Four cases of acute comitant esotropia associated with diffuse intrinsic pontine glioma in children.

BACKGROUND: Acute acquired concomitant esotropia (AACE) is usually a benign form of strabismus that infrequently is associated with intracranial pathology. Clinicians have noted an increase in its incidence and theorize that it may be related to public health "lockdown" measures taken in response to the COVID-19 pandemic. With an increased incidence of AACE clinicians must firstly differentiate AACE from common accommodative esotropia and secondly recognize AACE as a possible sign of serious neuropathology.Diffuse Intrinsic Pontine Glioma (DIPG) is a devastating diagnosis for affected families. Children typically present at age 6-7 years with cranial nerve palsies, long tract signs, and/or cerebellar signs. Diagnosis is made from characteristic findings on magnetic resonance brain imaging (MRI brain) and treatment includes radiotherapy and palliative care. Two years from diagnosis, 90% of affected children will have died from their disease. CASE SERIES: We present four cases that attended our pediatric ophthalmology clinic with AACE either as a presenting sign of DIPG or as a clinical finding following a DIPG diagnosis. Patient A (age 5 years) presented to the emergency eye clinic with sudden onset diplopia and intermittent esotropia. Suppression later developed, they had 0.00 logMAR visual acuity either eye, and bilateral physiological hypermetropia. MRI brain imaging requested as a result of the unusual presentation led to the DIPG diagnosis. The other 3 cases (ages 11, 5 & 5 years) were assessed post DIPG diagnosis and found to have an esotropia measuring bigger on 1/3-meter fixation than 6-meter fixation, full ocular motility, physiological hypermetropia or emmetropia, and visual acuity normal for age. Other than patient B (age 11 years), who had papilledema and gaze evoked nystagmus when they were assessed 2 weeks prior to death, no patient had any other clinical eye findings. CONCLUSIONS: This small series of 4 patients attending our clinic within a 12-month period supports the notion that children presenting with AACE should routinely be offered brain MRI. Not all children with DIPG-associated AACE have significant ophthalmic findings indicative of intracranial pathology. With the potential for increased incidence of AACE related to lockdowns, clinicians should be reminded of the infrequent possibility their patient has a more serious condition.

The effect of strabismus surgery on the learning abilities of school-aged children.

PURPOSE: To evaluate whether strabismus surgery improves the learning performance - calculation, reading and drawing - of school-aged children. METHODS: In a case-control study, patients between the ages of 7 and 10 years with horizontal strabismus, recommended for surgical correction, were prospectively included. Reading, calculating and drawing abilities were evaluated before and 3 months after corrective strabismus surgery using standardized tests. Cases were compared to control patients: patients with a surgical indication postponed due to the COVID lockdown. RESULTS: Forty-two operated patients and 42 controls between the ages of 7 and 10 years with horizontal strabismus were included. The average reading speed was 65.8 words per minute pre-operatively compared to 80.6 words per minute post-operatively (p = 0.0038). The average drawing score was 71.1 pre-operatively compared to 84.3 post-operatively (p = 0.012). The average calculation score was 3.2 pre-operatively compared to 3.4 post-operatively (p = 0.363). Improvement given by strabismus surgery was confirmed avoiding the learning effect by comparison with the control group. The improvements observed were more significant in the youngest patients and esotropia. CONCLUSIONS: This study highlights that strabismus surgery significantly improved the children's reading fluency and drawing task execution. These encouraging data should be taken into account when considering the indications for strabismus surgery.

Multiple Sclerosis Presenting as Intracranial Hypertension in the Setting of COVID-19 Infection (preprint)

Background Multiple sclerosis (MS) and Idiopathic Intracranial Hypertension (IIH) occur more commonly in women of childbearing age. There is cerebral spinal fluid (CSF) altered dynamics in both diseases causing them to have similar presentation at times. Coronavirus disease 19 (COVID-19) have also been reported to affect the Central Nervous System (CNS) of any age.Case Presentation: We report A-19-year-old male who initially presented with headaches, and fever and was diagnosed with COVID-19 infection. A few days later, he developed acute severe left eye pain, blurred vision, diplopia, and left ear tinnitus. The patient was found to have reduced visual acuity, left sixth nerve palsy, esotropia and asymmetric bilateral papilledema. Later, he developed left facial nerve palsy. MRI of the brain showed extensive demyelinating lesions. Lumbar puncture revealed significantly increased intracranial pressure (ICP) and positive oligoclonal bands.Conclusion This is a unique case of MS presenting with intracranial hypertension (IH) in the setting of COVID-19 infection that could have been the trigger for the MS clinical attack.

The effects of topical cycloplegics in acute acquired comitant esotropia induced by excessive digital device usage.

