Cynthia W. Avilla

Accommodative convergence in hypermetropia

We compared the clinical characteristics of esotropic, hypermetropic children whose strabismus was fully corrected with spectacles (refractive accommodative esotropia) with those who remained orthotropic (that is, had no manifest strabismus on the cover test) in the presence of uncorrected hypermetropia. In addition to a standard ophthalmologic and orthoptic examination, we determined the stimulus accommodative convergence/accommodation (AC/A) ratio by using the gradient method over a range of 6 diopters, the near point of accommodation, and random dot stereopsis. Hypermetropic patients without esotropia or significant esophoria were found to have a low AC/A ratio in contrast to those patients with refractive accommodative esotropia. This finding explains why esodeviations may be absent in some hypermetropic patients with uncorrected vision. We found a high prevalence of abnormally low near points of accommodation and defective or absent stereopsis in both groups of patients.

Early-onset refractive accommodative esotropia.

INTRODUCTION We studied the natural history of pure refractive accommodative esotropia after spectacle correction in patients with onset before 1 year old to determine whether their outcomes and characteristics were different from those of patients with more typical age at onset of refractive accommodative esotropia. METHODS We retrospectively reviewed the charts of 17 children with onset of refractive accommodative esotropia before 1 year old. Records of 26 children with onset after 2 years old were reviewed as controls. RESULTS The mean ages at diagnosis were 9 months and 48 months for the study and control groups, respectively. All 17 study patients and all 26 control patients were initially well aligned with spectacles at distance and near. Follow-up averaged 34 months for study patients and 41 months for control patients. Three study patients (17.6%) and 1 control patient (3.8%) had eventual deterioration and required strabismus surgery (P = .28). None of the study patients developed amblyopia, whereas 42% of control patients did (P = .001). Seven of 15 (47%) of the study patients with known birth history were born prematurely, whereas only 3 of 24 (12%) control patients were born prematurely (P = .03). CONCLUSIONS Refractive accommodative esotropia was diagnosed at as early as and age 4 months. Prematurity appeared to be a risk factor. Amblyopia was not detected in any patient with early-onset refractive accommodative esotropia. Treatment with full hyperopic spectacle correction led to long-term stable alignment, with relatively few patients requiring surgery.

Nonaccommodative Convergence Excess

Nonaccommodative convergence excess is a condition in which a patient has orthotropia or a small-angle esophoria or esotropia at distance and a large-angle esotropia at near, not significantly reduced by the addition of spherical plus lenses. The AC/A ratio, determined with the gradient method, is normal or subnormal. Tonic convergence is suspected of causing the convergence excess in these patients. Nonaccommodative convergence excess must be distinguished from esotropia with a high AC/A ratio and from hypoaccommodative esotropia. In 24 patients treated with recession of both medial recti muscles with and without posterior fixation or by posterior fixation alone, the mean correction of esotropia was 7.4 prism diopters at distance and 17 prism diopters at near.

Latent nystagmus and strabismic amblyopia.

Conventional occlusion of the sound eye improved visual acuity in 11 of 12 patients with latent nystagmus and strabismic amblyopia. The successful results reported in this study are in contradiction to current views that occlusion therapy is futile or even contraindicated in patients with amblyopia and latent nystagmus.

The Prevalence of Dissociated Vertical Deviation in Patients With Sensory Heterotropia

PURPOSE We reviewed 281 consecutive patients with sensory esotropia or exotropia to determine the prevalence of dissociated vertical deviation in patients with sensory strabismus. METHODS We reviewed the charts of all patients who received a diagnosis of sensory heterotropia or dissociated vertical deviation and who were examined at the Pediatric Ophthalmology Service at the Texas Childrens Hospital between 1973 and 1992. Statistical analyses of the prevalence of dissociated vertical deviation were determined after evaluating the direction of the accompanying horizontal strabismus and examining the temporal relationship of the unilateral vision loss. RESULTS Dissociated vertical deviation was diagnosed in 35 patients (12.5%). It occurred more frequently in sensory esotropia (22 patients, 18.3%) than exotropia (13 patients, 8.1%) (P = .009). The age at which unilateral visual loss occurred did not influence the development of dissociated vertical deviation. CONCLUSION Dissociated vertical deviation in patients with acquired loss of vision does not support the contention that dissociated vertical deviation is a genetically predetermined anomaly of binocular vision.

