Treatment for Adult-Onset Divergence Insufficiency–Type Esotropia
abstract
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Access this abstract now Full Text Available for ClinicalKey SubscribersPURPOSE
To describe 10-week and 12-month outcomes following treatment for divergence insufficiency-type esotropia in adults.
METHODS
In this prospective observational study, 110 adults with divergence insufficiency-type esotropia, with a distance esodeviation measuring 2Δ to 30Δ and at least 25% larger at distance than near, and binocular diplopia present at least "sometimes" at distance, were enrolled at 28 sites when initiating new treatment. Surgery, prism, or divergence exercises/therapy were chosen at the investigator's discretion. Diplopia was assessed at enrollment and at 10-week and 12-month outcome examinations using a standardized diplopia questionnaire (DQ). Success was defined as DQ responses of "rarely" or "never" when looking straight ahead in the distance, with no alternative treatment initiated.
RESULTS
Of the 110 participants, 32 (29%) were prescribed base-out prism; none had received prior treatment for esotropia. Success criteria were met by 22 of 30 at 10 weeks (73%; 95% CI, 54%-88%) and by 16 of 26 at 12 months (62%; 95% CI, 41%-80%). For the 76 (68%) who underwent strabismus surgery (82% of whom had been previously treated with prism), success criteria were met by 69 of 74 at 10 weeks (93%; 95% CI, 85%-98%) and by 57 of 72 at 12 months (79%; 95% CI, 68%-88%).
CONCLUSIONS
In this study cohort, both base-out prism as initial therapy and strabismus surgery (usually following prism) were successful in treating diplopia for most adults with divergence insufficiency-type esotropia when assessed during the first year of follow-up.
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Additional Info
Disclosure statements are available on the authors' profiles:
A Prospective Study of Treatments for Adult-Onset Divergence Insufficiency–Type Esotropia
J AAPOS 2021 Jul 13;[EPub Ahead of Print], ER Crouch, TW Dean, RT Kraker, AM Miller, CL Kraus, KB Gunton, MX Repka, JD Marsh, MA Del Monte, PA Luke, JH Peragallo, KA Lee, MB Wheeler, TJ Daley, DK Wallace, SA Cotter, JM HolmesFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
This is another impressive study from the Pediatric Eye Disease Investigator Group (PEDIG). Although it is a misnomer for a pediatric group to be studying adult-onset strabismus, it is only a recent trend for strabismologists to establish satellite practices dedicated entirely to adults. The study is commendable for using a standardized diplopia questionnaire (DQ) as well as the adult strabismus (AS-20) questionnaire, which evaluates health-related quality of life (HRQOL). Enrolled participants were scheduled to return at a 10-week and 12-month interval for follow-up after initiation of treatment. The allocation to each of the three treatment groups was arbitrary, and the authors acknowledge this as a shortcoming of the study. Only 3% were prescribed divergence exercises/therapy, whereas 29% were prescribed base-out prism, and 68% were prescribed surgery, which reflects bias in treatment. Surgery was considered successful even if patients were wearing prism glasses postsurgically, which may have boosted the robust 79% success rate found, and the prism-alone treatment result was reasonably good at 62%. There were too few patients in the divergence exercises/therapy group to permit analysis. It would have been helpful to look at clinical data on sensory and motor outcomes, in addition to the DQ and AS-20 questionnaire ratings. Further work needs to be done to remove examiner bias, but this is an important first step in looking at the potential synergy among these three approaches.