BACKGROUND: Acute acquired comitant esotropia induced by excessive digital device usage, especially smartphones (SAACE), has been increasing over the past few years. One suggested mechanism is convergence spasm induced by excessive near work, with refraining from digital device use considered to be an effective method for decreasing the degree of esodeviation. However, if symptoms persist and are untreated over time, recovery becomes more difficult. The present study evaluated the effects of topical cycloplegics on persistent SAACE untreated for over 1 year. METHODS: Patients with sustained SAACE that was untreated for over 1 year were evaluated. Digital device usage was discouraged and a topical cycloplegic, 0.4% tropicamide, was prescribed at bedtime. After obtaining informed consent, the 14 out of 23 enrolled patients who agreed to eye drop administration were defined as the study group, with the others serving as the controls. After a 3-month follow-up, patients who elected to undergo surgery were analyzed as the surgery group. Changes in esotropia angles, stereoacuity and diplopia complaints were evaluated after a 3-month follow-up. RESULTS: Esotropia angles decreased and stereoacuity improved after a 3-month treatment in the study group (P < 0.01). Diplopia disappeared in 13 patients (92.9%, totally disappeared or disappeared when using glasses with built-in prisms). Among 11 patients with untreated esotropia ranging from 1-3 years, decreases in esotropia angles were correlated to untreated esotropia duration (near: R = -0.6; distance: R = 0.7; both P < 0.05). Esotropia angles in the control group exhibited a tendency to increase while stereoacuity tended to deteriorate after the 3-month follow-up. As diplopia did not disappear in any patients, 7 elected to undergo surgery and were enrolled as the surgery group. While esotropia angles decreased in the study group, they were lower than the surgery group (P < 0.01), but higher than the control group (P < 0.01). Stereoacuity was worse in the control versus the study and surgery groups (both P < 0.05). CONCLUSION: Results suggest short-acting topical cycloplegics are effective in SAACE patients with long untreated periods. Decreases in esotropia angles were negatively correlated to untreated esotropia duration, which suggests the necessity of early treatment.

Acute acquired comitant esotropia precipitated by excessive near work during the COVID-19-induced home confinement.

Purpose: To evaluate the causes of acute acquired comitant esotropia (AACE) in young adults and children in the setting of COVID-19-induced home confinement. Methods: A retrospective, clinical study of all patients, who presented to the Pediatric Ophthalmology and Strabismus services of a tertiary eye care center in South India from August 2020 to January 2021 during the COVID-19 pandemic, with acute-onset, comitant esotropia. Results: 11 (73.3%) of the total 15 patients were students, above 10 years and with a mean age of 16.8 years. 12 patients (80%) had more than 8 hours of near activity a day with a mean duration of 8.6 hours per day. The most common near activity was online classes, followed by job-related work and mobile games, and 86.7% used smartphones for near work. The average esotropia was 22.73 prism diopter (PD) for distance and 18.73 PD for near. Majority (66.6%) had hyperopia with basic or divergence insufficiency esotropia, and the remaining 33.3% had myopia and fitted in to the Bielschowsky type AACE. There was no precipitating event other than sustained near work in all, except in one patient who also had fever prior to the onset of esotropia. Conclusion: The habit of long-time and sustained near work, especially on smartphones, may increase the risk of inducement of AACE.

How to Manage a Strabismus Clinic During the COVID-19 Pandemic; What is Really Urgent, What is Not?: A Single-Center Case Series from Turkey

Objectives: To evaluate the management of the pediatric ophthalmology and strabismus clinic when strict quarantine conditions were adopted during the coronavirus disease 2019 (COVID-19) pandemic in Turkey. Materials and Methods: The study presents a review of the patients examined during the quarantine period. All patients were assessed with the highest possible level of personal protection. Results: Ten patients (6 girls, 4 boys) with a mean age of 9 years (range: 2-16) were evaluated. The patients presented 3-20 days after symptom onset. Ocular misalignment and diplopia were the main symptoms. Four of the 10 patients were diagnosed with sixth cranial nerve palsy and three patients were diagnosed with acute-onset comitant esotropia. Six patients had significant cranial magnetic resonance imaging findings. Conclusion: Acute-onset neurological conditions are more common during the COVID-19 pandemic. These reports will contribute to global experience and understanding of COVID-19.

Series of cases of acute acquired comitant esotropia in children associated with excessive online classes on smartphone during COVID-19 pandemic; digital eye strain among kids (DESK) study-3.

Extra time of sitting in front of a digital device is required for e-learning by children during Corona virus (COVID-19) pandemic which can lead to many ocular problems including digital eye strain (DES). In view of increased incidence of DES in children, multiple studies had been conducted in central India to assess the eye strain in children due to excessive online classes as a research project named "Digital eye strain among kids (DESK) study." This study DESK-3 aimed to report series of cases of acute acquired comitant esotropia (AACE) in children attending online classes during COVID-19 pandemic. Children aged 6-18 years with recent onset of esotropia of < 1-month duration without any similar history in past presented in month of July-August 2020 at a tertiary children eye care hospital were evaluated. Data collection included age and gender of child, presence or absence of diplopia, visual acuity, duration of smartphone use, duration of online classes, angle of deviation for near and distance and cycloplegic refraction. Total eight children of AACE were included in the study. The mean age of children was 12.5 ± 4.2 years. All eight were males. The mean duration of smartphone use was 4.6 + 0.7 hours per day. All children were attending online classes > 4 hours per day on smartphone of average size 5.5 inches. Five children were emmetropic, one myopic, one pseudomyopic and one hyperopic. The angle of deviation for near and distance were 48.1 ± 16.4 PD and 49.3 ± 15.9 PD respectively with normal ocular motility. Seven children complained of horizontal diplopia in all gazes. Neurological examination and CT scan of brain and orbit was normal in all patients.  Two months before the lockdown only one case was identified as compared to eight during the lockdown. Prolonged near work during smart phone use for e-learning might lead to the development of AACE in children.

Acute Acquired Concomitant Esotropia From Excessive Application of Near Vision During the COVID-19 Lockdown.

The public health measures imposed in many countries to slow the spread of the novel coronavirus (COVID-19) outbreak could have negative effects on children's physical and mental health. The authors describe four cases of acquired concomitant acute esotropia likely caused from excessive application of near vision during the COVID-19 lockdown. [J Pediatr Ophthalmol Strabismus. 2020;57:e88-e91.].