Infantile Esotropia

Summary of Evidence

Natural history

Esotropia with onset in early infancy frequently resolves in patients first examined below 20 weeks of age when the deviation is < 40 pd in size and is intermittent/variable.{Pediatric Eye Disease Investigator Group. Spontaneous resolution of early-onset esotropia: experience of the Congenital Esotropia Observational Study. Am J Ophthalmol. 2002 Jan;133(1):109-18.}

Botulinum toxin

Clarification is required as to the effective use of botulinum toxin as an independent treatment modality in the treatment of strabismus. Six RCTs on the therapeutic use of botulinum toxin in strabismus, graded as low and very low-certainty evidence, have shown varying responses.{Rowe FJ, Noonan CP. Botulinum toxin for the treatment of strabismus. Cochrane Database Syst Rev. 2017 Mar 2;3(3):CD006499.}

Surgery

The Early vs late infantile strabismus surgery study (ELISSS) compared early with late surgery in a prospective, controlled, non-randomized, multicenter trial. Children operated early had better gross stereopsis at age six as compared to children operated late. They had been operated more frequently, however, and a substantial number of children in both groups had not been operated at all.{Simonsz HJ, Kolling GH, Unnebrink K. Final report of the early vs. late infantile strabismus surgery study (ELISSS), a controlled, prospective, multicenter study. Strabismus. 2005}

No statistically significant difference was found between bilateral recession (BR) or by unilateral recession-resection (RR) as surgery for infantile esotropia. The mean postoperative angle of strabismus at distance was +2.3 degrees (5.1) for BR and +2.9 degrees (3.5) for RR. {Polling JR, Eijkemans MJ, Esser J, Gilles U, Kolling GH, Schulz E, Lorenz B, Roggenkämper P, Herzau V, Zubcov A, ten Tusscher MP, Wittebol-Post D, Gusek-Schneider GC, Cruysberg JR, Simonsz HJ. A randomised comparison of bilateral recession versus unilateral recession-resection as surgery for infantile esotropia. Br J Ophthalmol. 2009 Jul;93(7):954-7}

Evidence

1. Background

1.1 Natural history

Cohort study

2002 PEDIG

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2002
Cohort study

Esotropia with onset in early infancy frequently resolves in patients first examined below 20 weeks of age when the deviation is < 40 pd in size and is intermittent/variable.{Pediatric Eye Disease Investigator Group. Spontaneous resolution of early-onset esotropia: experience of the Congenital Esotropia Observational Study. Am J Ophthalmol. 2002 Jan;133(1):109-18.}

Clinical Trial

1998 Birch et.al.

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1998
Clinical Trial

infants who present at 2 to 4 months of age with constant esotropia of 40 PD or greater are valid candidates for surgical treatment. In addition, data from long-term follow-up support the hypothesis that early surgical alignment may promote the development of at least coarse stereopsis in these infants.{Birch E, Stager D, Wright K, Beck R. The natural history of infantile esotropia during the first six months of life. Pediatric Eye Disease Investigator Group. J AAPOS. 1998 Dec;2(6):325-8; discussion 329.}

2. Botulinum Toxin

2.1 Initial treatment

Systematic review

2017 Rowe and Noonan (Cochrane review)

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2017
Systematic review

Clarification is required as to the effective use of botulinum toxin as an independent treatment modality in the treatment of strabismus. Six RCTs on the therapeutic use of botulinum toxin in strabismus, graded as low and very low-certainty evidence, have shown varying responses.{Rowe FJ, Noonan CP. Botulinum toxin for the treatment of strabismus. Cochrane Database Syst Rev. 2017 Mar 2;3(3):CD006499.}

Rowe and Noonan (Cochrane review)
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Meta-analysis

2017 Issaho et.al.

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2017
Meta-analysis

Analysis of nine studies showed grouped success rate of botulinum toxin (BT) treatment in infantile esotropia of 76%. The mean change of the deviation after BT injection was -30.7, demonstrating a significant improvement in alignment.{Issaho DC, Carvalho FRS, Tabuse MKU, Carrijo-Carvalho LC, de Freitas D. The Use of Botulinum Toxin to Treat Infantile Esotropia: A Systematic Review With Meta-Analysis. Invest Ophthalmol Vis Sci. 2017 Oct 1;58(12):5468-5476.}

Other findings:
- Complication rates:
  - The grouped consecutive exotropia rate was 1%
  - The grouped ptosis rate was 27%
  - The grouped vertical deviation rate was 12%.

