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Background/aims: This study aims to evaluate the clinical efficacy of botulinum toxin type A (BTXA) injection and augmented-dosed surgery in the treatment of acute acquired concomitant esotropia (AACE), and explore potential risk factors associated with recurrence., Methods: A total of 104 patients diagnosed with AACE between October 2020 and January 2021 were included and voluntarily chose to undergo augmented surgery or BTXA injection. The follow-up assessments ended in November 2022. Multivariable linear regression analysis was used to identify potential factors that influence the dose-response of bilateral medial rectus recession (MRrec). Kaplan-Meier survival analyses and Cox proportional hazards models were performed to evaluate rate and risk factors for AACE relapse., Results: A total of 31 AACE patients chose augmented-dosed esotropia surgery, and 73 chose BTXA treatment. During the 2-year follow-up, the surgical group achieved more stable postoperative results with no recurrence of diplopia, while only 68.68% (95% CI 55.31% to 78.79%) patients achieved orthophoria in the BTXA group. For patients undergoing BTXA treatment, hours of near work per day were demonstrated to be a significant risk factor for AACE relapse (HR 1.29, 95% CI 1.00 to 1.67). The dose-response of augmented-dosed bilateral MRrec was positively correlated with preoperative deviation angle (R 2 =0.833; β=0.043, 95% CI 0.031 to 0.055; p<0.001)., Conclusion: Our findings provided quantitative evidence that augmented-dosed surgery would achieve more stable and favourable surgical outcomes for AACE patients compared with BTXA injection. However, BTXA treatment is still proposed for patients with small deviation angles due to its advantages of reduced trauma, operational simplicity, low cost and quick recovery., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: To report the effect of two three-muscle surgeries, inferior rectus belly transposition plus augmented superior rectus transposition plus medial rectus recession (ISM) and modified vertical rectus belly transposition plus medial rectus recession (VM), in the management of large-angle esotropia in Chinese patients with chronic sixth nerve palsy., Methods: Twenty-eight consecutive patients with large-angle esotropia ≥50 Δ were prospectively enrolled and underwent either ISM or VM. Main outcomes included preoperative and postoperative deviation in primary position, abduction limitation and complications. Follow-up was at least 6 months., Results: Of the included patients, 13 underwent ISM and 15 underwent VM. Preoperatively, ISM group displayed larger esotropia and more severe abduction limitation. 27 patients completed the follow-up. The postoperative horizontal deviation and abduction limitation were similar in both groups. At the last follow-up, ISM group demonstrated greater improvement of abduction limitation than VM group in both grading (group difference -2.1, p<0.001) and quantitation (group difference 2.6 mm, p=0.001). However, eight (30%) patients revealed an induced adduction limitation ≤-1. Of the 22 patients with unilateral palsy, more esotropia of 14.8 Δ was corrected in ISM group, compared with VM group (p=0.003). Three patients (14%) developed vertical diplopia and three (14%) developed torsional diplopia. Unexpectedly, keratitis was observed in 4 of 27 (15%) patients, all with concurrent fifth and/or seventh nerve palsy. Three patients aggravated to corneal ulceration., Conclusions: Two three-muscle surgeries, ISM and VM were both effective for large-angle esotropia in Chinese patients with chronic sixth nerve palsy. However, attention should be paid to potential complications., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

