See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/354840342

Accommodative esotropia

Article · September 2021

CITATIONS READS

0 36

2 authors, including:

Antonela Ljubic
Polyclinic Medikaplus
27 PUBLICATIONS   96 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Ophthalmic manifestations in Down syndrome View project

Ophthlamic manifestations in Down syndrome View project

All content following this page was uploaded by Antonela Ljubic on 25 September 2021.

The user has requested enhancement of the downloaded file.

Year XXV – No 94 - March 2017
VOX medici
NEWS LETTER OF THE DOCTOR’S CHAMBER OF MACEDONIA
Professional and scientific papers

Accommodative esotropia

Antonela Ljubic1, Keti Tagasovska2

1
Department of Ophthalmology , Polyclinic Medika Plus, Skopje, R. Macedonia

2
Department of Ophthalmology, "St. Cyril and Methodius” University Polyclinic, Skopje, R.
Macedonia

ABSTRACT

Aim : Population - based study of prevalence of accommodative (AET) and partially

accommodative esotropia ( PAET) in a strabismic cohort of 215 patients in Macedonia ;
analyzing the spherical equivalent and risk factors in these forms of esotropia .

Patients and methods: A cross-sectional, population-based study was conducted. The

classification of the type of strabismus was made according to RCOPHT (Royal College of
Ophthalmologists). Snellen letters distant visual acuity was determined in each subject ,
refractive status in short-term cycloplegia as well tests of ocular motility, Cover/ Uncover
test.

Results:The prevalence of pure accommodative esotropia in Macedonian strabismic

cohort was 11.6% (25/215), partial accommodative esotropia 7.9% (17/215), and non-
accommodative esotropia 59.5% (128/215). In purely accommodative esotropia the mean
value of the spherical equivalent in diopters (D) in the right eye was + 5.73 D, in the left eye
+ 5.69 D, while in partial accommodative in the right eye +3.37 D, in the left eye + 3.38 D.

Conclusion: In the Macedonian strabismic population, pure AET accounted for 11.6%, while
partial AET accounted for 7.9%. The low obtained value of purely accommodative esotropias
should take into account the conversion of purely accommodative esotropia into partial-
accommodative and non-accommodative esotropia. Based on refractive examination in
short-term cycloplegia, treatment of choice for AET is complete hyperopic correction in the
form of glasses.

Keywords: accommodative esotropia, prevalence; cycloplegic refraction, АС/А index

INTRODUCTION

Common classification of the types of strabismus used in the scientific world, and having
clinical application as well, is the classification made by RCOPHT (Royal College of
Ophthalmologists)(1) according to which all types of strabismus are divided into 4 groups: the
first group being congenital esotropia (convergent strabismus), the second group - acquired
esotropia, the third group - exotropia (divergent strabismus) and the fourth group - vertical
strabismus.

Of particular clinical importance is the second group of strabismus from the classification,
which belongs to the large group of acquired esotropias. Acquired esotropias in this group
include: 1) pure accommodative esotropia, 2) partial accommodative esotropia and 3) non-
accommodative esotropia. Purely accommodative esotropia (or refractive accommodative
esotropia, as denominated by von Noorden GK) is defined as convergent strabismus that is
fully neutralized by prescribing full hypermetropic optical correction(2).

Accommodative esotropia usually occurs between the age of two and three, i.e. it does not
occur at birth and is therefore included in the group of acquired esotropias. The evolution of
accommodative esotropia goes through a stage of intermittent deviation of the eye. The
variability of strabismic deviation angle depends on the general condition of the child,
whether the child is tired, anxious or similar.

If the glasses partially neutralize strabismic deviation at near and far point fixation target,
then it is not a purely accommodative esotropia, but the so-called partial accommodative
esotropia.

Non-accommodative esotropia, as the name suggests, is an esotropia that is not neutralized

by wearing glasses (full hypermetropic optical correction) and requires a surgical intervention
to correct the strabismic deviation.

The aim of our population- based study was to determine the prevalence of pure
accommodative and partially accommodative esotropia in a cohort of 215 patients from the
Macedonian strabismic population, as well as to provide guidelines for the treatment of this
type of strabismus.

