Acute Acquired Comitant Esotropia: Etiology, Clinical Course, and Management

Abstract

Purpose To identify the etiologies, clinical course and management of acute acquired comitant esotropia in Ramathibodi Hospital, Thailand. Methods Thirty patients who were diagnosed with acute acquired comitant esotropia at Ramathibodi Hospital from January 1 2017 to December 31 2019 were identified using electronic medical records, from which demographic, etiology, clinical course and management, laboratory, and neuroimaging data were collected. Results The etiologies of acute acquired comitant esotropia were Swan (16.67%), Burian–Franceschetti (30.00%), Bielschowsky (36.67%), Arnold Chiari malformation (3.33%) and decompensated esophoria (13.33%). Mean age of onset was 19.8 ± 18.3 years. Mean angle of esodeviation was 28.4 ± 12.1 prism diopters for distance fixation and 29.3 ± 11.8 prism diopters for near fixation. Refraction differed between age groups: children under 10 years had mild hyperopia (median +0.63 diopters, first quartile +0.25 diopters, third quartile +0.75 diopters) and teenagers (10–18 years old) had emmetropia to mild myopia (median +0.25 diopters, first quartile −2.50 diopters, third quartile +0.75 diopters), whereas adults had mild to moderate myopia (median −0.75 diopters, first quartile −5.25 diopters, third quartile ±0.00 diopters). Twelve patients (40.00%) were prescribed spectacles and surgical intervention was performed in 26 patients (86.67%). All patients except one case of Arnold Chiari malformation (96.67%) maintained normal binocular function and alignment following strabismus surgery or spectacles correction. Conclusion Bielschowsky was the most common etiology of acute acquired comitant esotropia in our study. We suggest that refraction should be performed in all patients with acute acquired comitant esotropia. Most etiologies were benign and might not require neuroimaging. However, neuroimaging is recommended in those with atypical presentations, such as nystagmus, headache, or cerebellar signs. Surgical intervention with a 0.5–1.0 mm increase in recession was effective for restoring ocular alignment and binocular function in our patients.

The Effect of Different Treatment Methods on Acute Acquired Concomitant Esotropia

“…Acute acquired comitant esotropia (AACE) is a specific type of strabismus which occurs in older children and adults [ 1 ]. AACE is generally considered a relatively rare type of strabismus, accounting for approximately only 0.3% of patients with strabismus [ 2 ], which has a rapid onset and generally late onset [ 3 ].…”

“…However, in recent years, with the popularity of electronic products such as IPads and smartphones and the increased academic pressure on students, the incidence of AACE has been on the rise [ 6 ]. The etiology of AACE is still unclear, which may be related to the destruction of binocular fusion function, original cryptostrabismus or myopic ametropia, or the anatomical abnormality of medial rectus muscle or nervous system abnormality [ 1 ].…”

Clinical efficacy of botulinum toxin type A on acute acquired comitant esotropia

“…It is manifested as sudden onset of comitant esotropia with approximately the same degree of deviation in all fields of gaze, accompanied by diplopia [19] . AACE is considered to be an uncommon type of strabismus, accounting for only 0.3% of all the strabismus cases [6,20] . However, with the increasing prevalence of smartphones, Pad, and other electronic devices, as well as the heavier academic pressure on students, the incidence of AACE is gradually rising [21] .…”

Nonneurologic causes of binocular diplopia for the neurologist

“…During the coronavirus disease (COVID-19) pandemic the decrease in outdoor activities and shifting to an online education system caused a significant rise in the time spent in front of screens (>4–5 h) [31 ▪ ,35 ▪ ]. It has been proposed that this increase in “screen time” led to a significant rise in the diagnosis of AACE, particularly in children [31 ▪ ,35 ▪ ]. A study in 2020 found that 78% of the AACE patients had a history of excessive near-work activity [36].…”