A rare presentation of esotropia in high myopia in a young adult: a case report

Abstract

Esotropia in myopia is an uncommon occurrence. Most common cause of esotropia in high myopic elderly is Heavy Eye Syndrome. An uncommon cause in young adults is Acute Acquired Comitant Esotropia often associated with excessive indulgence in near work. A 21 year old male patient presented with diplopia for one year, more for distance than near and spent more than 8-10 hours for near tasks. Unaided visual acuity in BE was 2/60 and was 6/9 in RE and 6/6 in LE with correction. Prism base cover test revealed 25 BO PD for distance and 20 BO PD for near. Diplopia was seen in all position of gaze. Right Eye Lateral rectus resection 8 mm was done and HPE report revealed features of Lateral rectus Muscle atrophy. It is important to understand the pathogenesis of this entity and consider other possible causes of esotropia in myopia. Key words: Myopia, Esotropia, Comitant, Diplopia.

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Received: May 28, 2022. Revised: September 26, 2022. Accepted: October 2, 2022
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Oxford Medical Case Reports, 2022, 12, 424–426
https://doi.org/10.1093/omcr/omac137
Case Report
A rare presentation of esotropia in high myopia in a
young adult: a case report
Namrata Gupta 1, *,Kishore R. Pradhan 2,Geeta Chopra 3and Sajina Khadka 4
1Pediatric Ophthalmology and Strabismus Department, Matrika Eye Center, Kathmandu, Nepal
2Refractive Surgery Department, Matrika Eye Center, Kathmandu, Nepal
3Histopathology Department, Metropolis Healthcare Pvt. Ltd., New Delhi, India
4Refraction Unit, Matrika Eye Center, Kathmandu, Nepal
*Correspondence address. Pediatric Ophthalmology and Strabismus Department, Matrika Eye Center, Kathmandu 44600, Nepal. Tel: +977-9851087655;
E-mail: namratadoc@gmail.com
Abstract
Esotropia in myopia is an uncommon occurrence. Most common cause of esotropia in high myopic elderly is Heavy Eye Syndrome. An
uncommon cause in young adults is Acute Acquired Comitant Esotropia often associated with excessive indulgence in near work. A
21 year old male patient presented with diplopia for one year, more for distance than near and spent more than 8-10 hours for near
tasks. Unaided visual acuity in BE was 2/60 and was 6/9 in RE and 6/6 in LE with correction. Prism base cover test revealed 25 BO PD for
distance and 20 BO PD for near. Diplopia was seen in all position of gaze. Right Eye Lateral rectus resection 8 mm was done and HPE
report revealed features of Lateral rectus Muscle atrophy. It is important to understand the pathogenesis of this entity and consider
other possible causes of esotropia in myopia. Key words: Myopia, Esotropia, Comitant, Diplopia.
INTRODUCTION
Esotropia in myopia is a rare entity with varied presentation in
different age groups. The examination and management of such
patients can be very challenging [1].
The most common etiology of progressive esotropia in high
myopia in an elderly is the ‘Heavy Eye Syndrome’,which presents
with diplopia secondary to progressive esotropia and hypotropia
with limitation of abduction and elevation [1].
Another uncommon form of esotropia in young adults is Acute
Acquired Comitant Esotropia (ACCE) [2]. Prolonged adduction of
the medial rectus muscle due to near-target convergence may
cause shortening of the medial rectus muscle and reduced ability
to maintain orthotropia at a distance as proposed by Guyton [3].
This paper reports a similar case of a young adult with high
myopia with diplopia.
CASE REPORT
A 21-year-old myopic patient presented with diplopia for 1 year. It
was more for distance than during near work. He did ∼8–10 hours
of near work without using glasses as it reduced his diplopia.
The patient had no history of head trauma, use of systemic
medication or systemic illnesses. Ophthalmic examination
revealed unaided visual acuity (VA) of 2/60 in both eyes
and used −5.75 DS in the right eye (RE), giving VA of 6/36
and −5.75DS/−0.50 DC @180 in the left eye (LE), giving VA of
6/24. Cyclo-refraction revealed wet retinoscopic values of −8.00
DS/−1.50 DC @180 and −7.75 DS/−2.00 DC @180 in RE and LE,
