-maintained group). We investigated the age at first visit and at surgery, total angle of deviation and residual angle of deviation with correction before surgery, weaning time of hyperopic glasses, follow-up period, and the time at which the hyperopic glasses were discontinued in the glasses-discontinued group. RESULTS: There were no statistically significant differences in the age at first visit and at surgery as well as the duration of postoperative follow-up between both groups. The total esodeviated angle without hyperopic correction of the glasses-discontinued group was significantly lower than that of glasses-maintained group (37.4PD:46.7PD, p < 0.05); there were no significant differences in the remaining esotropic angle after hyperopic correction. The average hyperopic degree in the glasses-discontinued group was significantly lower than that in the glasses-maintained group (+3.0D:+4.7D, p < 0.05), there were no significant differences in the weaning time of hyperopic glasses between both groups. CONCLUSIONS: The esodeviated angle without hyperopic correction was smaller and hyperopic degree was lower in the glasses-discontinued group than in the glasses-maintained group after surgery for partially accommodative esotropia. Therefore, it might be helpful to predict the postoperative possibility to discontinue glasses in the patients with partially accommodative esotropia.

Changes in Hypermetropic Spectacle Correction after Surgery in Partially Accommodative Esotropia

PURPOSE: To investigate the characteristics of successfully weaning patients off of glasses and the change in hypermetropic spectacle correction required for maintaining orthotropia using an analysis of surgery results of patients with partially accommodative esotropia. METHODS: We reviewed the medical records of 104 patients who underwent standard surgery for correcting partially accommodative esotropia. In total, 64 patients who had follow-up periods of at least 2 years were included. The patients were divided into 2 groups: 28 patients who were asked to discontinue their hyperopic glasses (glasses-discontinued group) and 36 patients who still needed hyperopic glasses (glasses-maintained group). We investigated the age at first visit and at surgery, total angle of deviation and residual angle of deviation with correction before surgery, weaning time of hyperopic glasses, follow-up period, and the time at which the hyperopic glasses were discontinued in the glasses-discontinued group. RESULTS: There were no statistically significant differences in the age at first visit and at surgery as well as the duration of postoperative follow-up between both groups. The total esodeviated angle without hyperopic correction of the glasses-discontinued group was significantly lower than that of glasses-maintained group (37.4PD:46.7PD, p < 0.05); there were no significant differences in the remaining esotropic angle after hyperopic correction. The average hyperopic degree in the glasses-discontinued group was significantly lower than that in the glasses-maintained group (+3.0D:+4.7D, p < 0.05), there were no significant differences in the weaning time of hyperopic glasses between both groups. CONCLUSIONS: The esodeviated angle without hyperopic correction was smaller and hyperopic degree was lower in the glasses-discontinued group than in the glasses-maintained group after surgery for partially accommodative esotropia. Therefore, it might be helpful to predict the postoperative possibility to discontinue glasses in the patients with partially accommodative esotropia.

Comparison of Outcomes According to Surgical Method in Partially Accommodative Esotropia in Patients Over 4 Years of Age

PURPOSE: To compare postoperative outcomes according to surgical method in partially accommodative esotropia in patients over 4 years of age. METHODS: We compared motor and sensory outcomes between conventional and augmented surgery in 66 patients. The postoperative follow-up period was at least 24 months. The formula for the amount of the rectus muscle recession was based on the distant angle deviation after hyperopic correction in the conventional group and the average amounts of the distant angle deviation with and without full correction of hyperopia in the augmented group. In addition, the conventional group was divided into 2 sub-groups to compare surgical outcomes. The A group consisted of patients who underwent surgery with the amount of surgical correction based on distant angle deviation after full hyperopic correction. The B group consisted of patients under the same condition after reduced hyperopic correction to achieve best corrected visual acuity (BCVA). RESULTS: Among the patients who had an ocular alignment less than 10 PD, orthophoria was significantly higher in the conventional group than in the augmented group on the last follow-up. When comparing the 2 conventional sub-groups, the postoperative stereoacuity was better in group B than in group A. Among patients with a postoperative overcorrected alignment of more than 10 PD who underwent augmented surgery, 75% showed decreased postoperative stereoacuity compared to preoperative stereoacuity. CONCLUSIONS: In partially accommodative esotropia in patients over 4 years of age, conventional surgery compared to augmented surgery after reduced hyperopic correction is better in order to achieve BCVA for postoperative stereoacuity as well as ocular alignment.

