Journal of Pediatric Ophthalmology and Strabismus

Original Article 

Outcomes of Medial Rectus Recession With Adjustable Suture in Acute Concomitant Esotropia of Adulthood

Ignacio García-Basterra, MD, PhD; José Maria Rodríguez Del Valle, MD; Antonio García-Ben, MD, PhD; José María Rodríguez Sánchez, MD; José Manuel García-Campos, MD, PhD

Abstract

Purpose:

To review and analyze the surgical outcomes of bilateral medial rectus recession with adjustable suture in acute concomitant esotropia of adulthood (ACEA).

Methods:

The charts of all adults diagnosed as having ACEA between 2004 and 2017 were reviewed. Best corrected visual acuity, refractive error, ocular alignment measured in prism diopters (PD), and stereopsis were examined at presentation, 1 day postoperatively, and final follow-up visit (median: 10 months; range: 4 to 144 months). All patients underwent bilateral medial rectus recession using adjustable suture surgery and topical anesthesia. Statistical analysis was used to calculate surgical dose-responses and to study possible correlations with clinical parameters.

Results:

Fifteen patients diagnosed as having ACEA were included. The mean age was 39.2 ± 10.7 years, and the mean refractive errors in the right and left eyes were −3.97 ± 2.87 and −3.60 ± 2.74 diopters (D), respectively. Average esotropia deviations at near and distance were 22.7 ± 7.2 and 23.0 ± 7.5 PD. All patients improved with medial rectus recession (mean: 12.0 ± 2.2 mm) with a final mean deviation of 0.7 ± 1.8 PD. The mean dose-responses at 1 day postoperatively and final visit were 1.86 ± 0.58 and 1.83 ± 0.43 PD/mm, respectively. There was a significant positive correlation between surgical dose-responses at 1 day postoperatively and final visit and preoperative deviation (R2 = 0.55; P < .001; R2 = 0.66; P < .001), whereas there were no significant correlations with age, sex, refractive error, BCVA, or stereopsis (all P > .05).

Conclusions:

Good postoperative and final outcomes are achieved with large medial rectus recessions in ACEA. A larger dose-response can be expected in large preoperative deviations, independent of other clinical and ocular parameters.

[J Pediatr Ophthalmol Strabismus. 2019;56(2):101–106.]

Abstract

Purpose:

To review and analyze the surgical outcomes of bilateral medial rectus recession with adjustable suture in acute concomitant esotropia of adulthood (ACEA).

Methods:

The charts of all adults diagnosed as having ACEA between 2004 and 2017 were reviewed. Best corrected visual acuity, refractive error, ocular alignment measured in prism diopters (PD), and stereopsis were examined at presentation, 1 day postoperatively, and final follow-up visit (median: 10 months; range: 4 to 144 months). All patients underwent bilateral medial rectus recession using adjustable suture surgery and topical anesthesia. Statistical analysis was used to calculate surgical dose-responses and to study possible correlations with clinical parameters.

Results:

Fifteen patients diagnosed as having ACEA were included. The mean age was 39.2 ± 10.7 years, and the mean refractive errors in the right and left eyes were −3.97 ± 2.87 and −3.60 ± 2.74 diopters (D), respectively. Average esotropia deviations at near and distance were 22.7 ± 7.2 and 23.0 ± 7.5 PD. All patients improved with medial rectus recession (mean: 12.0 ± 2.2 mm) with a final mean deviation of 0.7 ± 1.8 PD. The mean dose-responses at 1 day postoperatively and final visit were 1.86 ± 0.58 and 1.83 ± 0.43 PD/mm, respectively. There was a significant positive correlation between surgical dose-responses at 1 day postoperatively and final visit and preoperative deviation (R2 = 0.55; P < .001; R2 = 0.66; P < .001), whereas there were no significant correlations with age, sex, refractive error, BCVA, or stereopsis (all P > .05).

Conclusions:

Good postoperative and final outcomes are achieved with large medial rectus recessions in ACEA. A larger dose-response can be expected in large preoperative deviations, independent of other clinical and ocular parameters.

