In a particularly relevant article in this issue, Leshno et al. describe the decline of published articles on pediatric topics in leading general ophthalmology journals. They cite multiple reasons for this trend, including a reduction in manpower leading to overworking and less time for significant research among pediatric ophthalmologists. This problem was addressed by our co-editor, Dr. Nelson, in a previous issue of the Journal of Pediatric Ophthalmology & Strabismus. Fortunately for our readers, a shift in the publication of pediatric ophthalmology articles from the top-rated comprehensive ophthalmology publications to pediatric subspecialty journals reflects our experience with the number of recent submissions. The Journal of Pediatric Ophthalmology & Strabismus is listed by the authors as one of the top three pediatric ophthalmology publications internationally! We need to ensure that access to the important research in our field continues to be available.
In one of those international studies, also in this issue, Brennan et al. found partially accommodative esotropia to be the most common type presenting in 117 children with concomitant esotropia in Northern Ireland. They identified modifiable factors associated with increasing the likelihood of a child with esotropia achieving fully accommodative status, meaning that the child is fully aligned with glasses on, but may have a phoria present. The authors found that minimizing the delay in prescribing and successful full-time wear of the full cycloplegic hypermetropic correction accounted for their best results. Brennan et al. concluded that children presenting with recent onset concomitant esotropia should undergo an immediate cycloplegic refraction, and the full hypermetropic correction should be prescribed if the refractive error measures more than +1.50 diopters. These glasses should be worn full time. This study also found refractive errors to be higher in the fully accommodative group compared to the partially accommodative group.
I find it more difficult to treat younger children who present with intermittent and variable angle esotropia with lesser amounts of hypermetropia. Frequently, they are converted from intermittent to constant esotropia when they take their glasses off. This has resulted in me not fully correcting the hypermetropia in some cases in an attempt to preserve their fusional divergence. This seems to work in some cases when stereopsis is present. There may not be a single preferred practice pattern for managing accommodative esotropia, but prescribing the full hypermetropic correction is usually a good starting point.
Rudolph S. Wagner, MD