A 28-year-old man presented with a progressive inward deviation of the left eye in the last 4 years. Examination revealed -3 abduction and elevation deficit in the left eye with 50 prism diopters (PD) esotropia and 12 PD of hypotropia. The patient had multiple fibromas on the forearms with pulsatile globe and was diagnosed as neurofibromatosis type 1. Myopic strabismus fixus was suspected. MRI revealed left temporal lobe herniation through a dysplastic sphenoid wing, compressing the posterior half of the superior rectus and lateral rectus muscles, resulting in an esotropia-hypotropia complex. Surgical treatment involved suture myopexy (Yokoyama's technique) of the left superior rectus and lateral rectus muscles with a 6.5 mm left medial rectus recession. Two months postoperatively, the patient had minimal residual esotropia and hypotropia. MRI orbits should always be performed in high myopes with strabismus to assess extraocular muscle pathways., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Management options in third nerve palsy are limited as four of the six extraocular muscles are involved. Surgery has to be tailored on a case-to-case basis. Aim of this retrospective case series is to report 1-year outcomes of a modified surgical technique entailing full tendon transposition of lateral rectus to medial rectus augmented with posterior fixation sutures in four patients with complete third nerve palsy. All four cases showed significant improvement of vertical and horizontal deviation with long-term stability of correction. Choice of route of full tendon augmented transposition of lateral rectus to medial rectus can aid in achieving good correction of the vertical misalignment in addition to horizontal correction., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Esotropia due to high myopia can be caused by inferior shift of the lateral rectus muscle (LRM). Innovative surgical methods have been developed to elevate the muscle and, thus, augment its abducting force. However, their efficacy is not yet proven to exceed that of recess-resect surgery (RR)., Methods: Data on high myopic esotropia were evaluated who received RR together with elevation of the LRM in the horizontal meridian by equatorial myopexy. Age, gender, axial length, amount of surgery, preoperative and 3 months postoperative strabismus angles and efficacy (mm/°) were analysed. Medians and ranges (minimum-maximum) are given., Results: The age of the 46 patients (37 females, 9 males) was 57 years (36-76). Axial length was 31.5 mm (26.0-35.6), total amount of RR 10.0 mm (5-24). Esotropia 16° (4-60) was reduced to 2° (-22 to 34), hypotropia from 3° (-3 to 30) to 0° (-8 to 18). Efficacy (eyes without prior surgery only) was 1.33°/mm (0.20-3.55)., Conclusions: Geometrical considerations rather than empirical data yield some evidence of an augmenting effect of equatorial myopexy on RR. Efficacy of RR with LRM myopexy was higher in unilateral than bilateral high myopia. Strict indication for myopexy appears appropriate., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

A 22-year-old man was referred for horizontal diplopia that worsened on left gaze. He had been admitted for a head trauma caused by a traffic accident. Brain CT scan showed a longitudinal fracture of the left temporal bone with extension to the left carotid canal and central skull base, including sphenoid lateral wall and roof, and left orbit medial wall non-displaced fracture. Prism cover test revealed 20 prism diopters of esotropia and abduction limitation in the left eye. Hess screening test results were compatible with left abducens nerve paralysis. Symptoms suggesting complete lower motor neuron palsy of the left facial nerve, such as unilateral facial drooping, inability to raise the eyebrow and difficulty closing the eye, were present. As there was no improvement in facial paralysis, the patient received surgical intervention using a transmastoidal approach. Three months postoperatively, prism cover test showed orthotropia, however, the facial nerve palsy persisted., (2015 BMJ Publishing Group Ltd.)

Background/aims: To compare surgical outcomes between preterm and full-term patients with infantile-onset esotropia., Methods: This study included 56 preterm and 162 full-term patients with infantile-onset esotropia who underwent strabismus surgery. The extent of surgery was reduced by 0.5 mm per muscle in preterm patients who were born at <30 weeks of gestation. Surgical outcomes over time, including surgical success, overcorrection rate, undercorrection rate and surgical dose-response were compared between preterm and full-term patients., Results: The Cox proportional hazards regression model and competing risk analysis showed no statistically significant differences in the rate of surgical success or undercorrection over time between preterm and full-term patients. However, the final overcorrection rate was greater in preterm children than in full-term children (p=0.019). The average surgical dose-response was 3.99 prism dioptres (PD)/mm in full-term children and 4.40 PD/mm in preterm children., Conclusions: The results of this study showed a favourable outcome using a mildly reduced amount of surgery in preterm patients with infantile-onset esotropia. Surgical dose-response was significantly greater in preterm patients than in full-term patients., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background/aims: A decrease in strabismus surgery in children has been previously documented in the UK. This study aims to examine whether the incidence of strabismus surgery in children is still decreasing and, if so, the possible reasons for this., Methods: Data on strabismus surgery from 2000 to 2010 in children in Scotland, England and Wales were obtained. Population statistics for the age group 0-14 years were obtained for England, Scotland and Wales. Annual incidence of strabismus surgery per 100 000 age-specific population was calculated. Data on the number of sight tests in children conducted by the hospital eye service from 1995 to 2004 in these regions were also obtained., Results: From 2000 to 2006, the annual incidence of paediatric strabismus operations decreased significantly in England (p=0.01) and Scotland (p=0.03), and showed a decreasing trend in Wales (p=0.06). Surgical rates, however, remained fairly constant from 2006 to 2010. The number of sight tests in children performed by the hospital eye service has remained fairly constant from 1995 to 2004 in England, Wales and Scotland., Conclusions: Rates of strabismus surgery in children, especially for esotropia, continued to decrease between 2000 and 2006, but may have stabilised from 2006 to 2010.