[J Pediatr Ophthalmol Strabismus. 2019;56(2):101–106.]

Introduction

Late-onset comitant esotropia has been classically defined as an acute inward comitant deviation with diplopia starting after 16 years of age. Burian and Miller1 classified this disease into three groups. Type I or “Swan type” is caused by temporal occlusion of one eye or loss of vision in one eye secondary to injury or disease. Type II or “Franceschetti type” occurs in mildly hyperopic patients with a larger angle of deviation at near than at distance fixation. Type III or “Bielschowsky type” is characterized by acute esotropia greater at far distance in young myopic patients. Because the latter group presents esotropia only at distance fixation, it has been proposed to classify this variant as divergence insufficiency. Aside from the age-related distance esotropia supposedly caused by aging anatomical changes in the orbit and muscles,2 the term acute comitant esotropia of adulthood (ACEA), coined by Spierer,3 describes a distinctive and well-defined group of adults with esotropia and no other neurologic or anatomic diseases.

The goals of this study were to describe the clinical features of ACEA, analyze the postoperative and final results of bilateral medial rectus recession performed with adjustable suture surgery and topical anesthesia, calculate surgical dose-response, and study possible correlations with clinical variables.

Patients and Methods

The medical records of consecutive adult patients diagnosed as having ACEA between 2004 and 2017 at Clínica Doctor Rodriguez Strabismus Clinic were retrospectively reviewed. The Clinical Research Ethics Committee approved the study according to the tenets of the Declaration of Helsinki and all federal laws in Spain. All patients were contacted for permission for this retrospective study. Written informed consent was given by all patients for their clinical records to be used in this study.

Based on the clinical features described by Spierer, ACEA was defined as an acute (< 12 months and no history of previous deviation or diplopia) concomitant esotropia (deviation in all directions of gaze differing by ≤ 2 prism diopters [PD]) in patients older than 16 years with corrected visual acuity better than 0.6 in both eyes and no other ophthalmic or neurologic disease.3 Patients with a history of any diagnosis other than refractive error, family history of strabismus, any cause of fusion interruption, or history of systemic disease or head trauma were excluded.

All patients recruited underwent a detailed ophthalmologic examination, slit-lamp examination, tonometry, and ophthalmoscopy. A full neurologic work-up, including neurologic examination and neuroimaging, was performed to exclude neurologic causes of diplopia. The best corrected visual acuity was measured using a Snellen chart at 6 meters. Cycloplegic refraction with cyclopentolate 1% (Alcon Cusi, El Masnou, Barcelona, Spain) was performed using an automated refractometer (RM-8900; Topcon, Tokyo, Japan) and stereopsis was measured using TNO and Titmus tests with prism compensation. Deviations were assessed using prisms and alternate cover test for near (30 cm) and distance (6 m) fixations and cardinal positions of gaze with refractive correction. Measurements were made in lateral and vertical gazes to ascertain concomitance and were performed at preoperative (1 day before surgery), 1-day postoperative, and final follow-up visits. All ocular examinations and strabismus surgery were performed by the same physicians (JMRS as first surgeon and JMRV as assistant).

All participants underwent medial rectus recession with the adjustable suture technique under monitored topical anesthesia with 2% lidocaine gel. The amount of surgery decided preoperatively and corrected during the procedure are presented in Table 1. After checking passive forced duction testing, limbal conjunctival incisions were performed. Muscles were isolated and a 6-0 traction suture was placed at the medial rectus insertion to gently pull the muscle into the center of the surgical field. The muscle was then imbricated close to their insertion with two 6-0 reabsorbable sutures and full-thickness locking bites. Then the muscles were disinserted from the sclera with scissors and recessed posteriorly using a hang-back technique and tying the muscle with a bow-tie adjustable knot. Alignment was then tested at the operation room in the seated upright position, with any refractive correction and centered targets at near and distance. Intraoperative adjustment to achieve orthophoria was performed in one eye. Caliper measurements of the position of each muscle were performed following each adjustment during surgery. Finally, both muscles were sutured directly to the sclera at the intended recession location using a central double tie knot. Two interrupted 7-0 reabsorbable sutures were used to close the conjunctiva.

