Accommodative esotropia is a convergent mis-alignment of the visual axes caused by an increased accommodative effort to compensate for uncorrected hyperopia or an abnormally high accommodative convergence/accommodation (AC/A) ratio. It usually begins at the age of 2 to 3 years, but may also occur in infancy or later in life. In the refractive accommodative esotropia form, the underlying mechanism is associated with uncorrected hyperopic error and insufficient fusional divergence. Nonrefractive accommodative esotropia is associated with an abnormally high AC/A ratio with esotropia greater at near than distance.1–5
If the residual esotropic deviation is less than 8 to 10 prism diopters (PD) at near and distance fixations with the treatment of full hyperopic correction determined by cycloplegic retinoscopy and/or bifocals, it is defined as fully accommodative esotropia. Despite the generally favorable prognosis in children with fully accommodative esotropia, deterioration may occur over the years and surgical treatment may be required.
The purpose of this study was to determine refractive error changes across time and to define factors contributing to decompensation in patients with fully accommodative esotropia.
Patients and Methods
This retrospective study was approved by the institutional review board and adhered to the tenets of the Declaration of Helsinki. Medical records of 3,012 patients who presented to the Strabismus Department of the University of Health Sciences Beyoğlu Eye Research and Training Hospital between January 2011 and January 2012 were retrospectively reviewed. Patients who were diagnosed as having fully accommodative esotropia and whose esotropia started before the age of 7 years were included. All patients were treated with full correction of hypermetropic error with spectacles. Amblyopia treatment including patching or atropine penalization was initiated when indicated. Atropine penalization was considered in patients who were unable to comply with patching.
Fully accommodative esotropia that deteriorated (developed 10 PD or more of esotropia with simultaneous prism and cover test) was distinguished from partially accommodative esotropia by maintaining 10 PD or less of esodeviation with spectacle correction for at least 1 year. These patients underwent surgery because they were no longer in the monofixation range. Surgery included unilateral medial rectus recession for distance deviations of 20 PD or less, uni-lateral medial rectus recession combined with lateral rectus resection, or bilateral medial rectus recession alone or in combination with lateral rectus resection for distance deviations greater than 20 PD. The amount of surgery was based on a standard table of surgical dosage.6 In patients with a near-distance disparity of greater than 15 PD, a bridge Faden operation of the medial rectus muscle was added. A bridge Faden operation was performed unilaterally for a near-distance disparity less than 20 PD and bilaterally for a near-distance disparity of 20 PD or greater.
Patients whose vision deteriorated but chose not to have surgery or who were lost to follow-up before surgery could be performed were excluded from the study. The other exclusion criteria were: nystagmus, dissociated horizontal or dissociated vertical deviations, significant developmental delay, neurological abnormalities, other ocular pathologies, and prior strabismus surgery.
Initial evaluation included a comprehensive medical history and complete ophthalmologic examination, including assessment of visual acuity by Snellen or E chart and Lea symbols in preverbal children, cycloplegic refraction, slit-lamp and fundus examinations, strabismus measurements, and ocular motility. Refraction measurements were performed using retinoscopy 30 to 45 minutes after the administration of 1% cyclopentolate. The spherical equivalent was calculated by adding the sum of the sphere power to half of the cylinder power. Ocular deviation angles were determined by simultaneous prism and cover and prism and alternate cover tests at 6 and 0.33 m fixation or with the Krimsky test in patients who were not able to cooperate, both with and without spectacles. Near-distance disparity was defined as a difference of greater than 10 PD between the near and distance prism and alternate cover measurements. Stereopsis was tested with the Titmus stereo test (Stereo Optical Co).
Multiple parameters were recorded: age at onset, age at presentation, gender, visual acuity at initial and final visit, spherical equivalent, spectacle wear discontinuation, time until deterioration, age at surgery, type of surgery performed, deviation angle without refractive correction and with full hyperopic correction at near and distance fixations, stereopsis, astigmatism and amblyopia at initial and final visit, inferior oblique overaction, and follow-up time. Visual acuity values were converted to logMAR units for the evaluations. Amblyopia was diagnosed if there was a difference of at least two lines in best corrected visual acuity between the two eyes in older children and a lack of alternate fixation determined by cover-uncover test in younger children. To determine refractive error change and spherical equivalent change over time, patients were divided into three age groups (younger than 7 years, 7 to 12 years, and 12 to 17 years). In the individual group, spherical equivalent change was assessed. This grouping was based on the substantial data demonstrating a myopic shift in refractive error occurs in children between 7 and 12 years old.7–9 Another grouping of patients was made according to the age of onset. Patients were also grouped according to the age of onset (early onset < 12 months and late onset > 12 months), and by degree of deterioriation (no decompensation and decompensation). Comparisons were made between these two groups.
