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European Journal of Applied Sciences – Vol. 9, No. 5
Publication Date: October 25, 2021
DOI:10.14738/aivp.95.10910. Li, Z., Li, G., Li., X., Xue, N., Sun, L., Zheng, H., Lee, L. R., Fung, D. D. (2021). Refractive Accommodative Esotropia Treated by
Asymmetric Refractive Accommodative Esotropia Correction. European Journal of Applied Sciences, 9(5). 127-141.
Services for Science and Education – United Kingdom
Refractive Accommodative Esotropia Treated by Asymmetric
Refractive Accommodative Esotropia Correction
Zhisheng Li
Department of Ophthalmology
Beijing Radiant Children’s Hospital, Beijing, China
Visual Brain Functional Imaging Joint Research Laboratory
Radiant-Peking University Magnetic Resonance Imaging Research Center
Peking University, Beijing, China
Geng Li
Radiant Children’s Hospital Management Group, Hong Kong
Visual Brain Functional Imaging Joint Research Laboratory
Radiant-Peking University Magnetic Resonance Imaging Research Center
Peking University, Beijing, China
Xueqiang Li
Department of Ophthalmology
Beijing Radiant Children’s Hospital, Beijing, China
Na Xue
Department of Ophthalmology
Beijing Radiant Children’s Hospital, Beijing, China
Lianjun Sun
Department of Ophthalmology, Shenyang Radiant Children’s Hospital
Shenyang, Liaoning, China
Huifang Zheng
Radiant Youth Vision Rehabilitation Center
Third People's Hospital of Xinjiang Autonomous Region
Urumqi, Xinjiang Uygur Autonomous Region, China
Lavonne Rayer Lee
Department of Ophthalmology
Beijing Radiant Children’s Hospital, Beijing, China
Radiant Children’s Hospital Management Group, Hong Kong
Diana Danlai Fung
Department of Ophthalmology, Beijing Radiant Children’s Hospital, Beijing, China
Visual Brain Functional Imaging Joint Research Laboratory
Radiant-Peking University Magnetic Resonance Imaging Research Center
Peking University, Beijing, China
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European Journal of Applied Sciences (EJAS) Vol. 9, Issue 5, October-2021
Services for Science and Education – United Kingdom
ABSTRACT
To compare deviation improvement in children with residual refractive
accommodative esotropia after previous treatment with spectacles, part-time
patching and visual training with asymmetric refractive accommodative esotropia
correction vs. full hyperopic correction. 72 participants (F=34, mean age 5.81
years) with residual partially refractive accommodative esotropia, mean deviation
without glasses was 18.33±5.61 prism dioptres (PD) at distance and 22.64±5.82 PD
at near. Participants (mean baseline visual acuity 62.43±18.97 letters) were
randomly assigned to treatment for 24-months with asymmetric refractive
accommodative esotropia correction (n=36) or full hyperopic correction (n=36).
Change in deviation, visual acuity, refraction and anisometropia from baseline to
the 24-month assessed by a masked examiner until deviation resolved and visual
acuity stabilized. At 24 months, mean deviation with glasses improved from
baseline by 21 PD with asymmetric esotropia correction, by 7 PD with full hyperopic
correction at near vision. Mean visual acuity was improved from baseline
72.08±16.62 letters to 108.06±2.47 letters; refraction was decreased from baseline
5.03±2.75 dioptres (D) to 2.49±1.39 D in refractive accommodative esotropia eye
(EE) in asymmetric refractive accommodative esotropia correction group, Visual
acuity difference between EE and dominated eye (DE) was reduced from baseline
3.22±3.39 to 0.25±0.44. Anisometropia was improved from the baseline 1.65±1.78
D to 0.14±0.14 D. Overall treatment outcome was not related to age, sex, or prior
treatment history, but were related to better baseline deviation and visual acuity.
Conclusion: Deviation and visual acuity were greater improvement with asymmetric
esotropia correction than full hyperopic correction treatment at 24-month in
children with residual refractive accommodative esotropia.