Clinical Characteristics of Patients With Acute Concomitant Esotropia of Adulthood

Table 1:

Clinical Characteristics of Patients With Acute Concomitant Esotropia of Adulthood

All statistical analyses were performed via Microsoft Excel (version 14; Microsoft Corporation, Redmond, WA) and SPSS statistical (version 20; SPSS, Inc., Chicago, IL) software. Mean and standard deviation for quantitative data and frequencies and percentages for qualitative values were calculated. The dose-response effects, or the amount of deviation corrected for each millimeter of surgery done, were calculated by dividing the difference between preoperative and postoperative deviation angle values by the total recession length in millimeters. Multiple and simple linear regressions were performed and a slope derived to approximate a surgical dosage. R2 was calculated to assess the fit of the linear regression line. Univariate and multivariate linear regression analyses were applied to investigate factors influencing surgical dose-response based on alignment at final visit. The multivariate model was adjusted for age, sex, refractive error, best corrected visual acuity, and preoperative horizontal angle of deviation. P values less than .05 were considered statistically significant.

Results

Fifteen patients were included in the study. The main characteristics of the study group are presented in Table 1. The mean age was 39.2 ± 10.7 years; 10 patients (66%) were male and 5 patients (33%) were female. The mean best corrected visual acuity in the right and left eyes was 1.1 ± 0.2 and 1.1 ± 0.2, respectively (range: 0.6 to 1.25), and the mean refractive error in the right and left eyes was −3.97 ± 2.87 and −3.60 ± 2.74 D, respectively (range: −10.00 to +1.00 D). Two patients suppressed one eye in stereopsis tests performed before surgery. The average stereopsis before and after surgery was 116.2 ± 104.0 seconds of arc (range: 40 to 400 seconds of arc) and 97.1 ± 128.9 seconds of arc (range: 40 to 400 seconds of arc), respectively. Except for one patient, all patients consulted for intermittent binocular diplopia recently. None of the patients had neurologic or other ophthalmic symptoms apart from diplopia.

At presentation, the mean esotropia deviations at far and near fixation were 22.7 ± 7.2 and 23.0 ± 7.5 prism diopters (PD), respectively. The average total recession performed was 12.0 ± 2.2 mm and the postoperative deviations at far and near were 0.9 ± 2.5 and 0.7 ± 1.8 PD, respectively. The mean follow-up time was 20.3 ± 35.3 months (median: 10 months; range: 4 to 144 months). At the final visit, the mean esotropia deviations at far and near were 1.3 ± 2.6 and 1.3 ± 2.7 PD, respectively.

Multiple regression linear model showed that the deviation corrected at the final visit was highly correlated with the amount of millimeters recessed and the preoperative angle of deviation (PD corrected at the final visit = −4.46 + 0.75 × preoperative angle + 0.76 × mm of medial rectus recession; R2 = 0.91; P < .001) (Figure 1), whereas prism diopters corrected at the 1-day postoperative visit was significantly correlated with the preoperative angle of deviation, independent of the millimeters recessed (PD corrected at 1-day postoperative visit = 1.17 + 0.92 × preoperative angle; R2 = 0.88; P < .001). The observed dose-response at the final visit is shown in Figure 2, along with the dose-response estimated by reference values obtained from Wright.4 Partial correlation was used to determine the relative importance of the amount of millimeters recessed and to compare this relation with reference values (R2 = 0.32; P = .03 vs R2 = 0.97; P < .001).

(Left) Three-dimensional scatter plot showing multiple lineal regression: deviation corrected at final visit as dependent variable and preoperative deviation and total medial rectus (MR) recession as independent variables (R2 = 0.91; P < .001). (Right) Scatter plots showing partial correlations between each independent variable (preoperative deviation and total MR recession) and total medial rectus recession (R2 = 0.86; P < .001; R2 = 0.32; P = .03, respectively). PD = prism diopters

Figure 1.

