Clinical features of acute acquired comitant esotropia in the Chinese populations.

Acute acquired comitant esotropia (AACE) is an unusual presentation of esotropia that occurs after infancy. This study was aimed to study the clinical features and the differences between children and adult patients with AACE in the Chinese populations.This was a retrospective analysis of patients diagnosed with AACE over 4 years; 69 patients (25 females and 44 males) were identified. The patients were divided into 3 groups: < 10 year-old (n = 6, 8.7%), 10-18 year-old (n = 23, 33.3%), and ≥18 year-old (n = 40, 58.0%). Patients underwent medical history, brain and orbital computed tomography, and ophthalmological and orthoptic examinations.The refractions of AACE patients varied among age groups: patients < 10 year-old had mild hypermetropia, while older children and adults showed moderate-to-high myopia (P < .001). The mean angles of esotropia were significantly larger in young children compared with older children and adults (P = .005). There was no significant difference in binocularity detected by either synoptophore or TNO stereoscopic testing among different disease durations. Stereopsis detected by synoptophore and TNO testing showed no significant difference at duration within half a year, but the stereopsis measured by TNO was significantly worse than that detected by synoptophore with extending disease duration (P < .05).AACE seems to occur mostly in older children and adults in the Chinese population. Younger children with AACE seem to demonstrate a common trait of mild hypermetropic refractive errors, while myopia can be seen in older children and adult patients. The duration from onset to treatment of esotropia does not affect the preoperative binocularity.

Detection of Strabismus by Non-Health Care Professionals in an Ethnically Diverse Set of Images.

IMPORTANCE: Understanding the criteria for when strabismus becomes detectable by non-health care professionals could influence the goals for determining the success of surgical intervention and how patients with such misalignments are counseled. OBJECTIVE: To examine the magnitude at which strabismus is detectable by lay observers in an ethnically diverse set of images. DESIGN, SETTING, AND PARTICIPANTS: Photographs of 12 ethnically diverse models (black, white, and Asian) were simulated to have strabismus from esotropia of 21 prism diopters (∆) to exotropia of 21∆. From July 1, 2007, to October, 1, 2008, images were presented to 120 non-health care professionals aged 21 years or older from the general community in Boston, Massachusetts, who were asked whether strabismus was present. Analysis was conducted from November 1, 2008, to March 31, 2009. MAIN OUTCOMES AND MEASURES: The threshold angle for detecting strabismus to enable 70% of lay observers to make a positive determination whether strabismus is present. RESULTS: In white and black models, the threshold allowing a 70% positive detection rate was higher for esotropia than for exotropia (P < .001 for both). For white models, the threshold was 23.2∆ (95% CI, 21.0∆ to 26.5∆) for esotropia and 13.5∆ (95% CI, 12.5∆ to 14.6∆) for exotropia. For black models, the threshold was 20.8∆ (95% CI, 19.2∆ to 22.2∆) for esotropia and 16.3∆ (95% CI, 15.5∆ to 17.2∆) for exotropia. Asian models showed an opposite trend, with the threshold allowing a 70% positive detection rate for esotropia (14.3∆; 95% CI, 13.2∆ to 15.7∆) being lower than that for exotropia (20.9∆; 95% CI, 18.0∆ to 24.6∆) (P < .001). CONCLUSIONS AND RELEVANCE: Esotropia was easier for lay observers to detect than exotropia in Asian models, and exotropia was easier to detect than esotropia in white and black models. This information should be considered when managing patients who have concerns about the social significance of their strabismus. Future studies should include diverse individuals and make an effort to account for individual factors that may alter the perception of strabismus.

Low positive predictive value of referrals for infantile esotropia among children of Chinese descent.

The prevalence of strabismus varies according to the population studied, ethnicity, and geographic region. Previous studies of Asian populations have found that, unlike Western populations, esotropia is 2.5 times less common than exotropia. Because of the homogeneous nature of the local populations studied, however, it is difficult to ascertain the real difference in the epidemiology among ethnic groups. The aim of this study was to determine the positive predictive value of referrals for infantile esotropia in otherwise healthy children referred to a tertiary eye care center in a large center in North America that serves a ethnically diverse population of over 8 million. We found a very low positive predictive value (5.9%) and a very high false referral rate (94.1%) among Chinese children referred for early-onset esotropia.

Comitant horizontal strabismus in South African black and mixed race children--a clinic-based study.

