Assessment of pattern of refractive errors in infantile esotropia- A single-center cross-sectional study

This was a cross-sectional study conducted to explore the patterns of refractive errors found in infantile esotropia patients from newborns to the age of 15 years, attending the Pediatric clinic of Al-Ibrahim Eye Hospital, Karachi, Sindh, Pakistan. Data was collected on a pre-designed proforma. A total of 79 patients (total of 158 eyes) including 44 males (55%) and 36 females (45%) were recruited. All these patients had infantile esotropia. The study showed out of 79 patients (158 eyes), 89 eyes had hyperopia, 15 eyes had myopic astigmatism, 44 eyes had hyperopic astigmatism, while 4 eyes had mixed astigmatism, and 6 eyes had myopia. The hypermatropia was found to be the most commonly occurring refractive error in infantile esotropia resulting in inward eye deviation.

The Results of Modified Hang Back Recession Surgery in Infantile Esotropia

PURPOSE:Bimedial rectus recession is one of the surgical treatment options for infantile esotropia. It is mainly performed with the Hang-Back technique, which has undesirable side effects. In this study, this technique has been modified, and its results are discussed.METHODS:The files of 120 patients followed with the diagnosis of infantile esotropia and treated bimedial rectus muscle recession using the modified Hang-Back technique were reviewed retrospectively. Cases were evaluated by the time of surgery, coexistence with inferior oblique muscle weakening surgery, and presence of refractive error. The factors investigated on the results of surgical treatment were determined as age, gender, amount of hyperopic refractive error, application age, amount of horizontal deviation, amount of recession, stereopsis, fusion, age of surgery.RESULTS:When the cases were divided into subgroups which were the time of surgery, the operation performed with inferior oblique weakening surgery and presence of refractive error; the difference between preoperative and postoperative 1st month, 6th month, and 1st-year angle of deviation was statistically significant in all three groups (p < 0.001).CONCLUSION:This novel technique aims to prevent unwanted movement of the muscle in the horizontal and vertical axis and a gap in the middle of the recessed muscle, seen in the classical Hang-Back technique. The difference between the preoperative and postoperative angle of deviation was statistically significant. Also, over and under-correction and the development of alphabetic pattern deviation were less common in our modified technique.

Comparison of bilateral medial rectus recession vs recession-resection as surgery for infantile esotropia

Background: Infantile esotropia is misalignment of eyes from bifoveal fixation where surgical correction at an early age usually presents with good outcomes. Aims and Objective: To compare the surgical outcome between bilateral medial rectus recession (BMR) and recession- resection (RR) surgery in infantile esotropia. Materials and Methods: The study was conducted in Lumbini Eye Institute, Bhairahawa, from December 2017 to December 2018. Patients with infantile esotropia who underwent surgical correction were included in the study. Patients were examined pre operatively, and post operatively at day one and third month, where the angle of deviation was measured and the level of binocular single vision (BSV) was assessed. Data was entered and analyzed using the SPSS program. Results: Total 79 patients were included in the study out of which 33 underwent BMR and 46 underwent RR. The mean pre-operative angle by PBCT was 52.58 PD (SD ±15.468) in the BMR group and 47.83 PD (SD ±12.140) in the RR group. Post-operative deviation in the BMR group had angle <35 PD. In the RR group the post-operative deviation observed was <35 PD, whereas 1/46 patients had angle between 35-50 PD. All patients who had residual esotropia (ET) in either the BMR or RR group had a pre-operative angle above 50 PD. Pre-operatively 43% had fusion and rest of them had suppression. Post-operatively 40.5% had fusion, 15.2% had stereopsis and rest of them had suppression or BSV could not be assessed in them. Therefore, there was increase in BSV by 2.5% from fusion to stereopsis. Those who initially showed suppression or in whom the BSV could not be assessed pre-operatively now showed to have fusion or some stereopsis. In total there was 15.2% increase in stereopsis. Conclusion: Though cosmesis has been improved in most patients after strabismus surgery, BSV improvement was insignificant as most surgery was performed after attainment of visual maturity. No significant difference between BMR and RR was found in terms of improvement of angle of deviation and BSV.