(Left) Three-dimensional scatter plot showing multiple lineal regression: deviation corrected at final visit as dependent variable and preoperative deviation and total medial rectus (MR) recession as independent variables (R2 = 0.91; P < .001). (Right) Scatter plots showing partial correlations between each independent variable (preoperative deviation and total MR recession) and total medial rectus recession (R2 = 0.86; P < .001; R2 = 0.32; P = .03, respectively). PD = prism diopters

Surgical dose-response curves in acute concomitant esotropia of adulthood (ACEA). Partial correlation between prism diopters (PD) corrected and amount of surgery done. Reference values obtained from Wright.4

Figure 2.

Surgical dose-response curves in acute concomitant esotropia of adulthood (ACEA). Partial correlation between prism diopters (PD) corrected and amount of surgery done. Reference values obtained from Wright.4

The average dose-response was 1.86 ± 0.58 PD/mm at the 1-day postoperative visit and 1.83 ± 0.43 PD/mm at the final visit. Univariate and multivariate linear regression analyses were used to evaluate factors associated with surgical dose-response. Surgical dose-responses at the 1-day postoperative and final visits were significantly correlated with preoperative angle of deviation, independent of millimeters recessed (postoperative dose-response = 0.54 + 0.06 × preoperative angle, R2 = 0.55; P < .001; final dose-response = 0.76 + 0.05 × preoperative angle; R2 = 0.66; P < .001) (Figure 3). There were no significant correlations between dose-responses and age, sex, refractive error, BCVA, or stereopsis (all P > .05).

Scatter plot showing correlation between preoperative deviation and surgical dose-responses at postoperative 1 day and final visit (median: 10 months). PD = prism diopters

Figure 3.

Scatter plot showing correlation between preoperative deviation and surgical dose-responses at postoperative 1 day and final visit (median: 10 months). PD = prism diopters

Discussion

Spierer3 proposed the concept of ACEA to define those patients older than 16 years with an acute comitant esotropia that was equal at far and near distances. Myopia, good stereopsis, and diplopia were constant findings in his case series. Although this disorder has well-defined signs that differ from the rest of early childhood esotropias and from Burian and Miller's classification of acute-onset esotropias, there are no published studies analyzing its management, follow-up, and long-term prognosis. In fact, the published studies to date about acute comitant esotropias usually comprise children and adults, including cases with different types of strabismus, refractive errors, or far/near incomitance.5–16 The lack of unification and agreement regarding the classification of esotropias not only makes the accurate diagnosis and management of each disease difficult, but also hinders a consistent interpretation of the literature.

All patients improved with a high amount of bilateral medial rectus recession using adjustable suture surgery and topical anesthesia. The average dose-response of bilateral medial rectus recession at 1 day postoperatively and final follow-up visit was slightly more than 1.8 PD for each 1 mm of surgery, significantly less than predicted by standard surgical normograms.4 Therefore, an increased surgical dose was needed to completely correct the esotropia in these patients. Although local surgery with intraoperative examination made it possible to correct the recession to achieve orthophoria in the operation, 5 patients presented some deviation the day after surgery. Tissue inflammation and pain may justify this finding. Nonetheless, at the final follow-up visit (mean: 20.3 months), the angle of deviation remained stable at orthophoria, except in one patient who developed a recurrent esophoria of 10 PD. Indeed, the millimeters recessed in that case were the same as recommended by Wright's table.4