Statistical analyses were performed using Statistical Package for the Social Sciences software version 20 (SPSS Inc). The descriptive statistics, frequencies, and percentages of categorical variables and the means and standard deviations of the numeric variables were assessed. The data were not distributed normally (Kolmogorov–Smirnov test). Therefore, nonparametric tests were used for comparison analysis. Categorical independent variables were compared by the chi-square test. The Mann–Whitney U test was used for the comparisons between independent numeric variables. When making comparisons between dependent variables, Friedman's two-way analysis of variance by ranks and McNemar tests were used. P values less than .05 were considered statistically significant.
A review of medical records identified 223 patients who were diagnosed as having fully accommodative esotropia. The mean age of the patients at presentation and onset was 5.36 ± 2.26 years (range: 1 to 16 years) and 2.23 ± 1.31 years (range: 6 months to 7 years), respectively. One hundred three patients (46.2%) were female and 120 patients (53.8%) were male. The mean spherical equivalent values were +4.58 ± 2.01 diopters (D) (range: +1.00 to +9.50 D) and +4.82 ± 2.01 D (range: +1.00 to +11.00 D) in the right and left eyes, respectively. The mean visual acuity was 0.04 ± 0.09 logMAR (range: 0.00 to 0.70 logMAR) in the right eye and 0.07 ± 0.16 logMAR (range: 0.00 to 1.00) in the left eye. The patients were followed up for a mean time of 5.94 ± 0.31 years (range: 5 to 8 years).
Considering all of the patients with fully accommodative esotropia, significant improvement in amblyopia, astigmatism, and visual acuity during the follow-up period was determined with the Wilcoxon signed-ranks test. The visual acuity of the right and left eyes improved from 0.16 to 0.04 logMAR (P < .001) and from 0.23 to 0.07 logMAR (P <.001), respectively. At the initial visit, 140 patients (62.8%) had amblyopia, whereas at the final visit 66 patients (29.6%) had amblyopia (P < .001). The mean astigmatic power of the right and left eyes declined from −0.93 ± 0.83 to −0.81 ± 0.92 D (P = .01) and from −1.02 ± 0.88 to −0.94 ± 0.98 D (P = .06), respectively.
Spherical equivalent changes from the initial visit to 7 years, between 7 and 12 years, and between 12 and 17 years were significantly different (P < .001). The decrease of hypermetropia was 0.13 D per year between 7 and 12 years and 0.06 D per year between 12 and 17 years. The mean spherical equivalent values obtained at the initial visit, 7, 12, and 17 years, and the mean spherical equivalent changes according to age are shown in Table 1.
Spherical Equivalent Values (D) and Changes According to Age
Forty-one of 223 patients (18.4%) discontinued spectacle therapy during the follow-up period. Age at onset, age at presentation, gender, and stereopsis were not statistically significant factors in spectacle discontinuation (P = .06, .44, .50, and .42, respectively). The mean spherical equivalent values of the right and left eyes at the initial visit were 5.11 ± 1.81 and 5.39 ± 1.75 D in the spectacle continuation group and 2.25 ± 0.71 and 2.30 ± 0.73 D in the spectacle discontinuation group, respectively. The difference was statistically significant (P < .001). The mean astigmatism values of the right and left eyes were significantly lower in the spectacle discontinuation group (−0.62 ± 0.70 vs −1.01 ± 0.84 D, P = .03 and −0.71 ± 0.76 vs −1.09 ± 0.89 D, P = .06, respectively). Initial visual acuity levels of the right and left eyes were significantly higher in the spectacle discontinuation group (0.10 ± 0.16 vs 0.18 ± 0.19 logMAR, P = .01 and 0.17 ± 0.27 vs 0.24 ± 0.26 logMAR, P = .02, respectively). Presence of amblyopia at the initial visit was significantly lower in the patients who discontinued spectacle wear (P = .007). Presence of near-distance disparity was found to be significantly higher in the spectacle discontinuation group (P = .01).