Essential Infantile Esotropia: A Course of Treatment From Our Experience

Background: Essential infantile esotropia (EIE) is the most common type of childhood esotropia. Although its classical approach is surgical, less invasive techniques have been proposed as an adjunct or alternative to traditional surgery. Among them, chemodenervation with botulinum toxin (BT) has been investigated, showing variable and sometimes conflicting results.Objectives: To compare the outcomes of bilateral BT injection and traditional surgery in a pediatric population with EIE in order to optimize and standardize the therapeutic approach. Other purposes are to evaluate whether early intervention may prevent the onset of vertical ocular deviation (which is part of the clinical picture of EIE) and/or influence the development of fine stereopsis, and also to assess changes in refractive status over time among the enrolled population.Methods: A retrospective consecutive cohort study was conducted in 86 children aged 0–48 months who underwent correction of EIE. The primary intervention in naïve subjects was either bilateral BT injection (36 subjects, “BT group”) or strabismus surgery (50 subjects, “surgery group”).Results: Overall, BT chemodenervation (one or two injections) was effective in 13 (36.1%) subjects. With regard to residual deviation angle, the outcomes at least 5 years after the last intervention were overlapping in children receiving initial treatment with either injection or surgery; however, the success rate of primary intervention in the surgery group was higher, and the average number of interventions necessary to achieve orthotropia was smaller. Both early treatment with chemodenervation and surgery at a later age were not found to prevent the onset of vertical ocular deviation, whereas, surprisingly, the percentage of subjects developing fine stereopsis was higher in the surgery group. Finally, with regard to the change in refractive status over time, most of the subjects increased their initial hyperopia, whereas 10% became myopic.Conclusions: Our data suggest that a single bilateral BT injection by age 2 years should be considered as the first-line treatment of EIE without vertical component; whereas, traditional surgery should be considered as the first-line treatment for all other cases and in subjects unresponsive to primary single BT injection.

Cost comparison between botulinum neurotoxin and surgery in the treatment of infantile esotropia in a tertiary public hospital

ObjectiveTo compare the cost implications of botulinum neurotoxin (BNT) injection to surgery in infantile esotropia (IE) in a public/government funded hospital.Methods and analysisA simple costing comparison was undertaken for a randomised clinical trial in IE. Patients were randomised to receive either BNT or standard surgery. The participants in the BNT arm were further subdivided into subgroups based on their age in months and degree of esotropia in prism dioptres (PD) at presentation: G1 ≤60 PD/24 months, G2 ≤24 months/>60 PD, G3 >24 months/≤60 PD, G4 >24 months/>60 PD. The costs were calculated for each arm from primary treatment to eventual satisfactory outcome defined as orthophoria or microtropia (≤10 PD). A bottom-up costing analysis was done for single and multiple procedures for each arm. Comprehensive variable costs as well as fixed costs were calculated at each point of intervention and expressed in local currency ZAR (US$1=ZAR15.00). Costing was analysed for surgery and BNT subgroups (based on clinical success)ResultsThere were 101 patients enrolled in the trial. 54 in the BNT arm and 47 in the surgery arm. Cost for single surgery and single BNT was ZAR 7743.04 and 1713.14, respectively. A favourable clinical outcome was achieved in 72% of surgery arm and 37% of BNT arm. The mean cost for eventual favourable outcome in BNT arm was ZAR9158.08 and in surgery arm ZAR9124.27 (p=0.26). Mean cost in G1 was ZAR6328.45, in G2 ZAR7197.45, in G3 ZAR11891.93 and G4 ZAR12882.44 (p=0.018).ConclusionBNT has a cost–benefit in IE and is a viable option in the primary treatment of IE in resource constrained regions. Clinical outcomes and economic benefit in smaller angle of esotropia and younger patients are comparable to surgery.

Motor and Visual-spatial Cognitive Abilities in Children Treated for Infantile Esotropia

While many studies have investigated links between motor and visual spatial cognitive abilities in typically developing children, only a few studies have tested this link among children with innate handicaps. Therefore, we assessed motor abilities (using the M-ABC-2) and visual spatial cognitive skills (using the Block Design subtest of the WPPSI-III and a picture mental rotation task, PRT) of 5-7 year old typically developing children (n= 17) and same-aged children with severe deficits in stereopsis due to infantile esotropia (n= 17). Compared to the typically developing children, children with esotropia showed significantly poorer motor performances, especially in manual dexterity and ball skills, and significantly poorer and slower performance on the visual spatial cognitive tasks. Especially the girls treated for infantile esotropia needed more time to mentally rotate the pictures of the PRT correctly. Overall, this study showed that perceptual, motor and cognitive processes are interconnected and that children treated for infantile esotropia had an increased risk of motor and visual spatial cognitive deficits.