Acquired Comitant Esotropia in Children and Young Adults: Clinical Characteristics, Surgical Outcomes, and Association With Presumed Intensive Near Work With Digital Displays

Abstract

Purpose: To describe the clinical characteristics and surgical outcomes of acquired comitant esotropia with symptomatic diplopia. Methods: The clinical features and surgical outcomes of 27 patients with diplopia due to acquired comitant esotropia were retrospectively reviewed. Exclusion criteria were a history of prematurity, cerebral palsy, head trauma, or febrile illness before the onset of acquired comitant esotropia, incomitant strabismus, accommodative spasm, and divergence paralysis. Neurological evaluation and neuroimaging was normal in all patients. Results: Mean age at onset of esotropia and diplopia was 17.8 ± 10.3 years (range: 6 to 44 years). Eighteen patients had simple myopia (range: −0.25 to −7.75 diopters [D]), 5 patients had hypermetropia (range: 0.50 to 1.50 D), and 4 patients had emmetropia. The angle of deviation prior to surgery was 35.6 ± 10.3 prism diopters (PD) for far and 38.0 ± 10.5 PD for near fixation. Twenty-three patients (85%) were prism responders. A history of excessive near work (≥ 4 hours a day) with digital displays was present in 21 (78%) patients. Diplopia resolved and some level of stereovision was achieved in all patients postoperatively. Three patients had recurrence of esotropia in long-term follow-up. Conclusions: The differentiation of a serious pathology from a straightforward optically or medically treatable condition in patients with a subacute or chronic history of diplopia is challenging for the clinician. The recognition of acquired comitant esotropia due to presumed intensive near activities with digital display may avoid time-consuming and costly laboratory investigations. Most of the patients in this series were prism responders and surgery for the prism-adapted angle was successful in restoring binocular vision. [ J Pediatr Ophthalmol Strabismus . 2020;57(4):251–256.]

Possibility of Neurological Diseases Associated with Acute Acquired Comitant Esotropia

“…Recently, many studies have suggested that an excessive use of smartphones may also be the root cause of AACE. [7,[23][24][25] In the present study, chronic use of near vision, namely using smartphones and other electronic devices, was not evaluated in relation to sudden-onset esotropia; however, the duration of near work was not related to the degree of angle deviation. This result is consistent with that of a study conducted by Meng et al [7] Acute Acquired Comitant Esotropia It is difficult to ascertain which patients presenting with AACE have underlying neurological diseases.…”

Clinical features and treatment of near-work-related acquired esotropia

“…There was also a significant difference in the esotropia angle between ten months before and after treatment, which indicated that the BTXA played an important role in treating the esotropia and reducing the diplopia symptoms. It was confirmed that this kind of esotropia is associated with medial rectus spasm [23][24][25] . Ten months after surgery, the diplopia and esotropia of most patients presented an improvement after treatment.…”

Surgical Outcomes with and without Prism Adaptation of Cases with Acute Acquired Comitant Esotropia Related to Prolonged Digital Device Use

“…Using DD for ≥4 h per day before or at symptom onset was defined as prolonged or excessive use of DDs according to previous reports. 8,10,12,14 At the first visit, all cases underwent ophthalmic and orthoptic examinations. Cycloplegic refraction was performed after administering 1% atropine sulfate eye drops once daily for 3-5 days to completely eliminate accommodative effects, and spherical equivalents (SE) of refractive error were calculated.…”

“…Since the first report pointing out a relationship between AACE and excessive smartphone use by Lee et al in 2016, 8 several investigations have proposed associations between AACE and excessive use of digital devices (DDs), such as computers, tablets, and smartphones for near work. [9][10][11][12][13][14] The use of DDs by adolescents and young adults has dramatically increased within the past decade, particularly during lockdowns associated with the coronavirus disease 2019 pandemic. [15][16][17] As a pathological etiology for this new type of AACE, Lee et al and Yilmaz et al speculated that excessive use of DDs would induce strong increases in the tone of both medial rectus muscles following long-acting accommodative efforts and disruption of vergence.…”

“…[15][16][17] As a pathological etiology for this new type of AACE, Lee et al and Yilmaz et al speculated that excessive use of DDs would induce strong increases in the tone of both medial rectus muscles following long-acting accommodative efforts and disruption of vergence. 8,10 All patients presenting with this condition are instructed to limit or reduce the use of DDs, resulting in improved esodeviation in some patients. 8 Nevertheless, if AACE does not improve, surgical treatment is required.…”