Refractive accommodative esotropia: a surgical problem?

Among the reasons given for surgery in refractive accommodative esotropia (RAET) are (1) frequent functional deterioration and (2) high prevalence of cyclovertical strabismus and oblique muscle dysfunctions. Of 30 patients with RAET, corrected with glasses and followed for an average of seven years only one deteriorated. We tested a second group of 53 patients with RAET for A- and V-patterns and dysfunction of the oblique muscles. Pseudo-A- and V-patterns occurred without glasses but were absent when glasses were worn during the measurement. Dysfunctions of the oblique muscles were observed without glasses but were clinically insignificant. Our data do not support the reasons cited above for performing surgery in RAET.

Etiology and surgical management of horizontal pontine gaze palsy with ipsilateral esotropia

INTRODUCTION An esotropia ipsilateral to a horizontal pontine gaze palsy has been infrequently reported. We discuss the etiology and review the surgical management of this ocular motility defect. METHODS Four patients with radiographically documented dorsal pontine lesions and persistent horizontal gaze palsy with esotropia ipsilateral to the gaze palsy were treated. In each patient, the esotropia was present in attempted primary gaze, producing symptomatic diplopia. An anomalous face turn was required to attain single binocular vision. RESULTS All 4 patients underwent surgical correction to alleviate the anomalous head position and diplopia. Bilateral, asymmetric surgery was required to achieve a long-term successful result. Single binocular vision in the primary position with elimination or marked improvement of the compensatory head posture was initially achieved in all 4 patients. One patient, who had not undergone asymmetric strabismus surgery to reconcile incomitance produced by the esotropia, rapidly developed a residual esotropia. CONCLUSIONS Ophthalmologists should recognize that concurrent esotropia may occur in patients with horizontal pontine gaze palsy. Single binocular vision in the primary position, an expanded binocular visual field, and alleviation of a compensatory head position are achievable with strabismus surgery.

Epidemiology of CN IV Palsies

Objective To examine the etiologies of CN IV palsies based on age and aid the clinician in more effective work-up and treatment. Methods Retrospective chart review of 124 patients presenting to Houston Eye Associates between 1968 and January 1999 with superior oblique palsies. Patients were divided into the following age groups: birth to 10 years, 11–20 years, 21–40 years, 41–60 years and over 60 years. Etiologies and treatment were then examined within each age group. Etiologies were categorized as congenital, traumatic, vascular, neoplastic, and idiopathic. Treatment was classified as observation, prisms alone, surgical repair, and surgical repair combined with prisms. Bilateral, unilateral, and masked bilateral palsies were included. Results Nine of 13 bilateral palsies were due to trauma. The masked bilateral palsy was congenital. Between the ages of birth and 10 years 26 of 37 (70.1%) palsies were congenital. Between the ages of 21 and 40 years 17/35 (48.6%) were due to trauma. Within the remaining age groups 11–20 years, 41–60 years, and over 60 years, the most common etiology was idiopathic 7/13 (53.8%), 11/24 (45.8%), and 7/15 (46.7%) respectively. Surgery was the most common treatment option within all age groups with the exception of the over 60 group. In this age group, prisms alone was most common.

Decompensated Strabismus in Adults

The onset of strabismus in the adult patient, if not the result of documented trauma, may be the harbinger of serious systemic disease. Certain findings, however, may indicate decompensation of a l...

Postoperative Orthoptic Pearls to Improve Surgical Results in Adults

The success of surgical alignment in the adult patient with strabismus is dependent upon numerous motor and sensorial factors that are assessed preoperatively. However, the same information determined prior to surgery is adapted after surgery to effect the most beneficial functional result that may be achieved in each patient. These simple and elegant pearls have been utilized daily by all practitioners of strabismus and their value remains timeless.