respectively.
Figure 1. RE esotropia without glasses.
On orthoptics examination, the Hirschberg test revealed 2 mm
(30 diopters) eso-deviation in RE. (Fig. 1). Extra ocular movement
was full. The worth four dot test revealed diplopia for distance
and near, with maximum separation of images in levoversion. The
Prism Base Cover Test with correction revealed 25 Base Out (BO)
Prism Diopter (PD) for distance and 20 BO PD for near (Fig. 2);
and without correction, it was 16 BO PD and 8 BO PD for distance
and near,respectively.Accommodative convergence to accommo-
dation ratio was 4:1 and was done by the gradient method [4].
The axial length measurement of RE was 26.91 mm and 26.99 mm
of LE. His corneal topography scan and magnetic resonance imag-
ing of brain and orbit were normal.
He was prescribed glasses after a post-mydriatic test. A prism
trial of 6 BO PD in RE and 6 BO PD in LE was started, which removed
diplopia for near and decreased for distance.
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N. Gupta et al. |425
Figure 2. RE esotropia increased with glasses.
Figure 3. Histopathology section using special stain of LR muscle
section.
Figure 4. RE orthotropic 1 week after surgery.
Definite management was done after 3 months with RE 8 mm
lateral rectus (LR) resection. During surgery, thinning of LR muscle
was seen, and its histo-pathological examination revealed fea-
tures of chronic myopathy with primarily collagenous tissue with
a single area of scattered muscle fibers and marked endomysial
fibrosis, suggestive of LR Muscle atrophy (Fig. 3).
After 1 month, the patient was orthotropic with BCVA 6/6 in
both eyes with glasses and no diplopia (Fig. 4).
DISCUSSION
AACE is a special subtype of esotropia that is characterized by
the acute onset of comitant esotropia with diplopia and is more
common in older children and adults. Ocular motility is generally
normal without the evidence of paralysis of the extraocular mus-
cle [5]. AACE is classified into three clinical types by Lee et al.[6]: (i)
Swan-type esotropia that occurs in eyes with fusion disruption, (ii)
Burian-Franceschetti type of esotropia characterized by minimal
hypermetropia and diplopia, often associated with physical and
psychological stress and (iii) Beilschowsky-type esotropia that
occurs in adolescents and adults with varying degree of myopia.
The mechanism of Beilchowsky-type AACE is thought to be uncor-
rected myopia with excessive near work, resulting in the inability
to maintain the balance between the converging and diverging
forces of the eye, and the subsequent development of increased
tonus of the medial rectus muscle, leading to esotropia [6]. In a
study of acquired distance esotropia associated with myopia in
young adults by Zheng K et al.[
2], 11 adult myopic patients with
distance esotropia were studied, who were engaged in near work
for an average of 12 hours per day. Among them, seven underwent
a pathological examination of their LR muscles, which showed no
muscle fibers but rather collagenous fibers [5]. In another study by
Zhu M et al., it was found that ACCE was more common in young
adults who performed excessive close visual activities and used
digital devices late night [7].
Since most of our daily activities are performed over smart
phones, smartphone use is the majority of ‘near work’. Decreasing
near work activities can help decrease the progression of esotropia
in myopia in young adults.
ACKNOWLEDGEMENTS
I extend my sincere thanks to the patient for trusting me with his
treatment. I extend gratitude to the refractive surgery department
for case identification and referral. I give special thanks to Dr
Abha Shrestha for guiding me with the pathological reports.
CONFLICT OF INTEREST
None declared.
FUNDING
None.
ETHICAL APPROVAL
This is not required as suggested by the National Health Research
Council of Nepal.
PATIENT’S CONSENT
A written consent was obtained from the patient for the publica-
tion.
GUARANTOR
Dr. Namrata Gupta, Orchid ID: 0000-0002-9479-9612.
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426 |Oxford Medical Case Reports, 2022, Vol. 9, No. 12
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