Infantile esotropia

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Interventions for infantile Esotropia : 

Interventions for infantile Esotropia Review The Cochrane Collaboration 2007 Rana N Al-Senawi

Infantile Esotropia (IE) : 

Infantile Esotropia (IE) Background Inward deviation of the eye ET by the age of 6 months Family history of squint usually, but well-defined genetic pattern unusual Usually in normal children 30% of children with neurologic and developmental problems like CP and HC

IE : 

IE Characteristics of EI Apparent, large angle more than 30 PD Alternation of fixation Cross fixation Manifest-latent nystagmus Oblique overaction (IO) DVD Suppression – no binocular vision Persistence of smooth horizontal pursuit asymmetry after 6 months of age

IE : 

IE IE affects : Binocularity Vision Normal eye alignment (cosmesis)

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Expert Opinion Case Report Case Series Retrospective Studies RCTs Multi-center RCT Meta-analysis Evidence-level

IE : 

IE Treatment Aims : - to align visual axis and enhances binocularity - to improve ocular misalignment Many authors consider that alignment within 10 diopters of orthotropia offers best prospect for binocular vision development

IE : 

IE Management : surgical , non-surgical or combination Treat ambylopia Correct refractive errors Non-surgical : botulinium toxin A injection into MR

IE : 

IE Surgical : adjust horizontally acting EOM Unilateral : MR recession and LR resection Bilateral : BMR 3 or more muscle surgery – combination of recession and resection Adjustment of vertical muscles – weakening IO or SR Timing of surgery : Ultra early : 4-6 months Early < 2 years Late > 2 years

IE : 

IE Objectives Effectiveness of treatment Optimal timing of intervention Criteria for considering studies: Study type : Only randomised controlled trials Participants : children with IE who may be treated for ambylopia/refractive error, but no intervention to correct misalignment

IE : 

IE Types of intervention :

IE : 

IE

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SEARCH STRATEGY Cochrane Central Register of Controlled Trials Cochrane Eyes and Vision Group Trial Register MEDLINE (1966 to September 2006) EMBASE (1980 to September 2006) LILACS European Strabismological Association (1975 1997, 1999 to 2002) International Strabismological Association (ISA) 1994 AAPOS (1995 to 2003) Contact researchers for published and unpublished studies

IE : 

IE Search methods

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Description of studies 280 reports of studies found All studies excluded except five. Kushner 1984, RCT : intervention not included in review Other four : not trials Methodological Quality No studies were found that met the inclusion criteria

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Discussion Literature available mainly retrospective studies and cohort studies or case series. Lack of RCTs Surgical interventions : Most authors agree for a form of surgery constant ET, angle > 40^ in patient ages 2-4 years not spotaneously resolve

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Arnoult et al (1976) retrospective study of 2 groups. Group 1- BMR , Group 2 – unilateral surgery. Post op angle same. No statistical analysis documented. Forrest (2003) case series 49 pts undewent 3 muscle sx. Concluded that 3 muscle sx has high success rate in attaining good ocular alignement. Ranomised comparison (Kushner 1984) of graded vs standard 10.5 mm BMR achieved better final ocular alignment.

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Randomised trial (Friendly 1993) of severing the check ligaments and intermuscular membranes on MR found no differnce between 2 groups No RCTs on different surgical approaches performed

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Non-surgical intervention (botulinium toxin) First reported in 1980 in Scott Biglan’s 1989 – not successful as sx 1990 Scott reported that 65% of this group achieved 10 ^ of orthotropia with 2 years follow up. No adverse effects. Ing 1992 looked at 49 pts, 3 years f/u. Positive binocularity (sensory and motor fusion) in half of this group. Then compared this group to sx group and concluded that BT less effective than sx to establish binocularity.

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McNeer 1994, 57 pts IE. All pts received BT injection in both MR. Found BT effective therapy to reduce angle of squint in pts under 12 months and under 24 months with 12 month period of f/u. Ruiz 2004, BT effective to reduce amount of further horizontal sx. Inj of 5 units of BT induced unbalanced DVD.

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Tejedor 1999, RCT. BT good alternative for re-surgery and equally successful to sx to retain binocularity. Ing 2006, alternating occlusion pre –op and comapred with control group. F/u for 6 months. No significant difference in outcome.

Age at intevention : 

Age at intevention Binocularity Less Muscle contraction Ambylopia Exam reliability Strab sx time Early < 2 years Late >2 years

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Prospective cohort studies (Birch 1995; Birch 1998) sx intervention is associated with better steropsis if received within 24 months of life. Wright 1994, early sx (2.5-3 months) results in good binocularity Ing 1995, multicenter study. 2 groups either sx at less than 6 months or later with 4 years f/u. Concluded no better binocularity with earlier group (<6months).

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Meyer 1998, started 1998 (not published yet). Non-randomized trial. ELISS (Early Vs Late starb sx) Simonsz 2005, large multicenter, non-randomised trial, involved 58 clincs. 2 groups : 231 pts early sx group (6-24 months). 301 pts late sx (32-60 months). Found that children operated early has better “gross” steopsis ate age 6 compared to late group.

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Authors’ Conclusion No RCT present – controversies not resolved regarding the modality of treatment or age of intervention. Available literature suggests : BMR is the surgical modality of choice. General agreement that intervnetion should be earlier than later. Current use of BT remains limited

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No potential conflict of interest No external or internal sources of support

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Implications for research : clear need for good quality trials to be conducted in various areas of IE to improve the evidence base for management. Agreement needed to constitute ‘positive binocularity’ and what is considered ‘success’ in surgical alignment.

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Thank You

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