Correspondence
Pediatric Strabismus
N Engl J Med 2007; 356:2750-2751June 28, 2007
- Article
To the Editor:
I disagree with the recommendation made by Donahue in his Clinical Practice article (March 8 issue)1 that children between the ages of 1 and 4 years with accommodative esotropia with near-distance disparity should be treated with bifocal eyeglasses. Data are very limited regarding the outcome of bifocal treatment with unifocal distance correction for such patients. Pratt-Johnson and Tillson,2 who reported on a nonrandomized, retrospective series of 99 patients with an average follow-up of 8 years, found no difference in final sensory outcome between the two groups. Another issue concerning bifocal eyeglasses in this population is practicality. It is extremely difficult to ensure that a child in this age range wears bifocals properly, even with a reading segment that bisects the pupil (i.e., executive style). In my experience, children with accommodative esotropia with near-distance disparity whose vision is aligned at distance with single-vision glasses do well with such eyeglasses; their residual esotropia at close range tends to decrease with time or can be addressed surgically. The optimal treatment for such patients is an “area of uncertainty,” since comparative outcome data are lacking.3
3 ReferencesArif O. Khan, M.D.
King Khaled Eye Specialist Hospital, Riyadh 11462, Saudi Arabia
arif.khan@mssm. edu 1
Donahue SP . Pediatric strabismus. N Engl J Med 2007;356:1040-1047
Full Text | Web of Science | Medline2
Pratt-Johnson JA ,Tillson G . The management of esotropia with high AC/A ratio (convergence excess). J Pediatr Ophthalmol Strabismus 1985;22:238-242
Medline3
Vivian AJ ,Lyons CJ ,Burke J . Controversy in the management of convergence excess esotropia. Br J Ophthalmol 2002;86:923-929
CrossRef | Web of Science | Medline
To the Editor:
The patient Donahue discusses shows noncongenital, progressive, unilateral esotropia. The physical examination was normal. However, we do not agree with his final recommendations. Although the author presents ophthalmologic guidelines for the management of strabismus and amblyopia, we would recommend that a child with new-onset esotropia should receive “a cycloplegic refraction,” as Donahue recommends, only after undergoing a complete neurologic evaluation. Many neurologic diseases could present with isolated, progressive esotropia,1 including type I Chiari malformation,2 cerebellar tumors,3 and childhood absence epilepsy.4 Therefore, the results of brain imaging and electroencephalography seem to be essential clues in the initial treatment of a patient with this kind of disorder. Moreover, a correct diagnosis may completely resolve esotropia2 and prevent disease progression.3
4 ReferencesLuigi Titomanlio, M.D., Ph.D.
Philippe Evrard, M.D., Ph.D.
Jean-Christophe Mercier, M.D., Ph.D.
Robert Debré Hospital, 75019 Paris, France
luigi.titomanlio@rdb. aphp. fr 1
Greenberg AE ,Mohney BG ,Diehl NN ,Burke JP . Incidence and types of childhood esotropia: a population-based study. Ophthalmology 2007;114:170-174
CrossRef | Web of Science | Medline2
Hentschel SJ ,Yen KG ,Lang FF . Chiari I malformation and acute acquired comitant esotropia: case report and review of the literature. J Neurosurg 2005;102:Suppl 4:407-412
Web of Science | Medline3
Musazadeh M ,Hartmann K ,Simon F . Late onset esotropia as first symptom of a cerebellar tumor. Strabismus 2004;12:119-123
CrossRef | Medline4
Gusek-Schneider GC ,Uberall MA ,Wenzel D . Intermittent esotropia as equivalent of absence in epilepsy. J Pediatr Ophthalmol Strabismus 2000;37:363-364
Web of Science | Medline
Author/Editor Response
Bifocals are commonly used in the United States, and reports of good sensory and motor outcomes have been published.1,2 The study to which Khan refers was underpowered to detect a difference in high-grade stereopsis; other outcomes, such as motor fusion and the lack of deterioration to surgery, are additional justifications for bifocal use. The theoretical basis for bifocals is to allow fusion when viewing proximate objects. Prolonged uncorrected esotropia decreases the likelihood of fusion. The use of bifocals decreases esotropia at close range in children who would otherwise be esotropic. Children who are esotropic at distance and at close range should have surgery. There is no indication for surgery if the eyes are straight with eyeglasses at distance and with bifocals at close range. Children with fusion use their bifocals spontaneously, provided the segment is appropriately positioned. The use of bifocals should be tapered since the need for such treatment decreases during elementary school.2 Some children do not use their bifocals (probably because they lack fusion), and it is unclear whether continued use in this situation is warranted.
I disagree with Titomanlio et al. that neuro-imaging and electrophysiological studies are needed to rule out disease of the central nervous system (CNS) in children with infantile esotropia. Infantile esotropia is a well-recognized entity first described by Costenbader in 1961. The diagnosis requires an “otherwise neurologically normal” infant; in my opinion, this determination does not typically require consultation from a pediatric neurologist. The motility findings in esotropic children with CNS disease are very different from those in children with infantile esotropia. Patients with infantile esotropia have ocular misalignment before the age of 6 months and have full versions, a comitant, large-angle esotropia, cross-fixation, and latent nystagmus. In contrast, nearly all CNS disease that affects eye movements produces either manifest nystagmus or a paretic strabismus with smaller-angle deviation, often with superimposed vertical ocular misalignment; such conditions occur in older children. The nystagmus is usually gaze-paretic, and other signs of elevated pressure (bulging fontanelle or papilledema) occur. Two prospective studies involving more than 200 infants who met the classic criteria for infantile esotropia3,4 found none who had CNS disease. The rare cases of acute comitant esotropia seen with posterior fossa masses5 involved older children, who usually had other neuro-ophthalmologic findings.
5 ReferencesSean P. Donahue, M.D., Ph.D.
Vanderbilt Medical Center, Nashville, TN 372321
von Noorden GK ,Morris J ,Edelman P . Efficacy of bifocals in the treatment of accommodative esotropia. Am J Ophthalmol 1978;85:830-834
Web of Science | Medline2
Ludwig IH ,Parks MM ,Getson PR . Long-term results of bifocal therapy for accommodative esotropia. J Pediatr Ophthalmol Strabismus 1989;26:264-270
Medline3
Birch E ,Stager D ,Wright K ,Beck R . The natural history of infantile esotropia during the first 6 months of life. J AAPOS 1998;2:325-328
CrossRef | Medline4
Pediatric Eye Disease Investigator Group
CrossRef | Web of Science | Medline5
Williams AS ,Hoyt CS . Acute comitant esotropia in children with brain tumors. Arch Ophthalmol 1989;107:376-378
CrossRef | Web of Science | Medline
