Evaluation of Post-Operative Outcomes in Acute Acquired Comitant Esotropia Brittany Kwait1, Sylvia Kodsi MD1,2, Stacey Kruger MD1,2, Hal Schwartzstein DO1,2, 1Donald
and Barbara Zucker School of Medicine at Hofstra/Northwell; 2 Northwell Health Department of Ophthalmology
Background - Acute acquired comitant esotropia is defined as medial deviation of the eye that presents after 6 months of age that does not sufficiently respond to correction of hyperopia, and represents only 0.3% of childhood strabismus. It is rarely associated with intracranial pathology, but an MRI is often part of preoperative workout to rule out any neurologic abnormalities. (Dotan et al.; Jacobs et al.; Sturm et al.; Jacobs et al.) - The standard of care is strabismus surgery, typically bilateral medial rectus recession (BMR), with relatively favorable success rates, considered here to be an alignment within 8 prism diopters at distance and near (Kim and Choi; Ing) - A slightly higher percentage of infants who present with congenital esotropia are born prior to 37 weeks gestation (12.3%) compared with the general U.S. population (10%). In general, there is an association between premature birth and ocular abnormalities, necessitating careful monitoring of visual development of premature infants (Louwagie et al.; Gallo and Lennerstrand) - Children whose deviation begins after a median age of 37 months are more likely to have a successful long-term outcome (Jacobs et al.)
Fig. 2: Study Sample Size
37 patients Ages 2-10
Ages 11-18 29
8 Surgery too recent to assess outcomes
6
Hypothesis
1 23
Fig. 3: Patient Characteristics And BMR Outcomes
Methods
Male (%)
Female (%)
Premature Birth (%)
39.1
60.1
34.8
Resources Successful Operation
MRI Ordered (%)
87.0
13.0
Age 2-10 28.6
71.4
0
100
85.7
Age 11-18 36.7 Total
63.3
23.3%
Future Direction - This project is a part of a large, multi-center study designed to assess the characteristics of AACE and different approaches to treatment and management. - As AACE is a rare condition, combining data from many surgeons is necessary to obtain a sufficient sample size for analysis. - The larger study is being submitted to the annual American Association of Pediatric Ophthalmology and Strabimus (AAPOS) meeting
7
Final Sample
- Older children (ages 11-18) will have higher rates of successful BMR surgery outcomes in comparison with younger children (ages 2-10), with success defined as alignment equal or less than 10 prism diopters with correction. - There will be a higher percentage of premature infants in our sample compared with the general U.S. population. - Providers will be more likely to request an MRI as part of the diagnostic workup for older children compared to for younger children.
Patients whose AACE is a result of a neurologic condition Age <2 or >18 years at time of esotropia onset Moderate hyperopia: hyperopia >+3.00 diopters Previous strabismus surgery or botulinum toxin injections Developmental abnormalities Incomitant strabismus on examination, defined as a difference in esotropia measuring more than 5 prism diopters in any field of gaze.
- While the overall success rate was found to be high (90%), older children had more successful BMR outcomes than the younger children. This may be because the visual system in older children is more fully developed, so restoring alignment should restore binocularity in these patients. - Of note, prematurity was only associated with esotropia when the the age of onset was prior to 11 years old - all patients in the 11-18 age group were born full term. This finding has not been previously described. - Our sample size was smaller than originally anticipated as several patients were lost to follow up. - Physicians treating older children were more likely to request imaging prior to surgery; the only child in the 11-18 group who did not have an MRI before surgery had a sister who developed esotropia after age 10, so an intracranial abnormality was not expected. - The prematurity rate in our patient sample, at 23.3%, was over 2.3X that of the general population of infants born in the United States.
Fig 1: Child with esotropia of the right eye
Lost to follow up
De-identified records of patients seen by Dr. Kodsi, Dr. Kruger, or Dr. Schwartzstein from January 2011-September 2020 who had BMR surgery for strabismus were selected, based on the exclusion criteria below:
Conclusions
Results
90
30%
Strabismus. (2018, February 12). Retrieved October 03, 2020, from https://aapos.org/glossary/strabismus Anatomy of the Eye. Retrieved October 08, 2020, from https://aapos.org/glossary/anatomy-of-the-eye Çerman, E., Eraslan, M., & Öğüt, M. S. (2014). The relationship of age when motor alignment is achieved and the subsequent development of stereopsis in infantile esotropia. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus, 18(3), 222–225. https://doiorg.medproxy.hofstra.edu/10.1016/j.jaapos.2013.12.017 Dotan, G., Keshet, Y., Qureshi, H. M., Friling, R., & Yahalom, C. (2020). When pediatric acute acquired comitant esotropia is not caused by a neurological disease. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus, 24(1), 5.e1–5.e5. https://doiorg.medproxy.hofstra.edu/10.1016/j.jaapos.2019.09.016 Gallo JE, Lennerstrand G. A population-based study of ocular abnormalities in premature children aged 5 to 10 years. Am J Ophthalmol. 1991 May 15;111(5):539-47. doi: 10.1016/s0002-9394(14)73695-5. PMID: 2021159. Ing M. R. (1981). Early surgical alignment for congenital esotropia. Transactions of the American Ophthalmological Society, 79, 625–663. Jacobs, S. M., Green-Simms, A., Diehl, N. N., & Mohney, B. G. (2011). Long-term follow-up of acquired nonaccommodative esotropia in a population-based cohort. Ophthalmology, 118(6), 1170–1174. https://doi-org.medproxy.hofstra.edu/10.1016/j.ophtha.2010.10.032 Kim E, Choi DG. Outcomes after the surgery for acquired nonaccommodative esotropia. BMC Ophthalmol. 2017 Jul 24;17(1):130. doi: 10.1186/s12886-017-0527-y. PMID: 28738831; PMCID: PMC5525222. Louwagie, C. R., Diehl, N. N., Greenberg, A. E., & Mohney, B. G. (2009). Long-term follow-up of congenital esotropia in a population-based cohort. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus, 13(1), 8–12. https://doi-org.medproxy.hofstra.edu/ 10.1016/j.jaapos.2008.06.013 Sturm, Veit & Menke, Marcel & Knecht, Pascal & Schöffler, Corinna. (2011). Long-term follow-up of children with acute acquired concomitant esotropia. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus / American Association for Pediatric Ophthalmology and Strabismus. 15. 317-20. 10.1016/j.jaapos.2011.03.018.