Keywords: Residual refractive accommodative esotropia; asymmetric anisometropic
correction; hyperopic correction; visual acuity, angle of deviation.
INTRODUCTION
Refractive accommodative esotropia is one of the most common forms of childhood eye
misalignment[1-5]. Children with refractive esotropia are typically hyperopic. The treatment
refractive accommodative esotropia consists the prescription of eyeglasses according to degree
of hyperopia and amblyopia to correct the children’s refractive error (full hyperopic
correction), and surgical correction for cases with the esotropia which is significantly under
corrected despite full hyperopic correction[6]. This study assessed the efficacy of asymmetric
refractive accommodative esotropia correction vs. full hyperopic correction for residual
refractive accommodative esotropia.
MATERIALS AND METHODS
The study was supported by the Asia Pediatric Ophthalmologist Association and was conducted
by the Radiant Children’s Hospital Group. Protocol and HIPAA compliance informed consent
forms were approved by the ethics committee of Radiant Children’s Hospital (Beijing, China).
The parent or guardian of each patient provided written informed consent. The study was
overseen by an independent data and safety monitoring committee. Patients were randomly
assigned to asymmetric refractive accommodative esotropia correction as treatment groups or
to full hyperopic correction as control groups. Patients had esotropia corrected to 10 prism
diopters (PD) of orthotropia at both distance and near vision with use of full cycloplegic
hyperopic correction as the diagnosis of refractive accommodative esotropia[5]. Exclusion
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Li, Z., Li, G., Li., X., Xue, N., Sun, L., Zheng, H., Lee, L. R., Fung, D. D. (2021). Refractive Accommodative Esotropia Treated by Asymmetric Refractive
Accommodative Esotropia Correction. European Journal of Applied Sciences, 9(5). 127-141.
URL: http://dx.doi.org/10.14738/aivp.95.10910
criteria included deteriorative accommodative esodeviation, history of developmental delay,
and any form of neurologic impairment.
Patients
The 72 participants (F=34, 47.2%) with residual refractive accommodative esotropia were
aged 4 to 10 years (mean age 5.64 ± 1.94 in treated; 5.81±1.39 in control) with a history of full
correction of the cycloplegic refractive error treatment (100% spectacle wear at least 1 years;
90% patching 4 hours per day at least 1 months; 20% atropine at least 0.28 years and 100%
visual training such as visual perception, spatial localization, hand eye coordination in both
groups) at least 1.5 years in Table 1.
Prior to enrollment into the study, participants were examined and excluded for potential
ocular pathological defects. Full orthoptic and ophthalmic examinations were performed
including intraocular pressure measurements, fundus examinations, stereopsis, visual contrast,
cycloplegic refraction, visual electrophysiology and binocular single vison, where cooperation
was adequate. Binocular sensory testing was performed through the patient’s optimum
hyperopic correction. Cycloplegia was performed with one drop of 1% cyclopentolate and 1%
tropicamide, repeated in five to ten minutes, with retinoscopy performed after 60 minutes. At
each visit, visual acuity and binocular vision were assessed without cycloplegia, by an
individual masked to the treatment assignment. Corrective lenses were prescribed based on
deviation, refraction, accommodation and subjective trails of lenses according to the
prescription principle: asymmetric hyperopic esotropia correction by increasing plus power of
spectacles in DEs and decreasing plus power of spectacles in EEs to maintain high
accommodation and to reduce esotropia[7-9]. All participants were prescribed new glasses at
the initial appointment. The control group was prescribed the full hyperopic correction. The
corneal light reflex test, cover-uncover test and alternated cover test were used to assess the
participants’ ocular alignment. The baseline demographics and the history at enrollment are
listed in Table 1. All participants maintained a calendar on which treatments were logged.
Calendars were reviewed at each follow-up visits. After randomization, follow-up visits were
scheduled at the 40th day (±2 days), the 3-month (±1 week), 6-month (±1 week), 12-month (±1
week) and 24-month (±1 month).