Deterioration of fully accommodative esotropia occurred in 30 of 223 patients (13.5%). The mean time interval from age of onset until deterioration was 6.20 ± 3.60 years (range: 3 to 20 years). The mean age at operation was 8.72 ± 3.61 years (range: 4 to 21 years). The mean follow-up time after surgery was 4.40 ± 0.84 years (range: 2 to 6 years). There were no surgical complications. In the decompensation group, the mean preoperative esotropia reduced from 27.8 to 4.4 PD postoperatively at near and from 19.1 to 2.6 PD at distance (P < .001). Two patients had a residual esotropia of 12 PD or greater and one patient had consecutive exotropia of 12 PD or greater and needed surgical intervention. Orthotropia within 10 PD of deviation was observed in 27 of 30 patients and remained so during the follow-up period. Only the patient with consecutive exotropia required reduction in the hyperopic correction to maintain alignment. The surgical procedures applied for these patients are shown in Table 2.
Surgical Procedures for Decompensated Fully Accommodative Esotropia
Age at onset, visual acuity values at the first and last visit, and follow-up time were not significantly different between the groups. Spherical equivalent values obtained at the initial visit, 7 years, 12 years, 17 years, and at the last visit did not differ significantly between the groups. Spherical equivalent changes from initial visit to 7 years, between 7 and 12 years, and 12 and 17 years were not found to be different among groups. The mean age at presentation and esotropia angle with and without refractive correction at both near and distance fixation were significantly higher in patients with decompensated fully accommodative esotropia. P values of comparisons between numeric variables are shown in Table 3. Boys were more likely to have decompensation and require strabismus surgery (P = .04). Presence of amblyopia at the first and last visits and stereopsis was similar between the two groups. The presence of inferior oblique overaction and surgery for inferior oblique overaction was significantly higher in patients with decompansated fully accommodative esotropia. The near-distance disparity was also significantly higher in patients with decompensated fully accommodative esotropia. P values of comparisons between categorical variables are shown in Table 4. Comparisons were made between the early-onset and late-onset groups; only two variables (stereopsis and age at operation) were found to be statistically different. The mean age at surgery was 7.5 ± 5.9 years in the early-onset group and 9.0 ± 2.5 years in the late-onset group (Kruskal–Wallis test, P = .11). Stereopsis was obtained in 69.2% of patients with late-onset esotropia and in 50% of patients with early-onset esotropia (chi-square test, P = .015).
Comparisons Between Numeric Variables
Comparisons Between Categorical Variables
Previous studies generally agree that an increase in hypermetropia up to 7 years old is followed by a small decline thereafter.10–12 In our study, the mean spherical equivalent changes were 0.16 and 0.19 D in the right and left eyes, respectively, during the follow-up period, which is equal to 0.027 and 0.03 D of decrease per year. In a study by Mohney et al13 in which prescribing the full hyperopic correction was the usual practice, similar to ours, hypermetropia decreased from an initial level of 3.80 to 2.80 D at final presentation over a mean follow-up of 9.8 years, representing a mean decrease of 0.10 D per year. Grouping of patients' refractive errors according to age (between 7 and 12 years) was based on the myopic trend in the normative data.14 In the current study, when change was grouped according to certain age transitions, a statistically significant increase in hypermetropic error before 7 years and a statistically significant myopic shift after 7 years was detected. The decrease of hypermetropia was 0.13 D per year between 7 and 12 years and 0.06 D per year between 12 and 17 years. Various myopic progression rates have been reported in the literature.13,15–22 Repka et al17 found a decrease of 0.11 D of hypermetropia per year in patients with accommodative esotropia after 7 years. Raab18 found 0.18 D of the decline of hypermetropia annually and Black15 found 0.17 D of the decline of hypermetropia annually after 7 years. In the current study, the annual decrease of hypermetropia was greater between 7 and 12 years compared to after 12 years. Black15 found the annual decrease of hypermetropia between 7 and 12 years to be approximately the same rate throughout the teenage years.
In this study, we found a significant decline in astigmatism during the follow-up time. In contrast with our findings, Park et al23 reported that cylinder power did not change significantly with age in children with accommodative esotropia, and Wang et al24 observed a significant increase of astigmatism in the infantile group but not in the late onset group.
In this study, we found no difference between the early-onset and late-onset fully accommodative esotropia groups in terms of refractive error change during the follow-up time. We observed an increase in hyperopia before age 7 years and a myopic shift after age 7 years in both groups. In contrast, Wang et al24 found that a myopic shift of −0.43 D per year occurred in the early onset group after age 7 years, but the late-onset group did not experience a myopic shift between 7 and 12 years.
