Surgical correction of congenital esotropia alternating and subsequent abnormal correspondence retinal: a case report

Abstract

Introduction: Accomodative esotropia is secondary to inappropriate convergence during accomodative effort in an uncorrected hyperope and is often familial.
Case presentation: we report the case of 20 year old Caucasian patient with congenital esotropia alternating, of 30 prism diopters distance (5 m) and 40 prism diopters of esotropia at near, in both eyes.
Measures: Was performed strabismus, in peribulbar anesthesia, the right medial rectus was cashed 3.0mm, the left medial rectus was collected 3.5 mm.
Results: Immediately after surgery, the patient complained of intermittent diplopia, resolved with orthotic exercise which stimulated binocular vision,
Conclusion: This case report suggests that the surgical correction strabismus, should be considered with due caution in the treatment of congenital esotropia alternating and branches, and in some clinical scenarios selected to avoid the complication of postoperative diplopia, that in the case report resolved so benign. After three months surgical treatmen, remains a small angle strabismus aesthetically acceptable, has not given double vision and remains abnormal retinal correspondence with orthotic exercise.

Full text

Mazzeo L, Mazzeo G, Mazzeo F, et al./Senses Sci 2015; 2 (1):13 -15
doi: 10.14616/sands-2015-1-1315
OPE AC
www.sensesandsciences.com
Surgical correction of congenital esotropia alternating and subsequent
abnormal correspondence retinal: a case report
Luigi Mazzeo, Girolamo Mazzeo, Francesco Mazzeo, Nadia Pasquale, Fernanda Pacella, Raffaele Migliorini,
Elena Pacella
Departement of Sense Organs, Faculty Medicine and Dentistry “Sapienza” University of Rome, Viale del Policlinico, 00161 Rome,
Italy
*Corresponding author Dr Fernanda Pacella, Department of Sense Organs, Faculty of Medicine and Dentistry, Sapienza
University of Rome, Viale del Policlinico, 00161 Rome, Italy. Tel.: +39.06.4997.5303; e-mail:
fernanda.pacella@gmail.com
Article history
Received: February 20, 2015
Accepted: March 24, 2015
Published: March 30, 2015
Abstract
Introduction: Accomodative esotropia is secondary to inappropriate convergence during accomodative effort in an
uncorrected hyperope and is often familial.
Case presentation: we report the case of 20 year old Caucasian patient with congenital esotropia alternating, of 30
prism diopters distance (5 m) and 40 prism diopters of esotropia at near, in both eyes.
Measures: Was performed strabismus, in peribulbar anesthesia, the right medial rectus was cashed 3.0mm, the left
medial rectus was collected 3.5 mm.
Results: Immediately after surgery, the patient complained of intermittent diplopia, resolved with orthotic exercise which
stimulated binocular vision,
Conclusion: This case report suggests that the surgical correction strabismus, should be considered with due caution in
the treatment of congenital esotropia alternating and branches, and in some clinical scenarios selected to avoid the
complication of postoperative diplopia, that in the case report resolved so benign. After three months surgical treatmen,
remains a small angle strabismus aesthetically acceptable, has not given double vision and remains abnormal retinal
correspondence with orthotic exercise.
Keywords: Esotropia, Surgical Correction, Abnormal correspondence retinal
Introduction
Strabismus is an eye disorder in which the visual
axes are not aligned; it affects 2-4% of children [1].
About half of these disorders are esodeviations, whose
causes are anatomical [2], neurological, mechanical,
refractive, genetic and accommodative [3,5]. Esotropia
is the most common form in Western populations [6]
and has several subtypes [7]. Accomodative esotropia
is secondary to inappropriate convergence during
accomodative effort in an uncorrected hyperope and is
often familial [8] Infantile esotropia, nonsyndromic
large-angle deviation noted within a few months of
birth, is usually not associated with significant
refractive error and is typically sporadic [9] but can be
familial [10].
Case Presentation
Approval of the local Ethics Committee and
written informed patient consent were obtained for this
study. A 20 year old Caucasian patient affect by with
congenital esotropia alternating non accommodative
esotropia, that developed by 6 months of age Fig.1. He
has never been subject to surgical correction of his
strabismus. He wants to improve his appearance by
reducing the angle of esotropia. Ophthalmologic
examination included measurement of the best visual
acuity (BCVA) Right eye had a visual acuity of 0,02
LogMar (Snellen equivalent:20/20) and the left eye had
a visual acuity of 0.18 LogMar (Snellen
equivalent:20/25). He preferred fixation with the right