PATIENTS AND METHODS

Total of 215 strabismic records from 2003 to 2016 were analyzed. The patients were
examined in "Professor Kosta Janev" Eye Health Center , Skopje,R.Macedonia and Private
Polyclinic "Medika Plus",Skopje, R. Macedonia. A cross-sectional, population-based study
was performed in order to determine the prevalence of a particular form of convergent
strabismus - accommodative esotropia and partially accommodative esotropia. Birth weight
(gr.), gestational age (gestational weeks), age of the mother at the time of delivery (years of
age), as well as the presence of prenatal, perinatal and postnatal risk factors were analyzed
with a separate questionnaire for risk factors (within strabismic record). The presence of
febrile convulsions, the presence of epilepsy, affection of a cranial nerve (n. statoacusticus)
were analyzed separately.
The classification of the type of strabismus was made according to RCOPHT (Royal College
of Ophthalmologists)(1) into: 1) congenital esotropia 2) acquired esotropia (which includes:
accommodative, partially accommodative and non-accommodative esotropia) 3) exotropia
and 4) vertical strabismus.

Distance visual acuity was determined in each subject, without correction and with
correction, using Snellen’s optotypes for distance. The oculomotor balance examination
(strabismic assessment) included: 1) determination of the deviation in primary position at
near and distant using the Hirschberg test in the presence of a corneal light reflex; 2) use
of Cover test and Cover/Uncover test in order to determine the alternation of the deviation;
3) ocular motility in 9 diagnostic directions and 4) determination of punctum proximum
convergenciae (PPC). The refractive status was determined in the short-term cycloplegia
using Potec Auto-Ref-KeratometarPRK-5000, Daejon, Korea, and Cyclopentolat 1% three
times, one drop each time at intervals of 5-10 minutes. The examination was performed 30
minutes after the first drop. A spherical equivalent was calculated for each subject as a
numerical value of the determined refraction. The statistical processing included calculating
percentages of structure and mean value.

RESULTS

In total 215 strabismic records (215 patients diagnosed with any form of strabismus),
10/215 (4.7%) showed the presence of a congenital form of strabismus (ETI) (Esotropia
Infantilis Essentialis). Pure accommodative esotropia accounted for 11.6% (25/215), while
partially accommodative esotropia accounted for 7.9% (17/215). Non-accommodative
esotropia from the group of acquired esotropias was the most common with 59.5% (128/215)
of the total strabismic population.

The subject of our study were pure accommodative esotropia and partially accommodative
esotropia. From the second classification group of acquired esotropias, 14.7% (25/170)
belonged to pure accommodative esotropia, while 10% (17/170) to partially accommodated
esotropia.

The mean age of the subjects with pure accommodative esotropia was 5.9 years , 52% were
female and 48% were male.

The mean value of visual acuity with correction of the right eye was 0.6, while on the left
eye 0.7. The mean value of the spherical equivalent expressed in diopters (D) was +5.73 D
in the right eye, +5.69 D in the left eye. The size of the strabismic deviation angle expressed
in prism diopters (PD) without optical correction was 27.2 PD.

The analyzed risk factors showed 3049 g. as mean birth weight of the subjects ,38.5
gestational weeks as mean value of gestational age, and 27.6 years of age as mean age of
the mother at the time of delivery.

The mean age of the subjects with partially accommodative esotropia was 4.5 years of age,
41% being female and 59% being male.
The mean value of visual acuity with correction of the right eye was 0.64 and 0.6 of the left
eye. The mean value of the spherical equivalent of the right eye was +3.37 D, of the left eye
+3.38 D. The mean value of strabismic deviation angle without optical correction was 29.7
PD.

The analyzed risk factors show mean birth weight of 2820 g., mean value of the gestational
age of 37.9 gestational weeks, while the mean age of the mother at the time of delivery was
27.6 years of age.

In the analyzed additional risk factors 10/25 in the group of pure accommodative esotropia
showed the presence of perinatal risk factors, whereas 5/17 in the group of partially
accommodative esotropia. Prenatal risk factors were present only in 3/25 and 2/17,
retrospectively, prematurity in 2/25 and 2/17, retrospectively. Additionally, in the group of
pure accommodative esotropia 3/25 showed the presence of convulsive syndrome, while in
the group of partially accommodative esotropia 1/17 showed presence of a cranial nerve (n.
statoacusticus), and 1/17 presence of another neurological disease.

DISCUSSION

According to the largest epidemiological strabismus center at the Mayo Clinic, Rochester,
Minnesota, USA (Dr. Brian Mohney), accommodative esotropia (AET) is the most common
form of childhood strabismus(3).

Despite the established prevalence of accommodative esotropias of 27.9%(4), the

prevalence of this type of esotropia in our Macedonian population showed a value of 11.6%
for pure accommodative esotropia, 7.9% for partially accommodative esotropia and 59.5%
for non-accommodative esotropia.

