Journal of Pediatric Ophthalmology and Strabismus

Hypermetropia in Accommodative Esodeviation/Discussion

Edward L Raab, MD

Abstract

ABSTRACT

Contradicting earlier doctrine, several studies have indicated that hypermetropia in childhood increases over the first seven years of life, and decreases thereafter. No clear consensus exists as to these characteristics in patients with accommodative esodeviation.

In 68 subjects (136 eyes), the mean annual change in hypermetropia up to the seventh birthday was an increase of +0.19 ± 0.36 D. Subjects whose accommodative deviation deteriorated showed changes similar in magnitude. The corresponding mean annual change in a previously reported age-matched series unselected for strabismus was +U. 28 D. Hypermetropia in accommodative esodeviation showed a mean annual decrease between ages 7 and 13 years of -0.18 ± 0.25 D. The corresponding finding in the general childhood population was -0.22 D.

While clinically important individual departures from these results do occur, an accelerated rate of increase in hypermetropia is not characteristic of most cases of either controlled or of deteriorated accommodative esodeviation.

Introduction

There is difference of opinion as to the natural course of hypermetropia in accommodative esodeviation. One classic doctrine has been that most infants are moderately to highly hypermétropie at birth and that this refractive state regularly diminishes over childhood.1 The investigations and clinical experience of several authors2'9 suggest instead that hypermetropia shows a tendency either to remain stable or to increase over the first seven years of life. There is no clear consensus on this point in patients with accommodative esodeviation.

The aims of this study were: (1) To observe the natural course of hypermetropia in this population of strabismus patients, and whether it differed from that in the general childhood population; and (2) To observe the evolution of hypermetropia in deteriorated accommodative esodeviation.

Materials and Methods

The records of patients in my practice were reviewed to identify those having presented initially with pure accommodative esodeviation. Where available, records of prior evaluation and treatment assisted in establishing age of onset and of confirmation, and initial response to treatment.

The refractive errors of these subjects were surveyed for changes in hypermetropia occurring over the first seven years of life. This age range encompasses the time of onset of the vast majority of accommodative esodeviations, and terminates at the expected peak of hypermetropia.5·7 Therefore clinically important early increases could be observed. Subsequent changes in the refractive errors of these individuals were surveyed also.

The cycloplegic routines were those listed in Table 1. To this extent these comparisons of cydoplegie measurements are not strictly uniform. However, no data are included in which tropicamide (Mydriacil) was the only cycloplegic agent used. Most examinations at all ages during childhood and irrespective of pigmentation, were accomplished with one drop of cyclopentolate 1%, repeated in five to ten minutes, with retinoscopy performed after 60 to 75 minutes.10 Wherever possible, distant fixation during retinoscopy was maintained, and any existing spectacle correction for hypermetropia was worn before and during the examination, so that residual accommodation would be stimulated as little as possible. Often an attempt was made to grossly estimate residual accommodation by an additional brief measurement with fixation on the examiner; however, this was impractical to do routinely. The refractive findings reported were not obtained during periods of use of miotica, nor within several weeks of their discontinuance.

Results

1. CHANGES IN HYPERMETROPIA IN ACCOM MODATIVE ESODEVIATION: From a much larger group, it waa possible to identify 68 subjects (136 eyes) for whom the results of at least two, and usually more, cycloplegic refractions over the longest possible time interval (of at least two years and not beyond the seventh birthday), were known. Mean values are compared and discussed in clinical rather than in statistical terms.

The…

ABSTRACT

Contradicting earlier doctrine, several studies have indicated that hypermetropia in childhood increases over the first seven years of life, and decreases thereafter. No clear consensus exists as to these characteristics in patients with accommodative esodeviation.

In 68 subjects (136 eyes), the mean annual change in hypermetropia up to the seventh birthday was an increase of +0.19 ± 0.36 D. Subjects whose accommodative deviation deteriorated showed changes similar in magnitude. The corresponding mean annual change in a previously reported age-matched series unselected for strabismus was +U. 28 D. Hypermetropia in accommodative esodeviation showed a mean annual decrease between ages 7 and 13 years of -0.18 ± 0.25 D. The corresponding finding in the general childhood population was -0.22 D.