In our study, 41 of 223 patients (18.4%) discontinued spectacle therapy during the follow-up period. The patients who needed to continue spectacle wear had higher hypermetropic error at the initial and final visits. Initial and final hypermetropic error were found to be significant in discontinuation of spectacle therapy. Similar to our findings, Mohney et al13 found that lower initial hyperopic error and full-term birth were associated with the discontinuation of spectacles for distance esotropia.
In the current study, in addition to the hypermetropia level, initial and final astigmatism level and initial amblyopia presence were statistically significantly lower in the spectacle discontinuation group. We also found that a higher initial visual acuity level was a significant factor in spectacle discontinuation. Near-distance disparity was higher in the spectacle discontinuation group. An explanation for this finding would be that, hyperopic error was lower and the deterioration rate and need for surgery were higher in patients with near-distance disparity.
In this study, we found that 30 of 223 patients (13.5%) with decompensated fully accommodative esotropia required strabismus surgery. Consistent with our findings, various deterioration rates (ranging from 2.4% to 50%) were reported in the literature.15,16,25–28 Black15 reported a Kaplan-Meier rate of 19% deterioration at 18 years after initial treatment for patients with fully accommodative esotropia.
In our study, boys were more likely to need surgical intervention. Age at onset was not different between the groups but age at presentation was higher in the decompensation group. This could be explained by inclusion of some patients who were previously followed up at another hospital but subsequently referred to our hospital or preferred to be treated at our hospital. Similar to our findings, Mohney et al13 found that the subsequent need for surgery among children with fully accommodative esotropia was greater among boys. Younger age at onset and diagnosis was reported to be associated with deterioration of fully accommodative esotropia. In contrast with findings in the literature, we found that the need for surgery was higher in those with older age at presentation.
Additionally, in this study, inferior oblique dysfunction and an abnormal near-distance relationship were significantly higher in the decompensation group. Similarly, Ludwig et al26 and Black15 found that decompensation was associated with oblique muscle dysfunction and an abnormal near-distance relationship. In the study by Ludwig et al,26 the mean AC/A ratio averaged over all visits was 10.9 in the decompensation group and 8.2 in the no decompensation group. In contrast with our findings, Von Noorden et al25 found a negative correlation between AC/A ratio and decompensation, whereas Dickey and Scott28 found no correlation.
We also found that there was a significant difference in percentage of decompensation between those who were orthophoric compared to those who manifested a small (< 10 PD) esotropia. Of 30 patients who had decompensation, esotropia of less than 10 PD manifested in 29 patients (96.7%).
Strengths of this study are the comparatively large patient population and long follow-up time. Another strength of our study is the uniformity in patient selection, such as including patients with fully accommodative esotropia only. We reported the decompensation rate, spherical equivalent change, and spectacle discontinuation rate in this unique group of patients. Limitations of this study are its retrospective design and the presence of missing data in cohort study models. Other limitations are that patients were not examined by the same specialist at all times and much of the collected data (including spectacle wear compatibility, age at onset) depended on the reliability of the parents' statements.
In this population-based cohort of 223 patients, accommodative esotropia resolution and spectacle wear discontinuation were obtained in a minority of children. Hyperopic error, astigmatism, visual acuity, and presence of amblyopia and near-distance disparity were significant factors affecting the likelihood of discontinuing spectacle wear. In addition, hyperopic error increased until 7 years and decreased later. Deterioration of fully accommodative esotropia occurred in a minority of patients, more often in boys, in individuals with older age at presentation, and in individuals with near-distance disparity and inferior oblique overaction, and required surgical intervention.
- Von Noorden GK. Binocular Vision and Ocular Motility, 6th ed. Mosby; 2002:311–355.
- Wright KW, Strube YN. Pediatric Ophthalmology and Strabismus, 3rd ed. Oxford University Press; 2012:293–298.
- Baker JD, Parks MM. Early-onset accommodative esotropia. Am J Ophthalmol. 1980;90(1):11–18. doi:10.1016/S0002-9394(14)75070-6 [CrossRef]
- Graham PA. Epidemiology of strabismus. Br J Ophthalmol. 1974;58(3):224–231. doi:10.1136/bjo.58.3.224 [CrossRef]
- Greenberg AE, Mohney BG, Diehl NN, Burke JP. Incidence and types of childhood esotropia: a population-based study. Ophthalmology. 2007;114(1):170–174. doi:10.1016/j.ophtha.2006.05.072 [CrossRef]
- Rosenbaum AL, Santiago AP. Clinical Strabismus Management: Principles and Surgical Techniques. Saunders; 1999.