Senses Sci 2015; 2 (1):13 -15
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eye, dominant eye. The fixation is central in the right
eye, while in the left eye fixation is parafoveal. The
initial angle of deviation was measured by the prism
and alternate cover test in both eyes,showing esotropia
of 30 prism dioptres at distance (5 m) and esotropia of
40 prism dioptres at near.
Figure 1. Congenital esotropia alternating non
accommodative esotropia, that developed by 6 months of
age.
There is no evidence of medial rectus muscle
hyperfunction in both eye; there was only a mild
hypofunction of the lateral rectus muscle of the left
eye. After cycloplegic refraction performed with
administration of cyclopentolate 1%, we obtained the
following results: the visual acuity of the right eye was
0.2LogMar (Snellen equivalent:20/25) and with
+0,75/+0,5x80° it was 0.02 LogMar (Snellen
equivalent:20/20) while the visual acuity of the left eye
was 0,6 LogMar (Snellen equivalent:20/30) and with
+0,75/+0,75x95° it was 0,18 LogMar (Snellen
equivalent:20/25). At cover test,in cycloplegia,the both
eyes showed esotropia of 40 prism dioptres at distance
(5 m) and esotropia of 45 prism dioptres at near. On the
synoptophore he did not fusion range of 20°,but
diplopia was present. Anterior segment examination
and fundoscopy were unremarkable. At full
neurological examination at presentation and during
follow up was normal. The strabismus surgery was
performed in peribulbar anesthesia [11,12]: the right
medial rectus was recessed 3.0mm, the left medial
rectus was recessed 3.5mm.
Results
Immediately after surgery, esotropia was of 15
prism and the patient did not present diplopia. But one
week after surgery, the patient complained of
intermittent diplopia, because esotropia was of 12
prism. The orthotic exercise were initiated to stimulate
the onset of abnormal retinal correspondence to win the
diplopia. The patient has been subjected to orthotic
exercise to stimulate binocular vision, researching in
his field of vision the best eye vergence to achieving
the binocular vision. After three months, the patient
won the diplopia, having achieved abnormal retinal
correspondence, suitable to the residual esotropia. At
cover test, the both eye showed esotropia of 12 prism
dioptres at distance (5 m) and esotropia of 17 prism
dioptres at near. The orthotics exercises, continued in
the 6 months after surgery, have stabilized both the
abnormal retinal correspondence and the residual
esotropia which is still, at 8 months after surgery,
satisfactory cosmetic result Fig.2.
Discussion
Congenital or infantile esotropia is a well-
recognized disorder of ocular alignment characterized
by a non-accommodative, relatively large-angle
constant esotropia that develops by 6 months of age in
an otherwise-healthy child [6].
Although recently reported to comprise only 8% of
all childhood esodeviations, congenital esotropia is
commonly encountered in ophthalmology clinics as the
result, in part, of the associated findings of amblyopia,
nystagmus, dissociated vertical deviations, oblique
muscle dysfunction, and consecutive deviations
[1,5,10].
Figure 2. Satisfactory cosmetic result at 8 months after
surgery.
This case report shows that congenital alternating
esotropia can be treated with dual purpose of not only
improve the aesthetics, but also to improve the vision.
Semmlow [8] shows that more the angle of esotropia is
reduced, more the patient has diplopia.
Conclusion
A careful study of preoperative correction of the
esotropia using prism, it is necessary and essential for
the choice of the surgery to be made [7,8]. So we can
estimate the surgical correction with minor muscle
movements,as the following rehabilitation of their
functionality will necessarily be accompanied by
orthotics exercises for a period not less than 12 months.
We will not have the ambition to reach the ortoforia,
but certainly we hope to facilitate the achievement of
abnormal retinal correspondence. Bagolini et coll. [13]
have demonstrated that the abnormal retinal
correspondence is the only mechanism present in the
strabismus at small angle, without suppression
scotoma, and it is necessary and indispensable to
remove diplopia.