The Comparison of Surgical Results Between Non-accommodative and Partially Accommodative Esotropia

PURPOSE: To examine the differences in surgical results between non-accommodative esotropia (NAE) and partially accommodative esotropia (PAE). METHODS: This retrospective study included 47 patients undergoing surgery for pediatric esotropia, defined as esotropia with a decrease in the deviated angle of greater than ten prism diopters (PD) upon administration of hyperopic spectacles. On the other hand, NAE was defined as esotropia with a decrease in the deviated angle of less than 10PD. We compared age at surgery, deviated angle at surgery, frequency of amblyopia, and deviated angle at each postoperative period in two groups. RESULTS: Twenty-nine patients belonged to the PAE group, and 18 patients belonged to the NAE group. The age at surgery in the PAE group was higher than that of the NAE group, and the deviated angle for surgical correction was smaller in the PAE group than in the NAE group. No statistically significant difference in the frequency of amblyopia presentation was found between the two groups. The surgical success rates were much higher in the PAE group at postoperative two years and at the final visit compared to those of the NAE group. CONCLUSIONS: In esotropic children who underwent surgery, the long-term surgical success rate was highest in the cases in which the esotropic angle was decreased by hyperopic correction.

Comparison of Standard and undercorrected surgical methods for treating partially accommodative esotropia / 国际眼科杂志(Guoji Yanke Zazhi)

·AIM: To evaluate the efficacy of standard and undercorrected surgical methods in patients with partially accommodative esotropia (PAET).·METHODS: Twenty-five patients with PAET and normal accommodative convergence/accommodation ( AC/A )were divided into two groups for alternate surgical plan including standard method (13 patients) and under-corrected method (12 patients) in a randomized fashion.Standard method is based on measured deviation through full hyperopic correction at distant target and was performed by Parks scheme. Undercorrected method criteria is 20% lower than standard. All patients underwent symmetrical bilateral medial rectus recessions (BMR), and all of them were followed for 6 months.·RESULTS: Six months after operation, surgical success (defined as tropia =s 8A at distant and near fixation through full hyperopic correction) was 46% in standard group and 91% in undercorrected group. Overcorrection were observed 54% in standard group and 9% in undercorrected group (P＜0.05). There was no residual esotropia. There was no correlation between surgical success rate or overcorrection rate and age, mean of preoperative spherical equivalent or preoperative eye deviation.·CONCLUSION: Undercorrected BMR surgery has a lower overcorrection rate and higher surgical success rate than standard surgery in patients with PAET and normal AC/A.

Long-term Follow-up Results of Partially Accommodative Esotropia After Near Geared Standard Surgery

PURPOSE: To analyze the long-term outcome of near geared standard surgery with full hyperopic correction for partially accommodative esotropia. METHODS: The medical records of a total of 24 patients with partially accommodative esotorpia, who had undergone bilateral or unilateral medial rectus recession were retrospectively reviewed. The amount of medial rectus recession was measured based on the near deviation after full hyperopic correction. During the follow-up period the changes of refractive error and angle of deviation were evaluated, and the titmus test and Worth 4-Dot test were performed. RESULTS: The mean ages were 36.63+/-13.38 months (14~59 months) at the time of wearing glasses and 61.25+/-25.55 months (25~132 months) at the time of operation. The average follow-up period was 59.67+/-32.12 months (18~120 months) and preoperative refractive errors were +3.93+/-1.73 D sph and refractive errors at final visit were +3.64+/-2.07 D sph (P=0.53). The mean amount of esodeviation were 26.08+/-8.13PD and 4.25+/-6.63PD for pre- and post-operatively respectively. Nineteen patients showed postoperative deviation of 10PD or less, one patient was overcorrected, and four patients were undercorrected. Worth 4-Dot test resulted in a fusion response at near and far in one patient preoperatively and in 17 patients postoperatively (P=0.30). A titmus stereotest of less than 100 seconds of arc resulted in 1 of 7 patients and 6 of 14 patients at the time of preoperation and postoperation each (P=0.34). The results were not statistically significant. Four of ten high hyperopic patients (> or = +4.00 diopter) had under- or over-correction (P=0.12), though it was not statistically significant. There were no significant differences in combined conditions. CONCLUSIONS: Near geared standard surgery with full hyperopic correction in partially accommodative esotropia patients gave a good surgical result for patients in the mean follow-up duration of 59.67 months.