It was previously thought that medial rectus recession could cause convergence insufficiency at near. However, more recent studies have demonstrated good outcomes with unilateral and bilateral medial rectus recessions for divergence insufficiency.17–20 In the current case series, the mean recession performed was 12 mm to correct an average of 23 PD, meaning that large recessions had to be done to achieve orthophoria and avoid undercorrection in these patients. Bothun and Archer18 reported successful surgical outcomes with standard medial rectus recessions, although their patients were generally undercorrected at distance. Chaudhuri and Demer19 observed that twice the usual surgical dose of medial rectus recession per prism diopter was required to achieve correction of the distance deviation in divergence insufficiency, and recommended doubling the target angle in these cases. Ridley-Lane et al.20 also supported this finding and reported an average change of 1.6 PD for each millimeter of medial rectus recession in divergence insufficiency. In age-related distance esotropia, similar results have been published by Repka and Downing,21 who reported an average change of 0.7 PD for each millimeter of bilateral medial rectus recession and an effect of just over 2 PD for each 1 mm of surgery in a sample of seven unilateral medial rectus recessions with lateral rectus resection. Likewise, low dose-responses have been reported in esotropias caused by thyroid eye disease and cranial nerve VI palsy.22

The current study has also showed that both surgical dose-response and deviation corrected were highly correlated with preoperative deviation. The average dose-response increased 0.5 PD/mm for each 10 PD of preoperative deviation and the deviation corrected increased 7.5 to 9.2 PD for each 10 PD of preoperative deviation. By contrast, the amount of millimeters recessed was only mildly correlated with deviation corrected at the final visit, demonstrating that more of the deviation finally corrected is explained by the preoperative deviation than by the amount of surgery. Other authors have reported similar results in divergence insufficiency20 and infantile esotropia,23,24 which suggests the presence of an adaptive biological response that takes place progressively, as has been recently proposed by Archer.25

ACEA typically starts with diplopia in otherwise healthy adults. All of our patients underwent an ophthalmic and neurologic examination and a careful history to rule out other conditions that may also present acutely. Although concomitancy generally represents a sign of a benign disorder, there are several reports of acute-onset comitant esotropia as the presenting sign of intracranial neoplasm.8,11,13,26–28 None of our patients presented with nystagmus, headache, or other neurologic signs, and all but one maintained or recovered stereopsis after surgery. Our results therefore support that ACEA may be considered an ophthalmic and benign disease.

Some limitations of this study must be addressed. First, this study did not use a control group of esotropias to compare the response to surgery in different kinds of convergent strabismus or the effectiveness of different surgical techniques. Second, a relatively small sample was studied and consequently it may have limited the possibility of obtaining significant associations between variables. The possibility exists that patients with low deviations and successfully treated with prisms had not been referred to our clinic, therefore not being represented in this work. Further studies comparing different esodeviations and surgical techniques may be useful to identify the best approach to this disorder.

A larger surgical dose than conventionally used may be necessary to achieve orthophoria in ACEA. The use of adjustable sutures allows for the appropriate adjustment of surgical dose with good clinical results. More preoperative deviation predicts more surgical dose-response soon after surgery and at several months of follow-up.