PURPOSE: To examine the types of comitant horizontal strabismus in children belonging to the two largest ethnic groups of the Western Cape, South Africa. METHODS: Retrospective review of 2371 children presenting with comitant horizontal strabismus to a single, large, pediatric tertiary referral center in Cape Town, South Africa, between 1997 and 2007. RESULTS: 81% of children were of mixed race and 19% were black. The overall esotropia:exotropia ratio was 73:27. For black children this was 85:15 and for mixed race, 71:29. The overwhelming majority of black children had congenital esotropias (74%), whereas accommodative esotropia was rare (9%). In mixed race children, esotopias were more equally divided between congenital (46%) and accommodative types (35%). Exotropias were uncommon in black children, and were mainly constant (61%). Intermittent exotropias predominated in mixed race children (55%). CONCLUSION: Congenital esotropia remains common in South African black children, and of the few who presented with exotropia, most had constant type. Accommodative esotropias were more prevalent in South African mixed race children, but in smaller proportions than in other studies. Exotropias were mostly intermittent in this ethnic group, and showed a similar profile to that in white American children.

Risk factors associated with childhood strabismus: the multi-ethnic pediatric eye disease and Baltimore pediatric eye disease studies.

OBJECTIVE: To investigate risk factors associated with esotropia or exotropia in infants and young children. DESIGN: Population-based cross-sectional prevalence study. PARTICIPANTS: Population-based samples of 9970 children 6 to 72 months of age from California and Maryland. METHODS: Participants were preschool African-American, Hispanic, and non-Hispanic white children participating in the Multi-Ethnic Pediatric Eye Disease Study and the Baltimore Eye Disease Study. Data were obtained by parental interview and ocular examination. Odd ratios and 95% confidence intervals were calculated to evaluate the association of demographic, behavioral, and clinical risk factors with esotropia and exotropia. MAIN OUTCOME MEASURES: Odds ratios (ORs) for various risk factors associated with esotropia or exotropia diagnosis based on cover testing. RESULTS: In multivariate logistic regression analysis, esotropia was associated independently with prematurity, maternal smoking during pregnancy, older preschool age (48-72 months), anisometropia, and hyperopia. There was a severity-dependent association of hyperopia with the prevalence of esotropia, with ORs increasing from 6.4 for 2.00 diopters (D) to less than 3.00 D of hyperopia, to 122.0 for 5.00 D or more of hyperopia. Exotropia was associated with prematurity, maternal smoking during pregnancy, family history of strabismus, female sex, astigmatism (OR, 2.5 for 1.50 to <2.50 D of astigmatism, and 5.9 for ≥2.5 D of astigmatism), and anisoastigmatism in the J0 component (OR, ≥2 for J0 anisoastigmatism of ≥0.25 D). CONCLUSIONS: Prematurity and maternal smoking during pregnancy are associated with a higher risk of having esotropia and exotropia. Refractive error is associated in a severity-dependent manner to the prevalence of esotropia and exotropia. Because refractive error is correctable, these risk associations should be considered when developing guidelines for the screening and management of refractive error in infants and young children. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Risk factors for decreased visual acuity in preschool children: the multi-ethnic pediatric eye disease and Baltimore pediatric eye disease studies.

OBJECTIVE: To investigate risk factors associated with unilateral or bilateral decreased visual acuity (VA) in preschool children. DESIGN: Population-based, cross-sectional prevalence study. PARTICIPANTS: Population-based samples of 6504 children ages 30 to 72 months from California and Maryland. METHODS: Participants were preschool African-American, Hispanic, and non-Hispanic white children from Los Angeles, California, and Baltimore, Maryland. Data were obtained by a parental interview and a detailed ocular examination. Logistic regression models were used to evaluate the independent associations between demographic, behavioral, and clinical risk factors with unilateral and bilateral decreased VA. MAIN OUTCOME MEASURES: Odds ratios (ORs) for various risk factors associated with interocular difference (IOD) in VA of ≥2 lines with ≤20/32 in the worse eye, or bilateral decreased VA <20/40 or <20/50 if <48 months of age. RESULTS: In multivariate logistic regression analysis, 2-line IOD with a VA of ≤20/32 was independently associated with Hispanic ethnicity (OR, 2.05), esotropia (OR, 8.98), spherical equivalent (SE) anisometropia (ORs ranging between 1.5 and 39.7 for SE anisometropia ranging between 0.50 to <1.00 diopters [D] and ≥2.00 D), and aniso-astigmatism in J0 or J45 (ORs ranging between 1.4 and ≥5.3 for J0 or J45 differences ranging between 0.25 to <0.50 D and ≥1.00 D). Bilateral decreased VA was independently associated with lack of health insurance (OR, 2.9), lower primary caregiver education (OR, 1.7), astigmatism (OR, 2.3 and 17.6 for astigmatism 1.00 to <2.00 D and ≥2.00 D), and SE hyperopia ≥4.00 D (OR, 10.8). CONCLUSIONS: Anisometropia and esotropia are risk factors for IOD in VA. Astigmatism and high hyperopia are risk factors for bilateral decreased VA. Guidelines for the screening and management of decreased VA in preschool children should be considered in light of these risk associations. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Predictive factors for long-term outcome of stereoacuity in Japanese patients with pure accommodative esotropia.