Malignant Hyperthermia in a Patient with Partially Accommodative Esotropia

PURPOSE: Malignant hyperthermia is hypermetabolic disorder of skeletal muscle that manifests during general anesthesia. Strabismus and ptosis are important risk factors in ophthalmology field for malignant hyperthermia. We report a case of malignant hyperthermia in patient with partially accommodative esotropia. CASE SUMMARY: A 6-year-old patient was supposed to undergo a surgical correction for 20 prism diopters of right esotropia after correction of hypermetropia. Because the patient showed tachycardia and hyperthermia just after inhalation of sevoflurane, we interrupted general anesthesia and cancelled the surgery. The patient was transferred to the intensive care unit. In this case, no significant familial and past histories were found. Intractable tachycardia and hyperthermia that had not responded to conservative management improved after two administration of dantrolene sodium. The patient was returned to the ward three days later. As the patient showed no other complication, he was discharged. CONCLUSIONS: In malignant hyperthermia, early diagnosis, appropriate management, and prompt administration of dantrolene sodium are important factors for better prognosis. Preoperatively, full explanation of possible complication and history taking are needed. Careful observation is necessary during anesthesia and surgery.

Reduction of Deviation Angle During Occlusion Therapy: In Partially Accommodative Esotropia with Moderate Amblyopia

PURPOSE: To evaluate changes in ocular alignment in partially accommodative esotropic children age ranged from 3 to 8 years during occlusion therapy for amblyopia. METHODS: Angle measurements of twenty-two partially accommodative esotropic patients with moderate amblyopia were evaluated before and at 2 years after occlusion therapy. RESULTS: Mean deviation angle with glasses at the start of occlusion treatment was 19.45+/-5.97 PD and decreased to 12.14+/-12.96 PD at 2 years after occlusion therapy (p<0.01). After occlusion therapy, 9 (41%) cases were indications of surgery for residual deviation but if we had planned surgery before occlusion treatment, 18 (82%) of patients would have had surgery. There was a statistical relationship between increase of visual acuity ratio and decrease of deviation angle (r=-0.479, p=0.024). CONCLUSIONS: There was a significant reduction of deviation angle of partially accommodative esotropic patients at 2 years after occlusion therapy. Our results suggest that occlusion therapy has an influence on ocular alignment in partially accommodative esotropic patients with amblyopia.

The Long Term Surgical Outcome after Bilateral Medial Rectus Muscle Recession in Partially Accommodative Esotropia

PURPOSE: To study the correlation between the outcome of the early postoperative period and the long-term outcome after surgery for partially accommodative esotropia. METHODS: The medical records of total 85 patients with partially accommodative esotropia, who underwent bilateral medial rectus muscle recession, and were followed-up at least 6 months, were retrospectively reviewed. The results were analyzed at 1 month, and 1 and 4 years after surgery. RESULTS: Of the 85 patients, 67 (78.8%) revealed postoperative deviation of less than 10 PD, 11 (12.9%) and 7 (8.2%) esotropia and exotropia more than 11 PD, respecrively, 1 month after surgery. At 1year postoperatively, 59 (77.6%), 8 (10.5%) and 9 (11.8%) showed acceptable deviation, undercorrection, and overcorrection, respectively. 4 years after surgery, 26 (81.2%) and 3 (9.4%) each showed acceptable deviation, undercorrection, and overcorrection, respectively. The results showed a tendency to become exotropic during the 4 years after surgery. CONCLUSIONS: In partially accommodative esotropia, it is essential that orthotropia or minimal esotropia should be present in the early postoperative period in order to obtain a good binocular alignment as the long term result. It is recommended that overcorrection be avoided in early postoperative exotropia.

