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Data on unstable ocular alignment in childhood esotropia call for further study
Ophthalmology. 2008;115(12):2266-2274.
Unstable ocular alignment is common in children with esotropia, but many surgeons hesitate to operate early if alignment may improve significantly with time.
The three types of childhood esotropia requiring surgery are infantile esotropia, acquired nonaccommodative esotropia and acquired partially accommodative esotropia.
“In subjects with unstable ocular alignment, it is possible that waiting for stability may result in better motor alignment after surgery and better long-term sensory outcomes,” the investigators said.
The study included 233 children who were 2 months to almost 5 years old with onset of infantile esotropia within the previous 6 months. Patients underwent a baseline examination and three follow-up examinations over 18 weeks.
Of 59 patients with infantile esotropia, 46% had alignment classified as unstable, 20% as stable and 34% as uncertain. Among the 60 patients with acquired nonaccommodative esotropia, 22% had unstable alignment, 37% had stable alignment and 42% had uncertain alignment. Among the 41 patients with acquired partially accommodative esotropia, 15% had unstable alignment, 39% had stable alignment and 46% had uncertain alignment.
“In each of these types of esotropia, randomized controlled trials are needed to compare outcomes after immediate surgery vs. waiting for alignment stability,” the study authors said.
We are fortunate as pediatric ophthalmologists to have the PEDIG to bring to the forefront questions that need to be addressed and answered by all of our colleagues in our clinical practices. The Amblyopia Treatment Studies have changed the way many of us treat amblyopia today, and in the above article, this collaborative group outlines for us that the angle of esotropia is unstable in all categories of childhood esotropia, with the infantile category being most common as compared to acquired nonaccommodative and acquired partially accommodative esotropia. The take-home message from the article is that the pediatric ophthalmologist needs to determine how long he will follow a patient to determine the optimal time for surgical correction, if clinically appropriate, until a randomized controlled trial can determine results with early surgery vs. waiting for alignment stability.
– Robert S. Gold, MD
OSN Pediatrics/Strabismus Section Editor