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Prompt dispensing of hypermetropic spectacle correction is therefore important to correct the esotropia totally or partially and reduce the occurrence of amblyopia.
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The most common types of acquired esotropia are the accommodative, the nonaccommodative, the cyclic, and the sensory esotropia. These often have an intermittent beginning. More seldom acute acquired concomitant esotropia develops [ 1 ]. Only the most frequent type, i. Accommodative esotropia can have an infantile onset at 2 months to 1 year of age but typically develop between 1 and 3 years of age. The deviation is often initially intermittent and becomes constant. The etiology is related to hypermetropia that necessitates increased accommodation for the child to achieve a clear image.
The goal is to establish straight eyes within 8 to 10 PD of orthotropia to stimulate binocular fusion. This can be achieved in some patients with optical correction alone, and surgery is not indicated then. The patients that do not get straight eyes wearing full hypermetropic correction, as the child in Figure 3 , needs urgent surgery. Therefore, these patients should be aggressively treated with early optical correction and surgery if indicated to avoid or treat amblyopia and stimulate binocular function in the small kids 2 months to 2 years , restore binocularity in older children 2 years to 6 years , and eliminate diplopia and regain stereo acuity in the children over 6 years of age.
The younger the children the more vulnerable is the binocularity, and visibility could be lost if treatment is delayed. These authors agree with the late Dr. Marshall Parks that recent onset accommodative esotropia is an ophthalmic emergency, and the patient should be seen at an urgent appointment.
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The management and preoperative evaluation includes the same examination procedures as patients with infantile esotropia, including the examination of ductions, versions, and evaluation for and treatment of amblyopia after full hypermetropic correcting spectacles is prescribed, following the same method as described previously. However, important additional preoperative orthoptic considerations and examinations are necessary:. Urgent performance of cycloplegic refraction and prescription of the full hypermetropic correction, even at babies only 2 months of age, is necessary in order to avoid development of amblyopia and loss of binocularity that is lost proportionally with the time after onset.
Single vision glasses are to be continued, and surgery is not indicated. This is termed accommodative esotropia. This is the case if the full hypermetropic correction corrects the distance deviation resulting in fusion i. Prescribe the least amount of near deviation add to obtain fusion at near deviation, i. Example: The patient, in Figure 4 , has a deviation of ET 20 with full hypermetropic correction but without extra lenses.
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Test for binocularity and stereo acuity using Bagolini-striated test, Titmus, Lang, or TNO test with correcting prism bar, depending on the age of the child and level of stereo acuity present. The surgeon should aim to slightly overcorrect those patients with binocular potential but undercorrect those patients with no binocular function, e.
Since accommodative esotropia is acquired, and the eyes are aligned during the early period of visual development, most patients have good binocular potential at the onset of the esotropia. The goal is to achieve orthotropia within 10 PD of esotropia to establish high-grade stereo acuity. The surgical goal for partially accommodative esotropia is not to operate patients out of glasses but to achieve alignment and fusion with full hypermetropic correction. Surgery is urgent as the longer the esotropia persists, the worse the prognosis for establishing binocular fusion. For infants, distance measurements are difficult to obtain; try to get this measurement but base the surgery on the near deviation.
Therefore, surgery for infantile partially accommodative esotropia requires bilateral medial rectus recessions augmented surgery Wright and Bruce-Lyle using the augmented formula, i. Average the near deviation with correction and the near deviation without correction or bilateral MR recessions 5. Bilateral medial rectus recessions are also the treatment of choice for partially accommodative esotropia in older children. A relatively small distance deviation and large near measurement is more difficult to manage as the near distance discrepancy tends to persists postoperatively.
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It is recommended to perform bilateral medial recessions using a target angle based on the augmented formula with slight reduction in the numbers to prevent consecutive exotropia at distance. The patients should be informed that bifocal spectacles may be required after surgery. There are 3 methods for determining the target angle for partially accommodative ET.
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These are described in the following examples:. Standard surgery formula uses the residual distance deviation with full hypermetropic correction as the target angle. Augmented surgery formula uses the target angle, which is the average between near deviation without correction largest and distance deviation with correction smallest.