Asymmetric refractive accommodative esotropia correction methods
In the asymmetric refractive accommodative esotropia correction group, all participants were
instructed to wear spectacles for all waking hours. Corrective lenses for refractive
accommodative esotropia were prescribed based on their deviation and refraction with
cycloplegia at the enrollment. In this groups, if the visual acuity of the fellow eye reached 0
logMAR, no refraction correction was prescribed for that eye. When the visual acuity difference
between two eyes larger than 300 D, the brain is difficult to fuse, and it may inhibit the visual
acuity of one eye, so if both esotropia and hyperopic were fully corrected, the visual acuity
difference between two eyes would be increased. The prescription principle of asymmetric
refractive accommodative esotropia correction is to increase plus power of spectacles in DEs
and to decrease plus power of spectacles in EEs, in order to blur the DE, decrease the degree of
esotropia and stimulate accommodation in the EE[8]. At the second visit (the 40th day), if the
refractive errors of the EE were improved to +5.00 D without cycloplegia (cycloplegia can cause
a transient hyperopia, frequently cycloplegia can make the lens being shorter which would
damage the hyperopic eye), the corrective lens was prescribed at +4.50 D to reduce the plus
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European Journal of Applied Sciences (EJAS) Vol. 9, Issue 5, October-2021
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further if the patient can accommodate. Participants were asked to return at the 40th day, 3, 6,
12, and 24-month, respectively for each follow-up therapy including the deviation, the visual
acuity, and the accommodative ability test and prescribed new corrective lens accordingly at
each follow-up visiting. The recurrence induced by poor eye coordination as well as the
developed diplopia would be prevented by the asymmetric refractive accommodative esotropia
correction.
Investigators and patients were unmasked to the asymmetric refractive accommodative
esotropia correction group, but responders and non-responders were based on the deviation
and visual acuity which were assessed by an individual masked to the treatment assignment.
In the asymmetric refractive accommodative exotropia correction group, both exotropia and
hyperopia were fully corrected or symmetrically under corrected by no more than 0.83 PD for
distance vision with glasses and 1.50 D.
Randomization
Each patient was randomly assigned with an equal probability to either asymmetric refractive
accommodative esotropia correction as the treatment group or to full hyperopic correction as
the control group. Randomization was accomplished following data entry by clinical staff using
a permuted design of varying block sizes, with a separate sequence of computer-generated
random numbers for each clinical site. Both children and parents were masked.
Statistical Analyses
The sample size of 80 participants was computed to heave 90% power with 2-sided type I error
rate of 5% and type II error of 10%, the cure rate assumes 45% in the asymmetric refractive
accommodative esotropia correction group and 15% in the full hyperopic correction group, a
5% loss to follow-up rate, a minimum sample size of 40 patients in each group was planned.
The primary outcome was the change of the deviation and visual acuity scores in EEs from
baseline to 40 day (± 2 days). A modified intent-to-treat analysis of covariance was performed
to estimate the treatment group difference in mean change in deviation and visual acuity at 40
day and a 2-sided 95% confidence interval (CI), adjusted for baseline deviation and visual
acuity. For each patient, the difference in mean deviation, visual acuity, interocular acuity
difference, refractive errors and degree of anisometropia with 95% confidence intervals were
computed at the 40th day, 3, 6, 12 and 24-month. Latency and amplitude of visual
electrophysiology were computed at the 24-month.
The resolution of esotropia was defined when the deviation in the EE was no more 6 PD. The
proportion of patients whose esotropia resolved was computed and 95% confidence intervals
were calculated. The association of age, sex, prior treatment history (spectacles, patching,
atropine and visual training), binocular vision, visual acuity, degree of anisometropia with
improvements in the resolution of esotropia and treatment days were assessed using the
analysis of linear regression, paired test and one sample test. All p-values were two-tailed. SPSS
version 22 was used for data analyses.
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Li, Z., Li, G., Li., X., Xue, N., Sun, L., Zheng, H., Lee, L. R., Fung, D. D. (2021). Refractive Accommodative Esotropia Treated by Asymmetric Refractive
Accommodative Esotropia Correction. European Journal of Applied Sciences, 9(5). 127-141.