While clinically important individual departures from these results do occur, an accelerated rate of increase in hypermetropia is not characteristic of most cases of either controlled or of deteriorated accommodative esodeviation.

Introduction

There is difference of opinion as to the natural course of hypermetropia in accommodative esodeviation. One classic doctrine has been that most infants are moderately to highly hypermétropie at birth and that this refractive state regularly diminishes over childhood.1 The investigations and clinical experience of several authors2'9 suggest instead that hypermetropia shows a tendency either to remain stable or to increase over the first seven years of life. There is no clear consensus on this point in patients with accommodative esodeviation.

The aims of this study were: (1) To observe the natural course of hypermetropia in this population of strabismus patients, and whether it differed from that in the general childhood population; and (2) To observe the evolution of hypermetropia in deteriorated accommodative esodeviation.

Materials and Methods

The records of patients in my practice were reviewed to identify those having presented initially with pure accommodative esodeviation. Where available, records of prior evaluation and treatment assisted in establishing age of onset and of confirmation, and initial response to treatment.

The refractive errors of these subjects were surveyed for changes in hypermetropia occurring over the first seven years of life. This age range encompasses the time of onset of the vast majority of accommodative esodeviations, and terminates at the expected peak of hypermetropia.5·7 Therefore clinically important early increases could be observed. Subsequent changes in the refractive errors of these individuals were surveyed also.

The cycloplegic routines were those listed in Table 1. To this extent these comparisons of cydoplegie measurements are not strictly uniform. However, no data are included in which tropicamide (Mydriacil) was the only cycloplegic agent used. Most examinations at all ages during childhood and irrespective of pigmentation, were accomplished with one drop of cyclopentolate 1%, repeated in five to ten minutes, with retinoscopy performed after 60 to 75 minutes.10 Wherever possible, distant fixation during retinoscopy was maintained, and any existing spectacle correction for hypermetropia was worn before and during the examination, so that residual accommodation would be stimulated as little as possible. Often an attempt was made to grossly estimate residual accommodation by an additional brief measurement with fixation on the examiner; however, this was impractical to do routinely. The refractive findings reported were not obtained during periods of use of miotica, nor within several weeks of their discontinuance.

Results

1. CHANGES IN HYPERMETROPIA IN ACCOM MODATIVE ESODEVIATION: From a much larger group, it waa possible to identify 68 subjects (136 eyes) for whom the results of at least two, and usually more, cycloplegic refractions over the longest possible time interval (of at least two years and not beyond the seventh birthday), were known. Mean values are compared and discussed in clinical rather than in statistical terms.

The age at first refraction, interval to last included refraction, initial spherical equivalent hypermetropia, and annual change in hypermetropia are shown in Table 2. There was an increase of +0.19 ±0.36 Dlrange -1.26 to +1.03 D) per year. The corresponding mean change from the study of Slataper,6 interpolated for the same interval and commencement age, was an increase of +0.28 D per year.

Of the changes in hypermetropia, 92 (68%) were increases and 32 (24%) were decreases; 12 (8%) of the eyes showed no change (Table 3). The corresponding findings are not stated by Slataper, but those of an earlier study of Brown4 for "strabismus" patients type not specified) are included for comparison. No significant difference is noted (p >0.05>.

It was possible to isolate from these patients 30 (60 eyes) whose initial and last included refraction had been performed using cy elope n to late 1% (two doses) on each occasion. These findings were tabulated separately (Table 4) to observe any effect of this added uniformity in examination technique. The change of hypermetropia over the interval of observation was an increase of + 0.24 ± 0.45 D per year. Interpolation in Slataper's study for a comparable time span reveals an increase of +0.25 D. In the present group, 42 (70%) of the hypermétropie eyes showed an increase, 14 (23%) a decrease, and 4 (7%) no change (see Table 3 for comparative data).