References

  1. Burian HM, Miller JE. Comitant convergent strabismus with acute onset. Am J Ophthalmol. 1958;45:55–64. doi:10.1016/0002-9394(58)90223-X [CrossRef]
  2. Mittelman D. Age-related distance esotropia. J AAPOS. 2006;10:212–213. doi:10.1016/j.jaapos.2006.01.217 [CrossRef]
  3. Spierer A. Acute concomitant esotropia of adulthood. Ophthalmology. 2003;110:1053–1056. doi:10.1016/S0161-6420(03)00102-7 [CrossRef]
  4. Wright KW. Colour Atlas of Strabismus Surgery: Strategies and Techniques, 3rd ed. New York: Springer-Verlag; 2007:219–220.
  5. Clark AC, Nelson LB, Simon JW, Wagner R, Rubin SE. Acute acquired comitant esotropia. Br J Ophthalmol. 1989;73:636–638. doi:10.1136/bjo.73.8.636 [CrossRef]
  6. Ohtsuki H, Hasebe S, Kobashi R, Okano M, Furuse T. Critical period for restoration of normal stereoacuity in acute-onset comitant esotropia. Am J Ophthalmol. 1994;118:502–508. doi:10.1016/S0002-9394(14)75803-9 [CrossRef]
  7. Legmann Simon A, Borchert M. Etiology and prognosis of acute, late-onset esotropia. Ophthalmology. 1997;104:1348–1352. doi:10.1016/S0161-6420(97)30136-5 [CrossRef]
  8. Lyons CJ, Tiffin PA, Oystreck D. Acute acquired comitant esotropia: a prospective study. Eye (Lond). 1999;13:617–620. doi:10.1038/eye.1999.169 [CrossRef]
  9. Kothari M. Clinical characteristics of spontaneous late-onset comitant acute nonaccommodative esotropia in children. Indian J Ophthalmol. 2007;55:117–120. doi:10.4103/0301-4738.30705 [CrossRef]
  10. Strum V, Menke MN, Knecht PB, Shöffler C. Long-term follow-up of children with acute acquired concomitant esotropia. J AAPOS. 2011;15:317–320. doi:10.1016/j.jaapos.2011.03.018 [CrossRef]
  11. Kemmanu V, Hegde K, Seetharam R, Shetty BK. Varied aetiology of acute acquired comitant esotropia: a case series. Oman J Ophthalmol. 2012;5:103–105. doi:10.4103/0974-620X.99373 [CrossRef]
  12. Sturm V, Menke MN, Töteberg M, Jaggi GP, Schoeffler C. Early onset of acquired comitant non-accommodative esotropia in childhood. Klin Monbl Augenheilkd. 2012;229:357–361. doi:10.1055/s-0031-1299237 [CrossRef]
  13. Buch H, Vinding T. Acute acquired comitant esotropia of childhood: a classification based on 48 children. Acta Ophthalmol. 2015;93:568–574. doi:10.1111/aos.12730 [CrossRef]
  14. Chen J, Deng D, Sun Y, et al. Acute acquired concomitant esotropia: clinical features, classification, and etiology. Medicine (Baltimore). 2015;94:e2273. doi:10.1097/MD.0000000000002273 [CrossRef]
  15. Erkan Turan K, Kansu T. Acute acquired comitant esotropia in adults: is it neurologic or not?J Ophthalmol. 2016;2016:2856128. doi:10.1155/2016/2856128 [CrossRef]
  16. Lee HS, Park SW, Heo H. Acute acquired comitant esotropia related to excessive Smartphone use. BMC Ophthalmol. 2016;16:37. doi:10.1186/s12886-016-0213-5 [CrossRef]
  17. Thomas AH. Divergence insufficiency. J AAPOS. 2000;4:359–361. doi:10.1067/mpa.2000.111783 [CrossRef]
  18. Bothun ED, Archer SM. Bilateral medial rectus muscle recession for divergence insufficiency pattern esotropia. J AAPOS. 2005;9:3–6. doi:10.1016/j.jaapos.2004.09.006 [CrossRef]
  19. Chaudhuri Z, Demer JL. Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. Arch Ophthalmol. 2012;130:1280–1284. doi:10.1001/archophthalmol.2012.1389 [CrossRef]
  20. Ridley-Lane M, Lane E, Yeager LB, Brooks SE. Adult-onset chronic divergence insufficiency esotropia: clinical features and response to surgery. J AAPOS. 2016;20:117–120. doi:10.1016/j.jaapos.2015.12.005 [CrossRef]
  21. Repka MX, Downing E. Characteristics and surgical results in patients with age-related divergence insufficiency esotropia. J AAPOS. 2014;18:370–373. doi:10.1016/j.jaapos.2014.04.001 [CrossRef]
  22. Grace SF, Cavuoto KM, Shi W, Capo H. Surgical treatment of adult-onset esotropia: characteristics and outcomes. J Pediatr Ophthalmol Strabismus. 2017;54:104–111. doi:10.3928/01913913-20160929-02 [CrossRef]
  23. Park KA, Oh SY. Long-term surgical outcomes of infantile-onset esotropia in preterm patients compared with full-term patients. Br J Ophthalmol. 2015;99:685–690. doi:10.1136/bjophthalmol-2014-305325 [CrossRef]
  24. Issaho DC, Wang SX, de Freitas D, Weakley DR Jr, . Variability in response to bilateral medial rectus recessions in infantile esotropia. J Pediatr Ophthalmol Strabismus. 2016;53:305–310. doi:10.3928/01913913-20160629-02 [CrossRef]
  25. Archer SM. Why strabismus surgery works: the legend of the dose-response curve. J AAPOS. 2018;22:1.e1–1.e6. doi:10.1016/j.jaapos.2017.12.001 [CrossRef]
  26. Williams AS, Hoyt CS. Acute comitant esotropia in children with brain tumors. Arch Ophthalmol. 1989;107:376–378. doi:10.1001/archopht.1989.01070010386029 [CrossRef]
  27. Schreuders J, Thoe Schwartzenberg GW, Bos E, Versteegh FG. Acute-onset esotropia: should we look inside?J Pediatr Ophthalmol Strabismus. 2012;49:e70–e72.
  28. Hoyt CS, Good WV. Acute onset concomitant esotropia: when is it a sign of serious neurological disease?Br J Ophthalmol. 1995;79:498–501. doi:10.1136/bjo.79.5.498 [CrossRef]