Mazzeo L, Mazzeo G, Mazzeo F, et al
OPE AC
www.senseandsciences.com
Author Contributions
Conceived and designed the experiments: FM, NP, EP, RM, Analyzed the data: EP, RM, GM, FP, LM, NP, FP. Wrote
the first draft of the manuscript: NP, FM, FP. EP, FM, LM. Contributed to the writing of the manuscript: FP, EP, RM,
FM, GM. Agree with manuscript results and conclusions: EP, FP, LM GM. Jointly developed the structure and
arguments for the paper: NP, EP, FP, RM, GM, FP, LM, . Made critical revisions and approved final version: EP, FP,
LM, FM, GM, NP, RM.
"The authors declare that they have no competing interests."
References
1. Mohney BG, Greenberg AE, Diehl NN. Age at
strabismus diagnosis in an incidence cohort of children.
Am J Ophthalmol 2007;144(3):467-9.
2. Chew E, Remaley NA, Tamboli A, et al. Risk
factors for esotropia and exotropia.Arch Ophthalmol
1994;112(10):1349-55.
3. Curtis R. Louwagie, MD,a Nancy N. Diehl et al.
Long-term follow-up of congenital esotropia in a
population-based cohort. J AAPOS 2009;13(1):8-12.
4. Engle EC Genetic basis of congenital strabismus.
Arch Ophthalmol 2007;125:189–95.
5. Arnoldi Ka, Tychsen L.,: Surgery for esotropia with
a high accommodative convergence/accommodation
ratio: effects on accommodative vergence and
binocularity. Ophthalmic Surg Lasers 1996;
27(5):342-8
6. Greenberg AE, Mohney BG, Diehl NN et al.
Incidence and types of childhood esotropia. A
population-based study. Ophthalmology
2007;113:170–4.
7. Maruo T, Kubota N, Sakaue T, et al. Esotropia
Surgery in children:long term outcome regarding
changes in binocular alignment; a study of 956 cases.
Binocul. Vis Strabismus Q 2000; 15(3): 213-20.
8. Semmlow J, Putteman A, Vercher JL, et al. Surgical
modification of the AC/A ratio and the binocular
alignment (“Phoria”) at distance; its influence on
accommodative esotropia: a study of 21 cases. Binocul.
Vis Strabismus Q 2000; 15(2): 121-30.
9. Pacella E, Abdolrahimzadeh S, Mollo R, et al.
Photorefractive keratectomy in the management of
refractive accommodative esotropia in young adult
patients. J Cataract Refract Surg 2009;35(11):1873-7.
10. Shippman S, Weseley AC, Cohen KR.
Accommodative esotropia in adults. J Pediatr.
Ophthalmol Strabismus 1993; 30(6),368-71.
11. Pacella E, Collini S, Pacella F, Piraino DC,
Santamaria V, De Blasi RA. Levobupivacaine vs.
racemic bupivacaine in peribulbar anaesthesia: a
randomized double blind study in ophthalmic surgery.
Eur Rev Med Pharmacol Sci. 2010;14(6):539-44.
12. Pacella E, Pacella F, Troisi F, Dell'edera D,
Tuchetti P, Lenzi T, Collini S. Efficacy and safety of
0.5% levobupivacaine versus 0.5% bupivacaine for
peribulbar anesthesia. Clin Ophthalmol. 2013;7:927-
32.
13. Bagolini B. Sensory anomalies in strabismus. Brit
.J Ophthal 1974; 58:313.