Table

TABLE 1ROUTINES FOR CYCLOPLEGIA

TABLE 1

ROUTINES FOR CYCLOPLEGIA

Table

TABLE 2CHANGE IN HYPERMETROPIA TO AGE SEVEN YEARS IN PATIENTS WITH ACCOMMODATIVE ESODEVIATlON

TABLE 2

CHANGE IN HYPERMETROPIA TO AGE SEVEN YEARS IN PATIENTS WITH ACCOMMODATIVE ESODEVIATlON

Table

TABLE 3DIRECTION OF CHANGE IN HYPERMETROPIA TO AGE SEVEN YEARS IN PATIENTS WITH ACCOMMODATIVE ESODEVIATION

TABLE 3

DIRECTION OF CHANGE IN HYPERMETROPIA TO AGE SEVEN YEARS IN PATIENTS WITH ACCOMMODATIVE ESODEVIATION

Table

TABLE 4CHANGE IN HYPERMETROPIA (CYCLOPENTOLATE 1%) TO AGE SEVEN YEARS IN PATIENTS WITH ACCOMMODATIVE ESODEVIATtON

TABLE 4

CHANGE IN HYPERMETROPIA (CYCLOPENTOLATE 1%) TO AGE SEVEN YEARS IN PATIENTS WITH ACCOMMODATIVE ESODEVIATtON

Table

TABLE SCHANGE IN HYPEHMETROPIA FROM AGES EIGHT TO THIRTEEN YEARS IN PATIENTS WITH ACCOMMODATIVE ESODEVIATION

TABLE S

CHANGE IN HYPEHMETROPIA FROM AGES EIGHT TO THIRTEEN YEARS IN PATIENTS WITH ACCOMMODATIVE ESODEVIATION

Table

TABLE 6CHANGE IN HYPERMETROPIA TO AGE SEVEN YEARS IN PATIENTS WITH DETERIORATED ACCOMMODATIVE ESODEVIATION

TABLE 6

CHANGE IN HYPERMETROPIA TO AGE SEVEN YEARS IN PATIENTS WITH DETERIORATED ACCOMMODATIVE ESODEVIATION

Changes in hypermétropie also could be studied in 56 patients (112 eyes) over at least a two-year period between their seventh and thirteenth birthdays. This age span corresponds to that associated with lessening severity of accommodative esodeviation. Such cases included any from the group under age seven years who fulfilled the criteria for both determinations; this is consistent with the method in other studies cited in this report. The change in hypermétropie was -0.18 ± 0.25 D per year (Table 5). The previously reported corresponding finding was -0.22 D .6

Of these 112 hypermétropie eyes, the change was an increase in 19 (17%), a decrease in 87 (78%), and none in 6 (5%). Corresponding findings in other series were not stated.

II. CHANGES IN HYPERMETROPIA AND DETERIORATION: Increases in hypermetropia also have been considered a contributing element to deterioration. Of the 32 patients demonstrating deterioration after initially good control, li. 12 Ig conformed to the criteria for inclusion in the study of refraction changes prior to age seven years. In these 36 eyes, hypermetropia showed an increase of +0.22 ± 0.26 D per year (Table 6).

Discussion

It is a common perception that childhood hypermetropia undergoes sizable changes, leading to the recommendation that patients with accommodative esodeviation be refracted at very frequent intervals and especially when their state of control is precarious.

This perception undoubtedly is at least in part responsible for the traditional preference for atropine in cycloplegic refraction, even among those ophthalmologists who would rely on an alternate drug in routine examinations. However, the use of multi-day atropine instillations, despite techniques to limit systemic absorption, undoubtedly present the dangers of tachycardia, fever, dryness, and psychic disturbances that, although frequently described as "allergy" by the lay person, are actually a poisoning effect, as was suggested by Knapp.3 Apart from this, the prolonged wear-off time and the necessity of a repeat visit merely to accomplish the refraction are distinct practical hardships. The experience of many strabismologists indicates that several drugs other than atropine are entirely satisfactory for clinical purposes.

The most widely quoted surveys of refractive errors in children are those of Brown5 and Slataper.6 In Brown's effort a three- to four-day atropine regimen was employed in all examinations. He found that over the first seven years of life, hypermetropia underwent an average yearly increase which was unimpressive in most patients. Thereafter a trend toward decreasing hypermetropia was apparent. The results were similar in both strabismic and nonstrabismic subjects of either sex. Slataper reported closely similar results. Neither of these very comprehensive series indicate clearly their composition with respect to strabismus.

One more recent report13 dealing with strabismic children (not specified further) has indicated that 11% of eyes initially hypermétropie by at least +3.50 D, and 35% with less hypermétropie, increased by only a mean total of +1.00 and +1.02 D, respectively, over a three- to five-year interval prior to age seven years.