The low value of pure accommodative esotropias should take into account the conversion of
pure accommodative esotropia to partially accommodative and non-accommodative
esotropia. The prevalence of decompensation of pure accommodative esotropia ranged from
13% to 40% in various studies(5,6).

The occurrence of strabismic deviation between the second and third year of age in a child
with a normal neurologic finding, which at first occurs intermittent and then becomes
constant, should raise suspicion about the diagnosis of accommodative esotropia.

According to the protocol, this group of children is examined for refraction in short-term
cycloplegia (its principle is described in the section Patients and Methods). Based on this
examination, a complete hypermetropic correction in the form of glasses is prescribed.
Initially, this is sufficient for the rehabilitation of these children and the prognosis for the
establishment of normal binocular vision (stereoacuity) is excellent.

If the glasses neutralize the deviation at distance, but the esotropia remains at near fixation
target, we conclude that the AC/A index is higher than normal and that there is a so-called
convergence excess. In this case, bifocal glasses for children are prescribed, where the
lower segment should have special features and cut the pupil. The diopter strength of the
lower segment of this type of bifocal glasses is obtained by adding +2.50 to +3.00 D to the
diopter strength of the upper distant segment. This refers to the so-called accommodative
convergence excess which responds to near add. In non-accommodative convergence
excess that does not respond to near add, surgical intervention is recommended( 7) .

Most of children with accommodative esotropia, regular wearing of glasses causes

stabilization of strabismic deviation angle , a small number develop esotropia with a high
AC/A index (Excess convergenciae), non-accommodative esotropia or consecutive
(8)
esotropia .

Most of children with AET need glasses in their second decade of life. The spherical
equivalent of hypermetropia i.e. the strength of plus diopters in patients with AET who wear
glasses regularly decreases continually over time(9, 10). The latest published studies on Pub
Med confirm that refractive surgery has the potential to be a definitive treatment for AET, but
additional studies are needed(11, 12, 13).

BIBLIOGRAPHY

1. The Royal College of Ophthalmologists. Guidelines for The Management of Strabismus in

Childhood. www.rcophth.ac.uk, accessed January 2012

2. Noorden GK.Clinical characteristics of neuromuscular anomalies ofthe eye.Esodeviations.

In: Noorden GK, editor.Binocular Vision and Ocular Motility-Theory and Management of
Strabismus.5th ed. St.Louise (MO) Mosby; 1996, p. 303-8

3. Mohney BG. Common forms of childhood esotropia.Ophthalmology 2001; 108 (4): 805-
809

4. Mohney BG.Common forms of childhood strabismus in an incidence cohort. Am J

Ophthalmol 2007; 144 (3): 465-7

5. Ludwig IH, Imberman SP, Thompson HW , Parks MM. Long-term stabilization of

accommodative esotropia. JAAPOS 2005; 9 (6): 522-526

6. Raab EL.Outcome of deteriorated accommodative esotropia. Trans Am Ophthalmol Soc

1989; 87: 185-196

7. Raab EL .Comitant Esotropia. In: Wilson ME, Sanders RA, Trivedi RH editors.Pediatric
Ophthalmology-Current Thoughts and Practical Guide. 5 ed. Berlin Heidelberg: Springer
Verlag; 2009, p.89-91

8.Mohan K, Sharma A.Long-term treatment results of accommodative esotropia.JAAPOS

2014; 18 (3): 261-5

9. Park KA, Kim SA, Oh SY.Long-term changes in refractive error in patients with
accommodative esotropia.Ophthalmology 2010; 117 (11): 2196-2
10. Mohney BG, Lilley CC, Green-Simms AE, Diehl NN.The long-term follow-up of
accommodative esotropia in a population-based cohort or children. Ophthalmology 2011;
118 (3): 51-5

11. Magli A, Forte R , Gallo F, Careli R.Refractive surgery for accommodative esotropia: 5-
year follow up. J Refract Surg 2014; 30 (2): 116-20

12. Hutchinson AK. Refractive surgery for accommodative esotropia: past, present and
future.Curr J Ophthalmol 2012; 22 (6): 871-7

13: Kirwan C, O Keefe M, O Mullane GM, Sheehan C. Refractive surgery in patients with
accommodative and non-accommodative strabismus: A prospective follow up. Br J
Ophthalmol 2010; 94 (7): 898-902
View publication stats