The Long-term Follow-up Results of Patients with Partially Accommodative Esotropia after Conventional Surgery

PURPOSE: To evaluate the changes of clinical features after long-term follow-up observation on patients with partially accommodative esotropia who had undergone conventional surgery. METHODS: Thirty-five patients who maintained orthophoria for at least one year duration after surgery were evaluated. The amount of surgery was measured based on the near angle of deviation after full hyperopic correction. The comparison was made based on the best corrected visual acuity, refractive errors, degree of stereopsis and ocular positions before and after surgery. RESULTS: The mean spherical equivalent was +4.46 D before surgery and +3.66 D at the final examination. Among a total of 70 eyes, the best corrected visual acuity of 0.6 or less was seen in 16 before surgery, and in 12 at the final examination. The average angle of deviation was 50.14 PD before correction and 34.43 PD after correction. The Titmus stereotest after surgery was 80 sec of arc in 6, and even 40 sec of arc in 2 out of the 35 patients. At the final examination, 29 of the 35 patients revealed stable orthophoria, but exophoria, in a range of 15-25 PD, developed in 6 patients. Of these 6, 4 had anisometropic amblyopia, and 1 had bilateral high hyperopia of 8.0 D with refractive amblyopia. CONCLUSIONS: Long-term follow-up observation is essential after surgery for partially accommodative esotropia due to fear of the gradual development of consecutive exotropia, particularly in amblyopia cases, even though acceptable initial postoperative orthophoria has been achieved.

Clinical Features of Refractive Accommodative Esotropia and Partially Accommodative Esotropia

PURPOSE: To examine the difference between refractive accommodative esotropia and partially accommodative esotropia retrospectively. METHODS: Children with refractive accommodative esotropia and partially accommodative esotropia respectively were included in the study. The features studied were sex, age at the time of presentation, ocular alignment, refractive error, and amblyopia. RESULTS: Seventy-two children with refractive accommodative esotropia and 60 children with partially accommodative esotropia were identified. The age of each group was 40.51 +/- 9.63 months and 30.15 +/- 16.95 months respectively at the time of presentation. Amounts of esodeviation were 29.40 +/- 12.13PD and 44.57 +/- 15.92 PD. Refractive error were +4.59 +/- 1.43D and +3.63 +/- 1.61D at the time of presentation. Incidence of amblyopia were 31% and 40% at the time of presentation. Refractive error at the final visit were +3.79 +/- 1.37D and +3.18 +/- 1.48D. Incidence of amblyopia at the final visit were 11% and 23%. CONCLUSIONS: Patients of partially accommodative esotropia showed statistically significantly different features: early onset, large amount of esodeviation, and small refractive errors. Higher incidence of amblyopia was noted at partially accommodative esotropia, but this result was not statistically significant.

Long-Term Outcome of Patients with Partially Accommodative Esotropia Who had Augmented Surgery

PURPOSE: To investigate the long-term outcome of patients with partially accommodative esotropia who had augmented surgery. METHODS: Twenty patients with partially accommodative esotropia who underwent augmented surgery were studied retrospectively. The amount of medial rectus recession was measured based on the average of the near deviation with and without spectacle correction. During the follow-up period, the changes of refractive error and angle of deviation were evaluated and the Titmus test and Worth 4-Dot test were performed. The follow-up period was at least 24 months. RESULTS: The average follow-up period was 51.6+/-18.16 months (28~86 months). Seventeen patients showed postoperative deviations of 10 PD or less, one patient was overcorrected, two patients were undercorrected. Sensory tests were performed in 17 patients. Worth 4-dot test resulted in a fusion response at far in 6 patients and at near in 8 patients. Titmus stereotest resulted in positive fly (3000 seconds of arc) in all patients and more than 80 seconds of arc in 3 patients. CONCLUSIONS: Surgical overcorrection in patients with partially accommodative esotropia who had augmented surgery is not worrisome and augmented surgery provides some degrees of stereoacuity and fusion.