2.2 Following surgical failure

Clinical Trial

1999 Tejedor & Rodriguez

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1999
Clinical Trial

The motor and sensory outcomes and the stability of motor results were similar in patients reoperated and treated with botulinum injection who had been unsuccessfully operated for infantile esotropia.{Tejedor J, Rodríguez JM. Early retreatment of infantile esotropia: comparison of reoperation and botulinum toxin. Br J Ophthalmol. 1999 Jul;83(7):783-7.}

Tejedor & Rodriguez
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3. Surgical treatment

Review

2015 Hug

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2015
Review

Surgery is the treatment of choice for infantile esotropia but no method has a clear advantage. The literature suggests that treatment before age 2 and perhaps even earlier improves the potential for binocular vision. Botulinum toxin continues to be used for treatment of infantile esotropia, although it has not been shown to be a superior treatment.{Hug D. Management of infantile esotropia. Curr Opin Ophthalmol. 2015 Jul;26(5):371-4.}

3.1 Early vs late surgery

Review

2008 Wong

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2008
Review

Clinical Trial

2005 Simonsz et.al.

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2005
Clinical Trial

The Early vs late infantile strabismus surgery study (ELISSS) compared early with late surgery in a prospective, controlled, non-randomized, multicenter trial. Children operated early had better gross stereopsis at age six as compared to children operated late. They had been operated more frequently, however, and a substantial number of children in both groups had not been operated at all.{Simonsz HJ, Kolling GH, Unnebrink K. Final report of the early vs. late infantile strabismus surgery study (ELISSS), a controlled, prospective, multicenter study. Strabismus. 2005 Dec;13(4):169-99.}

3.2 Pre-operative measures

3.2.1 Alternating occlusion

Clinical Trial

2006 Ing et.al.

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2006
Clinical Trial

Alternating occlusion before surgical alignment does not detectably alter the increase in angle of deviation between the dates of entry and the date of the initial surgical alignment procedure, nor does it influence the postoperative alignment at 6 weeks or at 1 year.{Ing MR, Norcia A, Stager D Sr, Black B, Hoffman R, Mazow M, Troia S, Scott W, Lambert S. A prospective study of alternating occlusion before surgical alignment for infantile esotropia: one-year postoperative motor results. J AAPOS. 2006 Feb;10(1):49-53.}

3.3 Surgical technique

Clinical Trial

2016 Fouad et.al.

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2016
Clinical Trial

In a prospective randomized interventional study of augmented MR muscle recession (augmented group) or MR muscle pulley posterior fixation (pulley group) in 60 children with convergence excess esotropia or variable-angle infantile esotropia, the success rate was statistically significantly higher in the pulley group (70%) than in the augmented group (40%).{Fouad HM, Abdelhakim MA, Awadein A, Elhilali H. Comparison between medial rectus pulley fixation and augmented recession in children with convergence excess and variable-angle infantile esotropia. J AAPOS. 2016 Oct;20(5):405-409.e1.}

Clinical Trial

2009 Polling et.al.

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2009
Clinical Trial

No statistically significant difference was found between bilateral recession (BR) or by unilateral recession-resection (RR) as surgery for infantile esotropia. The mean postoperative angle of strabismus at distance was +2.3 degrees (5.1) for BR and +2.9 degrees (3.5) for RR.{Polling JR, Eijkemans MJ, Esser J, Gilles U, Kolling GH, Schulz E, Lorenz B, Roggenkämper P, Herzau V, Zubcov A, ten Tusscher MP, Wittebol-Post D, Gusek-Schneider GC, Cruysberg JR, Simonsz HJ. A randomised comparison of bilateral recession versus unilateral recession-resection as surgery for infantile esotropia. Br J Ophthalmol. 2009 Jul;93(7):954-7}

3.4 Stereoacuity outcomes after treatment

Review

2009 Birch & Wang

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2009
Review

Stereoacuity maturation normally proceeds rapidly during the first year of life. Infantile and accommodative esotropia are associated with profound and permanent disruption of stereopsis. Although rehabilitation of stereoacuity after treatment of esotropia remains a challenge, even the achievement of subnormal stereoacuity may have real benefits to the child.{Birch EE, Wang J. Stereoacuity outcomes after treatment of infantile and accommodative esotropia. Optom Vis Sci. 2009 Jun;86(6):647-52.}

References

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Summary of Evidence

Evidence

1. Background

1.1 Natural history

2. Botulinum Toxin

2.1 Initial treatment

Details

2.2 Following surgical failure

3. Surgical treatment

3.1 Early vs late surgery

3.2 Pre-operative measures

3.2.1 Alternating occlusion

3.3 Surgical technique

3.4 Stereoacuity outcomes after treatment

References

Comments