The present investigation is an attempt to resolve this question with respect to accommodative esodeviation. The prominent warnings with respect to possibly undetected hypermetropia predisposing to deterioration and requiring the intense vigilance of frequently repeated cycloplegie examinations are not well supported by the fractional increases that were revealed. In addition, there was no observed difference in annual increment whenever the distance near esodeviation comparison was normal or high ( + 0.18 and +0.20 D, respectively). It is true that clinically meaningful individual departures from these overall figures occur; in this group of patients, the largest single annual increase was +1.03 D. However, the results are not consistent with the suggestion that an accelerated rate of increase in hypermetropia is characteristic of most cases of accommodative esodeviation. Moreover, although a larger number of observations would have been preferred, the same was true for cases that evolved to a deteriorated state.

The decrease in hypermetropia after age seven years found here was in general agreement with the data of Brown and Slataper. The modest rate of this decrease suggests that the natural tendency of accommodative esodeviation to improve during that age period probably also involves etiologic influences other than changes in the refractive error. This question was not studied directly.

The comparisons pointed out to other series are inexact for several reasons. In the present report, although the findings are those of one examiner, several cycloplegie drugs (excluding tropicamide and homatropine, generally considered the least reliable) were employed. Moreover, the number of observations is relatively small and statistical comparison is not altogether feasible. Nevertheless, these results suggest that the evolution of hypermetropia in childhood in individuals with accommodative esodeviatioa ia similar clinically in that of a population of a corresponding age range not selected for this particular variety of strabismus.

References

1. LyIe TK: Worth and Chavasse's Squint. London, Bailliere, Tindall and Cox, 1950, p 139.

2. Round table discussion on use of cycloplegics, in Symposium on Strabismus. Transactions of the New Orleans Academy of Ophthalmology. St Louie, CV Mosby Co, 1978, pp 589-592.

3. Round table discussion on esotropia, in Symposium on Strabismus· Transactions of the New Orleans Academy of Ophthalmology. St Louis, CV Mosby Co, 1978, pp 513-531.

4. Brown EVL: Apparent increase of hyperopia up to the age of nine years. Am J Ophthalmol 1936; 19:1106.

5. Brown EVL: Net average yearly change in refraction of atropinized eyes from birth to beyond middle age. A re ? Ophthalmol 1938; 19:719-734.

6. Slataper FJ: Age norms of refraction and vision. Arch Ophthalmol 1950; 43:466-481.

7. Ruskell GL: Some aspects of vision in infants. Brii Orthopt J 1967; 24:25-32.

8. Cook RC, Glasscock RE: Refractive and ocular findings in the newborn. Am J Ophthalmol 1951; 34:1407-1413.

9. Ingram RM, Ban· A: Changes in refraction between the ages of 1 and 3 1/2 years. Brii J Ophthalmol 1979; 63:339-342.

10. Gettes BC: Choice of mydriatics and cycloplegics for diagnostic examination in children, in Apt L (ed): Diagnostic Procedures in Pediatrie Ophthalmology. Boston, Little Brown and Co, 1963, pp 183-188.

11. von Noorden GK: Burian-??? Noarden's Binocular Vision and Ocular Motility, ed 2. St Louis, CV Mosby Co, 1980, pp 287-313.

12. Parks MM: Ocular Motility and Strabismus. Hagerstown, Maryland, Harper and Row, 1975, pp 99-111.

13. Bielik M, Friedman Z, Peleg B, et al: Changée in refraction over a period of 3-5 years in 212 strabismic children aged one to two and a half. Metabol Ophthalmol 1973; 2:115-117.

Edward L. Raab, M.D.

New York, New York

From the Department of Ophthalmology, Mount Sinai School of Medicine, City University of New York.

Presented at the Ninth Annual Meeting of The American Association for f^diatric Ophthalmology and Strabismus, Vancouver, British Columbia, August 3-6, 1983.

Modified portion of candidate's thesis for the American Ophthalmological Society, May i982.

Requests for reprints should be addressed to Edward L. Raab, M.D,, Annenberg Building, Room 22-85, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, New York 10029

Discussion

Marshall M. Parks, M.D.

