Long-term strabismus outcomes after unilateral infantile cataract surgery in the Infant Aphakia Treatment Study.

PURPOSE: To characterize long-term strabismus outcomes in children in the Infant Aphakia Treatment Study (IATS). METHODS: This study was a secondary data analysis of long-term ocular alignment characteristics of children aged 10.5 years who had previously been enrolled in a randomized clinical trial evaluating aphakic management after unilateral cataract surgery between 1 and 6 months of age. RESULTS: In the IATS study, 96 of 109 children (88%) developed strabismus through age 10.5 years. Half of the 20 children who were orthophoric at distance through age 5 years maintained orthophoria at distance fixation at 10.5 years. Esotropia was the most common type of strabismus prior to age 5 years (56/109 [51%]), whereas exotropia (49/109 [45%]) was the most common type of strabismus at 10.5 years (esotropia, 21%; isolated hypertropia, 17%). Strabismus surgery had been performed on 52 children (48%), with 18 of these (35%) achieving microtropia <10Δ. Strabismus was equally prevalent in children randomized to contact lens care compared with those randomized to primary intraocular lens implantation (45/54 [83%] vs 45/55 [82%]; P = 0.8). Median visual acuity in the study eye was 0.56 logMAR (20/72) for children with orthotropia or microtropia <10Δ versus 1.30 logMAR (20/400) for strabismus ≥10Δ (P = 0.0003). CONCLUSIONS: Strabismus-in particular, exotropia-is common irrespective of aphakia management 10 years following infant monocular cataract surgery. The delayed emergence of exotropia with longer follow-up indicates a need for caution in managing early esotropia in these children. Children with better visual acuity at 10 years of age are more likely to have better ocular alignment.

Nonsurgical treatment of teenagers with high AC/A ratio esotropia.

Nonsurgical treatment options commonly prescribed for teenagers with high AC/A ratios are progressive lens spectacles, single vision lens spectacles, bifocal contact lenses, and monovision. The gold standard treatment for high AC/A ratios in patients with esotropia is bifocal spectacles, but they are not cosmetically acceptable for most teenagers. However, excellent binocularity is often sacrificed with the alternative treatment options. Quality of life surveys acknowledge that poor cosmesis can have a negative psychosocial impact on individuals. Therefore, it is often necessary for practitioners to strike a balance between good psychosocial health and best visual potential with treatment options other than bifocal spectacles.

The efficacy of botulinum toxin treatment for children with a persistent esotropia following bilateral medial rectus recessions and lateral rectus resections.

BACKGROUND AND PURPOSE: To report on the outcomes of treating children with a persistent esotropia with an injection of botulinum toxin in a medial rectus muscle. PATIENTS AND METHODS: The medical records were reviewed of all children at one institution with a persistent esotropia after bilateral medial rectus recessions and bilateral lateral rectus resections then treated with a botulinum toxin injection. RESULTS: Five patients with a mean preoperative esotropia of 37Δ (range 25­50Δ) underwent bilateral medial rectus recessions and then bilateral lateral rectus resections. Their residual esotropia (mean of 25Δ; range 18­35Δ) was then treated with a single injection of 3­5 units of botulinum toxin into one medial rectus muscle. The patients were then followed for a mean of 34 months (range 14­79 months). At last follow-up, two patients had an esotropia <10Δ. The other three patients had no long-term improvement in their ocular alignment. Two of these patients then underwent additional strabismus surgery. In both cases, they then developed a consecutive exotropia. CONCLUSION: Treatment with a single injection of botulinum toxin was beneficial in 2 of 5 children. Botulinum toxin treatment alone did not result in a consecutive exotropia in any patients treated.

Vision therapy and orthoptics.

Vision therapy by orthoptists is a form of treatment to restore binocular single vision and to enhance the control of a deviation using prisms and convergence therapy. It is differentiated from optometric behavioral vision therapy (BVT) as a form of treatment to decrease rates ofjuvenile recidivism and to improve learning disabilities using colored overlays and tools such as trampolines. Evidence-based findings of randomized controlled clinical trials versus conclusions drawn from nonrandomized, poorly controlled studies of various forms of vision therapy are explored. Concrete evidence in the mainstream literature supports the positive effects of eye exercises in patients with convergence insufficiency and yoked prisms in patients with neurologic deficits. Vision therapy for juvenile delinquents and patients with dyslexia is unsubstantiated.