- Gwiazda J, Grice K, Held R, McLellan J, Thorn F. Astigmatism and the development of myopia in children. Vision Res. 2000;40(8):1019–1026. doi:10.1016/S0042-6989(99)00237-0 [CrossRef]
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- Parks MM. Management of acquired esotropia. Br J Ophthalmol. 1974;58(3):240–247. doi:10.1136/bjo.58.3.240 [CrossRef]
- Slataper FJ. Age norms of refraction and vision. Arch Ophthalmol. 1950;43(3):466–481. doi:10.1001/archopht.1950.00910010475007 [CrossRef]
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- Mulvihill A, MacCann A, Flitcroft I, O'Keefe M. Outcome in refractive accommodative esotropia. Br J Ophthalmol. 2000;84(7):746–749. doi:10.1136/bjo.84.7.746 [CrossRef]
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Spherical Equivalent Values (D) and Changes According to Agea
|Spherical Equivalent Values||Age|
|< 7 Years||7 Years||12 Years||17 Years|
| Right eye||4.68 ± 2.02||4.91 ± 1.97||4.08 ± 1.94||3.59 ± 1.96|
| Left eye||4.87 ± 2.04||5.12 ± 1.95||4.35 ± 1.96||3.79 ± 1.81|
|Spherical Equivalent Changes||0 to 7 Years||P||7 to 12 Years||P||12 to 17 Years||P|
|Right eye||0.29 ± 0.71b||< .001||−0.62 ± 0.57b||< .001||−0.20 ± 0.39b||.08|
|Left eye||0.29 ± 0.59b||< .001||−0.68 ± 0.65b||< .001||−0.27 ± 0.61b||.07|
Surgical Procedures for Decompensated Fully Accommodative Esotropia
|Unilateral bridge Faden||1|
|Unilateral (MRc + bridge Faden)||3|
|Unilateral (MRc + LRc)||3|
|Bilateral (MRc + bridge Faden)||1|
|Bilateral MRc + unilateral bridge Faden||1|
|Bilateral MRc + unilateral LRc||1|
|Bilateral (MRc + LRc)||1|
Comparisons Between Numeric Variables
|Variables||No Decompensation (n = 193)||Decompensation (n = 30)||Pa|
|Mean ± SD||Range||Mean ± SD||Range|
|Age at onset (years)||2.21 ± 1.33||0.0 to 7.0||2.40 ± 1.22||0.5 to 5.0||.76|
|Age at presentation (years)||5.13 ± 2.87||1.0 to 16.0||6.80 ± 3.19||1.0 to 15.0||.03|
| Right||4.59 ± 2.01||1.00 to 9.50||4.55 ± 1.93||1.50 to 8.50||.98|
| Left||4.82 ± 2.00||1.00 to 11.00||4.81 ± 2.13||1.50 to 9.50||.99|
| Right||0.04 ± 0.09||0.0 to 1.0||0.04 ± 0.12||0.0 to 0.7||.25|
| Left||0.07 ± 0.15||0.0 to 1.0||0.08 ± 0.22||0.0 to 1.0||.42|
|ET without spectacles (PD)|
| Near||21.53 ± 8.11||10 to 55||38.83 ± 11.17||30 to 80||< .001|
| Distance||18.20 ± 7.76||0 to 55||30.33 ± 11.18||10 to 60||< .001|
|ET with spectacles (PD)|
| Near||4.37 ± 4.35||0 to 12||27.86 ± 8.71||18 to 50||< .001|
| Distance||2.37 ± 3.61||0 to 10||19.13 ± 7.70||0 to 40||< .001|
Comparisons Between Categorical Variables
|Variable||No Decompensation, (n = 193) n (%)||Decompensation, (n = 30) n (%)||Pa|
| Male||99 (51.3%)||21 (70%)|
| Female||94 (48.7%)||9 (30%)|
| Initial visit||124 (64.2%)||16 (53.3%)||.25|
| Last visit||57 (29.5%)||9 (30%)||.95|
|Stereopsis presence||103 (65.2%)||15 (55.6%)||.33|
|IOOA presence||14 (9%)||7.3 (30%)||.01|
|Near-distance disparity||13 (6.7%)||18 (60%)||< .001|
|Spectacle discontinuation||33 (17.1%)||8 (26.7%)||.15|
|Orthophoria||96 (50.8%)||1 (3.3%)||< .001|
|Esotropia < 10 PD||93 (49.2%)||29 (96.7%)||< .001|