The Longterm Postoperative Alignment and Binocularity of Partially Accommodative Esotropia

In this study, 63 patients underwent unilateral or bilateral medial rectus recession for nonaccommodative portion of partially accommodative esotropia and were followed up for more than 2 years after surgery.The nonaccommodative portion was measured by wearing the least hyperopic glasses for the best corrected visual acuity.The amount of recession of medial rectus was determined considering the patients'characteristics such as fusional ability, amount of hyperopia, AC/A ratio, visual acuity, and quality of muscle at forced duction test. The mean follow-up period was 5.2 +/-2.53 (2~13)years.Seven (11.2%) patients underwent surgery for recurrent esotropia due to deterioration. Consecutive exotropia did not occur.At the last visit all eyes were aligned with favorable stereopsis.Forty eight patients (76.2%)had deviation up to 8 PD of orthophoria and 15 patients showed esophoria greater than 8 PD, with fusional ability and stereoacuity of 40~400 seconds of arc (sec).Preoperatively, only 28.1%of the patients had gross stereopsis of 200~3000 sec.Postoperatively, 98.6%of the patients showed good stereopsis better than 800 sec : 75.5%better than 200 sec and 76%normal stereopsis more than 40 sec. This study revealed that individualized surgery for nonaccommodative component, and meticulous pre-and postoperative management resulted in good alignment and binocularity during long-term follow-up.Recurrent esotropia due to detrioration occurred more than consecutive exotropia after surgery.

Augmented Surgery for Partially Accommodative Esotropia

The conventional surgery, based on the nonaccommodative angle after full correction of a hypermetropic refractive error, has resulted in a high incidence of undercorrection in the partially accommodative esotropia. In this study, we compared the conventional surgery group (82 patients)to the augmented surgery group (102 patients)in a total of 184 patients.The follow-up period in each group was at least 6 months. Of the 82 patients in conventional surgery group, 55 (67%)showed postoperative deviations of 10 delta or less, 25 (30%)undercorrection, and 2 (3%)overcorrection.Of the 102 patients in augmented surgery group, 81 (79%)revealed postoperative deviations of 10 delta or less, 9 (9%)undercorrection, and 12 (12%) overcorrection.The deviation was improved toward orthotropia by spectacle reduction of less than +2.0 D in overcorrected patients (2 of 2 in conventional surgery group, and 9 of 12 in augmented group).But 3 patients in augmented surgery group remained overcorrected. Our conclusion is that augmented surgery, even if it increase overcorrection, provides better postoperative alignment than conventional surgery in partially accommodative esotropia.

Treatment for Convergence Excess Esotropia by Slanted Medial Rectus Muscle Recession

To investigate whether the slanted medial rectus recession can correct excess esotropia at near without overcorrection at distance and reduce the distance-near deviation difference, we examined 11 convergence excess esotropia patients who had deviation at near exceeding distance esotropia by 15PD or more, and underwent this operation. They composed of 7 partially accommodative esotropia with high AC/A ratio and 4 nonaccommdodative convergence excess esotropia. The surgical procedure consisted of bilateral, symmetrical slanted recession of the medial rectus muscle. The amount of recession of the upper and lower margins were calculated so as to correct the esotropia with correction at distance, and near respectively. The preoperative mean near and distance deviation were 33.8PD and 15PD, and each decreased to 9.2PD and 4.3PD postoperatively. The preoperative mean distance-near deviation difference were 18.8PD, and decreased to 5.4PD postoperatively. The 3 patients decreased over 10PD in the distancenear deviation difference. In conclusion, the surgical procedure, as bilateral slanted medial rectus recession, can correct excess esotropia at near without overcorrection at distance and reduce the distance-near deviation difference. Therefore, the bilateral slanted medial rectus recession may be used as the method of surgical treatment in convergence excess esotropia.