Clinical Characteristics of Patients With Acute Concomitant Esotropia of Adulthood

Patient Age (y) Sex SE (OD/OS) Stereopsis (Sec of Arc) Preop Deviation (PD): Far/Near Total MR Recession (mm) Postop Deviation (PD): Far/Near Final Deviation (PD): Far/Near Postop Stereopsis (Sec of Arc)

Tablea Surgery
1 42 M −0.50/−0.50 40 30/30 9 13 0/0 2/2 40
2 34 F −4.25/−3.75 40 20/20 7 13.5 0/0 Mild hyperphoria 40
3 51 M −9.25/−6.87 OD supp 40/40 11 16 3/0 0/0 OD supp
4 32 M −2.25/−1.75 60 35/35 10 10 0/0 10/10 40
5 31 M −3/−3.75 60 20/20 7 9 8/6 2/2 40
6 46 M −3.25/−3.25 40 20/20 7 12 0/0 1/1 40
7 53 M −6.12/−5.87 50 15/15 6 13 −3/0 0/0 80
8 26 M −1.25/−1.50 200 20/20 7 10.5 2/1 4/4 40
9 33 M −4.25/−3.25 40 18/18 6.5 14 0/0 0/0 60
10 51 M −10.00/−10.00 140 16/16 6 to 6.5 12 0/0 0/0 40
11 51 F −3.50/−3.60 400 18/16 6.5 10 0/0 0/0 40
12 32 F −2.75/−3.62 100 25/25 8 14 4/4 0/0 40
13 53 M −0.25/+1.00 200 20/22 7 to 7.5 10 0/0 0/0 60
14 23 F −2.62/−1.50 140 18/18 6.5 9 0/0 0/0 400
15 30 F −6.25/−5.86 OS supp 25/30 9 14 0/0 0/0 400
Authors

From the Department of Ophthalmology, University Hospital Virgen de la Victoria, Málaga, Spain (IG-B, JMG-C); the Department of Ophthalmology, Hospital Costa del Sol, Agencia Sanitaria Costa del Sol, Marbella, Spain (IG-B); the Department of Ophthalmology, Ramón y Cajal, Madrid, Spain (JMRV, JMRS); the Clinica Doctor Rodríguez, Madrid, Spain (JMRV, JMRS); and the Department of Ophthalmology, University Hospital Santiago de Compostela, Santiago de Compostela, Spain (AG-B).

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Ignacio García-Basterra, MD, PhD, Department of Ophthalmology, University Hospital Virgen de la Victoria, Málaga, Campus Teatinos S/N, 29010, Málaga, Spain. E-mail: ignaciobas@hotmail.com

Received: August 12, 2018
Accepted: December 31, 2018

10.3928/01913913-20190206-01

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