Washington, D.C.

The aim of the hypermétropie study of Dr. Raab was twofold: 1) to verify the natural course of hypermétropie in accommodative esotropia patients, and 2) to determine whether the hypermetropia differed among the accommodative esotropia patients who deteriorated.

The author presents us with a relatively small sample of accommodative esotropia patients, reporting on their hypermétropie refractive errors determined essentially by cyclopentolate cycloplegia. None of the refractions were performed with atropine. Though the patient sample is small it undoubtedly is adequate to provide sufficient data for sound statistical study.

I do sense that some refractionists will be troubled by the drug selected to induce the cyclopledia since many still are devoted worshippers of their sacred cow-atropine. This discussor certainly is not one of those. Were I to present this study, the cycloplegic drug also would have been cyclopentolate. Though the absolute quantities of hypermetropia among individual patients may be different for cyclopentolate and atropine refractions, either cycloplegic technique, consistently applied, should make no difference in the changes recorded for different chronologic ages. The author demonstrated the validity of this premise in the comparison of his cyclopentolate refractions to EVL Brown's atropine refractions. With either cycloplegia, the absolute hypermetropia change for each chronologic age was similar.

What Dr. Raab's figures show is that the average patient with accommodative esotropia manifests approximately a total of one diopter increase in hypermetropia while aging from three to six years, and then, starting at age eight, begins to decrease in hypermetropia returning back to the original three-year-old level by 12 years of age. The clinician cannot infer from this natural course of hypermetropia, verified by Dr. Raab, that repeat cycloplegic refractions at various intervals are unnecessary. The patient is not satisfactorily managed by simply doing an original cycloplegic refraction when first examined and then arbitrarily adding a plus quarter diopter to the initial spectacle lens power each year until six, and withdrawing a plus quarter diopter each year between the ages of nine and 12. Not all patients conform to the average; some manifest changing anisometropia, astigmatism, and some change opposite to what you would expect. So, despite the average figures cited in this study, repeat cycloplegic refractions on a regular basis remains the pillar for quality care provided to accommodative esotropia patients.

The author makes the point that the refractive error change according to chronologic age is the same, regardless of the beginning quantity of hypermetropia, whether the patient has esotropia or straight eyes, or whether the accommodative esotrope deteriorated by developing a superimposed nonaccommodative esotropia component. From the latter he concludes that the cause of the deterioration in an accommodative esotrope is not to be found in an unusual increase of hypermetropia associated with increasing age. I suspect the author's conclusion is valid, but basing the conclusion on a sample of only 18 cases impresses me as precarious, particularly when the age between the youngest and the oldest patients' initial refraction ranged from less than 15 months to more than 43 months, and the interval between initial and final refractions among these 18 patients ranged from less than 28 months to more than 54 months. I hope the author will continue to add more deteriorated accommodative cases to the 18 he studied and reported here.

I enjoyed discussing this paper. Thank you, Dr. Raab, for supplying us with data important to our clinical work. Dr. Raab was very considerate of me as a discussor by making sure I had all the necessary facts and ample time to prepare my discussion.

TABLE 1

ROUTINES FOR CYCLOPLEGIA

TABLE 2

CHANGE IN HYPERMETROPIA TO AGE SEVEN YEARS IN PATIENTS WITH ACCOMMODATIVE ESODEVIATlON

TABLE 3

DIRECTION OF CHANGE IN HYPERMETROPIA TO AGE SEVEN YEARS IN PATIENTS WITH ACCOMMODATIVE ESODEVIATION

TABLE 4

CHANGE IN HYPERMETROPIA (CYCLOPENTOLATE 1%) TO AGE SEVEN YEARS IN PATIENTS WITH ACCOMMODATIVE ESODEVIATtON

TABLE S

CHANGE IN HYPEHMETROPIA FROM AGES EIGHT TO THIRTEEN YEARS IN PATIENTS WITH ACCOMMODATIVE ESODEVIATION

TABLE 6

CHANGE IN HYPERMETROPIA TO AGE SEVEN YEARS IN PATIENTS WITH DETERIORATED ACCOMMODATIVE ESODEVIATION

10.3928/0191-3913-19840901-09

Sign up to receive

Journal E-contents