URL: http://dx.doi.org/10.14738/aivp.95.10910
RESULTS
Baseline Characteristics
Between April 2017 and May 2020, 72 participants (F=34) with residual refractive partially
accommodative esotropia, the mean deviation without glasses was 21.88±7.42 PD for distance
vision and 23.47±7.63 PD for near vision. mean baseline visual acuity of 62.43±18.97 letters;
mean baseline interocular acuity difference of 3.29±2.97 lines. The baseline demographics,
clinical history and characteristics of the study cohort are provided in Tables 1.
Treatment and follow-up
After the first visit, 4 patients were dropped in both groups, respectively. The 40th day primary
outcome, the subsequent 3-month, 6-month, 12-mongh and 24-month visits were completed
by 36 (90%) participants in both groups, respectively (Fig.1). The deviation and visual acuity
measurement were performed by masked testers at 90% of visits for both groups. No
participant in both groups was prescribed treatment other than the randomly assigned
treatment during the study.
Binocular vision in EE
At the 40th day primary outcome visit, after adjusting for baseline, mean difference of deviation
at near with glasses drastically improved from baseline by 1 PD (95% CI: 0.4 to 1.8 PD) with
asymmetric refractive accommodative esotropia correction, and by 0.1 PD (95% CI: -0.1 to 0.4
PD) with full hyperopic correction (Table 2). Follow-up at the 3, 6, 12 and 24 months, mean
difference of deviation at near glasses by 7 PD (95% CI: 6.5 to 8.2 PD), 11 PD (95% CI: 10.4 to
12.3 PD), 16 PD (95% CI: 14.7 to 17.2 PD), 21 PD (95% CI: 20.1 to 22.6 PD), respectively, with
asymmetric refractive accommodative esotropia correction, and by 5 PD (95% CI: 4.0 to 5.2
PD), 6 PD (95% CI: 5.4 to 7.1 PD), 9 PD (95% CI: 7.7 to 9.8 PD), 13 PD (95% CI: 12.0 to 14.1 PD),
respectively, with full hyperopic correction. At the 40th day primary outcome visit, after
adjusting for baseline, mean difference of deviation at far with glasses improved from baseline
by 2 PD (95% CI: 1.0 to 2.9 PD) with asymmetric refractive accommodative esotropia
correction, and by 1 PD (95% CI: 0.4 to 1.8 PD) with full hyperopic correction. Follow-up at the
3, 6, 12 and 24 months, mean difference of deviation at far with glasses by 8 PD (95% CI: 6.7 to
8.8 PD), 10 PD (95% CI: 8.8 to 11.5 PD), 12 PD (95% CI: 10.2 to 13.1 PD), 18 PD (95% CI: 16.1
to 19.2 PD), respectively, with asymmetric refractive accommodative esotropia correction, and
by 5 PD (95% CI: 3.9 to 5.5 PD), 7 PD (95% CI: 5.9 to 7.7 PD), 10 PD (95% CI: 8.7 to 10.5 PD),
13 PD (95% CI: 12.1 to 14.0 PD), respectively, with full hyperopic correction. In both
asymmetric refractive accommodative esotropia correction and full hyperopic correction
groups, the deviations were improved gradually (p<0.05) in 24 months, but there were not
statistically significant different (t=1.00, p=0.324) in the deviation between the 1st day and the
40th day visits in full hyperopic correction groups only. From the 3-month visit to the 24-month
visit, there were a statistically significant difference (t=2.97, p<0.005 for 3-month visit; t=3.57,
p<0.001 for 6-month visit; t=4.65, p<0.001 for 12-month visit; t=5.62, p<0.001 for 24-month
visit) in the deviations at far with glasses between asymmetric refractive accommodative
esotropia correction and full hyperopic correction groups. From the 6-month visit to the 24-
month visit, there were a statistically significant difference (t=4.16, p<0.001 for 6-month visit;
t=5.90, p<0.001 for 12-month visit; t=6.26, p<0.001 for 24-month visit) in the deviations at near
with glasses between asymmetric refractive accommodative esotropia correction and full
hyperopic correction groups (Table 2).