Then have the patient wear the glasses for 1 week. The deviation is then remeasured, and if it increases, additional base out prism is applied. This process is repeated until the deviation is stabilized. Prescribe 30 PD base out press-on prisms over full hypermetropic correction and return in 1 week. At follow-up visit, there is no change in the deviation, after placing the 30 PD base put prism; target angle: 30 PD; surgery: BMR recessions 4. If the exotropic angle persists more than 3 months, reoperation should be considered. If the exotropia is large and associated with even mild adduction deficit, stretched scar or slipped muscle should be suspected, and the medial muscle should be explored and advanced if there is an insertion dehiscence.
Surgery plan is the same as for consecutive exotropia as described above in congenital esotropia. The normal eye position of rest is divergent due to the divergent positioning of the orbits. Intermittent exotropia is a large exophoria usually between 20 and 40 PD that is difficult to fuse and intermittently breaks down and manifests especially when fatigued, daydreaming, or takes sedatives or drinking alcohol. Patients with intermittent exotropia have perfect stereoacuity when aligned phoria phase , but no stereoacuity when tropic because the patient suppress the image from the deviated eye tropia phase.
Rarely patients will see double or have ARC when tropic. This is the case in patients with late onset exotropia during late childhood or adulthood. Patients with intermittent exotropia do not get strabismuc amblyopia because they have intermittent binocular fusion with high-grade stereoacuity that provides binocular visual stimulation. Patients with intermittent exotropia can have anisometropic amblyopia with the same incidence as the general population. Figures 6 and 7 show a child with intermittent exotropia and straight eyes when the deviation is fused phoria phase , and moments later, where the patient lost concentration, fusion broke and exodeviation became manifest tropia phase.
For the most part, the treatment of intermittent exotropia is surgical. The indication for surgery is poor fusion control. Large deviations over 20 PD will eventually need surgery as they are difficult to fuse and will increase over time. Nonsurgical options is not effective except for convergence exercises for convergence insufficiency, which is the preferred management in that disorder. Convergence exercises consist of pencil push-ups, which improve fusional convergence for near deviation, useful for convergence insufficiency, but will not reduce the distance exodeviation.
Other nonsurgical treatment options is over minus glasses and monocular occlusion.
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Over minus glasses reduce the exotropia by stimulating accommodative convergence, which is not well tolerated because it requires the patient to constantly overaccommodate. Increase myopic correction by Monocular occlusion by patching the dominant eye for 2 to 4 h a day has been described, but recent prospective study shows no significant effect [ 8 ].
A surgical indication is poor fusion control. In general, it is preferable to operate after 4 years of age. This is because a small consecutive esotropia can occur after surgery, and as young children have the ability to suppress and develop amblyopia, they can loose stereoacuity after surgery. Older children with deviations greater than 20 PD are difficult to fuse and can causes eye strain, so these patients should be considered for surgery.
The procedure of choice for intermittent exotropia is bilateral rectus recessions. A small consecutive esotropia 4—8 PD immediately after surgery is desirable as the late recurrence of the exotropia is common.
This consecutive exotropia will cause diplopia but usually resolve in a few days. The standard surgical number chart Appendix I have this small overcorrection built in. The pattern of the deviation is important for determining the surgical plan. Exopatterns are classified based on difference of deviation, distance deviation versus near deviation: 1 basic, 2 convergence insufficiency, and 3 divergence excess divided into pseudo and true divergence excess. Convergence insufficiency intermittent exotropia type includes patients with weak convergence with a greater esotropia for near deviation.
If the eyes are straight for distance, it is best to avoid surgery and treat with convergence exercises. Convergence insufficiency is the one strabismus that can be helped by exercises, e. Nsc X T 30; plan: convergence exercises—no surgery. Patients will require convergence exercises after surgery for an X T at near deviation.
follow link Divergence excess X T intermittent is when the exotropia is larger for distance than near, by at least 10 PD, e. There are 2 types of divergence excess:. Tenacious fusional convergence is near convergence that persists for several minutes after monocular occlusion. Patching one eye for 45 min breaks tenacious fusional convergence. If the near exodeviation increases to be similar to the distance angle, e. Bilateral LR recessions with target angle somewhere between distance and near deviations; see example below:.
Therefore, bifocals and more than one surgery are likely, and patients should be told this preoperatively. The immediate postoperative goal of surgery for intermittent exotropia is to achieve a small consecutive esodeviation of about 5 PD esotropia; in the long term, it is common for exotropia to recur. Larger consecutive esodeviations will often require further surgery. Children under 4 years of age with a small consecutive esotropia can rapidly develop amblyopia.
That is why Dr. Wright suggests to postpone surgery to after 4 years of age if possible.