PURPOSE: To find clinical factors related to the long-term outcome of stereoacuity in Japanese patients with pure accommodative esotropia, including both the refractive type and the nonrefractive type. METHODS: The medical charts of 19 Japanese patients (8 boys and 11 girls) with pure accommodative esotropia who were followed for 10 years or more at Okayama University Hospital were reviewed retrospectively. Refractive accommodative esotropia was diagnosed in 8 patients while nonrefractive accommodative esotropia was diagnosed in 11 patients. The patients were divided into two groups, based on a stereoacuity of 120 seconds of arc or better versus 240 seconds of arc or worse as measured by the TNO test at the final visit, and the clinical factors were compared between the two groups. RESULTS: Clinical factors related to a stereoacuity of 240 seconds of arc or worse at the final visit were higher accommodative convergence to accommodation (AC/A) ratios at 6 years of age (p = 0.05), larger residual esodeviations at distance under full correction with glasses at 8 years of age (p = 0.03), and larger residual esodeviations at near at 6 years of age (p = 0.01, Mann-Whitney U-test). Overall, patients with nonrefractive accommodative esotropia tended to show poor levels of stereoacuity at the final visit compared to those with refractive accommodative esotropia (p = 0.059, Fisher exact probability test). CONCLUSION: This is the first study of the long-term visual outcome in Japanese patients with pure accommodative esotropia including both refractive and nonrefractive types. To obtain better levels of stereoacuity, the residual esodeviations at near and at distance should be kept as small as possible under full correction with glasses, including bifocals, especially at the ages of 6 and 8 years.

Risk factors for esotropia and exotropia.

OBJECTIVE: To identify risk factors associated with the two major types of strabismus--esotropia and exotropia--in a cohort of children followed up from gestation to age 7 years. DESIGN: Pregnant women were enrolled in the Collaborative Project of the National Institute of Neurological Disorders and Stroke, Bethesda, Md, from 1959 to 1965 at 12 university centers. This large multidisciplinary study was designed to evaluate the developmental consequences of complications during pregnancy and the perinatal period. Data on maternal, socioeconomic, perinatal, and neonatal characteristics were collected from 39,227 children and their mothers by medical examination and interview. Examinations of the children were performed at birth, 4 months, 8 months, 1 year, and 7 years. OUTCOME MEASURES: The evaluation of the presence of strabismus was performed during follow-up examinations and confirmed at the 7-year follow-up visit. Potential risk factors for strabismus were evaluated from the maternal, socioeconomic, perinatal, and neonatal characteristics. RESULTS: Esotropia developed in 1187 children (3.0%), and exotropia developed in 490 children (1.2%). Esotropia was more common in whites (3.9% in whites vs 2.2% in blacks, P < .0001). The occurrence of exotropia was similar in the two races (1.2% in whites and 1.3% in blacks). Results of multivariable logistic regression models showed that the risk of strabismus increased with low birth weight (P < .0001). For infants weighing 1500 g at birth compared with those weighing 4000 g at birth, the odd ratios were 3.26 (95% confidence interval, 2.50 to 4.25) for esotropia and 4.01 (95% confidence interval, 2.77 to 5.80) for exotropia. Maternal cigarette smoking during pregnancy also increased the risk of each type of strabismus (P < .0001). For offspring of mothers who smoked more than two packs of cigarettes per day compared with those whose mothers did not smoke, the odds ratios were 1.83 (95% confidence interval, 1.51 to 2.22) for esotropia and 2.32 (95% confidence interval, 1.72 to 3.13) for exotropia. Maternal age was also a significant risk factor for esotropia (P = .0005). The risk of esotropia increased with increasing age until age 34 years. In particular, the odds ratio for mothers aged 30 to 34 years relative to that for mothers aged 20 to 24 years was 1.43 (95% confidence interval, 1.19 to 1.70). CONCLUSIONS: Esotropia was more common in whites than in blacks. The occurrence of exotropia was similar in the two races. Maternal cigarette smoking during pregnancy and low birth weight were independent and important risk factors for both esotropia and exotropia. There was an increased risk of esotropia with increasing maternal age.

Predictors of prism response during prism adaptation. Prism Adaptation Study Research Group.

Results of the Prism Adaptation Study (PAS) indicate that prism adaptation improves the success rate of strabismus surgery for patients with acquired esotropia. Patients who show a fusion response to the prisms benefit most from this preoperative treatment. This study analyzes the characteristics of those patients who were and were not prism responders in the PAS. Significant factors predicting a prism response included: patients who were older at the time of onset of their esodeviation (P = .007), duration of deviation less than 1 year (P = .04), alternating fixation (P = .003), fusion on the Worth four-dot test at near with prism neutralization (P = .008), and equal vision (P = .009). Demographic characteristics were similar for both responders and nonresponders except that non-Hispanic patients were significantly more likely to respond to prisms than Hispanic patients (P less than .002). No test or characteristic was found which could reliably predict the prism response. Therefore, all patients with acquired esodeviations should be considered candidates for prism adaptation prior to strabismus surgery.