Aims: To evaluate the results of Faden operations on the medial rectus (MR) muscles with or without recession for the treatment of partially accommodative esotropia associated with a high accommodative convergence to accommodation (AC : A) ratio and to determine whether there was a decrease in the effects of posterior fixation over time., Methods: In this retrospective study, 108 of 473 patients who underwent surgery for partially accommodative esotropia with a high AC : A ratio received Faden operations on both MR muscles, and 365 received symmetric MR muscle recessions combined with a Faden operation., Results: For the Faden operation, a satisfactory outcome of 76.9% at 1 month postoperation, decreased to 71.3% by the final follow-up visit (mean 4.8 years). A moderate positive correlation was observed between the increase in the postoperative near deviation and postoperative time. For the Faden operations combined with MR recession, a satisfactory outcome of 78.9% at 1 month post-operation, decreased to 78.4% by the final follow-up visit., Conclusion: A Faden operation of the MR muscles with or without recession is an effective surgical option for treating partially accommodative esotropia associated with a high AC : A ratio. For Faden operations of the MR muscles without recession, the effects of the posterior fixation decline over time.

Aims: To compare the postoperative surgical outcomes and the changes in deviation achieved per millimetre of recession in patients treated by graded unilateral medial rectus (UMR) or bilateral medial rectus (BMR) recession for small to large angle esotropia with a minimum follow-up of 6 months., Methods: In a retrospective, consecutive and interventional case series, 102 patients underwent UMR recession and BMR recession for constant esotropia measuring 15-35 prism diopters (PD) and 30-70 PD, respectively, from 1 January 2007 to 30 September 2010. Successful alignment was defined as ± 8 PD of orthophoria in primary and lateral gaze., Results: No significant difference was observed between: (1) the success rates of the BMR and UMR recession groups at postoperative days 1∼3 (p=1.00) or at final follow-up (p=0.421); (2) the variation in the mean change in deviation from postoperative days 1∼3 to the final follow-up of the UMR (p=0.58) and BMR (p=0.56) recession groups; and (3) the mean correction in PD per millimetre of muscle recession in the UMR and BMR (p=0.63) recession groups., Conclusion: Graded UMR recession for 15-35 PD of esodeviation was as effective as graded BMR recession for 30-70 PD of esodeviation. There was no statistical difference in changes in deviation per millimetre of recession between equivalent amounts of unilateral and bilateral recession.

Aim: To investigate the development of dissociated vertical deviation (DVD) in infantile esotropia and its relationship with the infant's age and the surgical intervention technique., Material and Method: The medical records of the patients that were diagnosed with infantile esotropia and followed-up in the Strabismus Department of our clinic (Department of Ophthalmology, Ankara University Faculty of Medicine, Ankara, Turkey) were reviewed retrospectively. The patients' ages at the time of admission, risk factors, ophthalmological examinations before and after treatment, and treatment mode were recorded and compared., Results: DVD was found to develop in approximately one-half of the cases (47.9%) at an average age of 3.2 years (20 months-5.5 years) regardless of the type of treatment. DVD developed in 80.5% of cases that had no surgery and in 37.5% of cases who were surgically treated. On comparison according to age, DVD was seen in 24.1% of the cases that were treated between ages 6 months and 2 years and in 52% of the cases that were treated after age 2 years. The difference was found to be statistically significant (p<0.01). On comparison according to the surgical technique, DVD developed in 34.8% of the cases who had undergone bimedial rectus recession and in 38% of the cases with unilateral recession and resection. This difference was not statistically significant (p>0.05)., Conclusions: In the treatment of infantile esotropia, early surgical intervention to obtain binocularity and prevent amblyopia is associated with a reduced incidence of the development of DVD. It is concluded that the incidence of the development DVD increases if surgery is not performed, if performed at a later age, or if additional muscle surgery is needed during follow-up due to undercorrection.

Aims: To report the long term outcomes of photorefractive keratectomy (PRK) for the treatment of hyperopia associated with purely refractive accommodative esotropia., Methods: This study was a retrospective chart review of 40 patients aged 17-39 years who underwent PRK to eliminate their dependence on glasses. Pre- and postoperative best spectacle corrected visual acuity (BSCVA), uncorrected visual acuity (UCVA), refractive spherical equivalent (SEQ), ocular alignment and stereoacuity were reviewed., Results: Forty patients (80 eyes) with a mean age of 27.9 years were treated for a mean preoperative SEQ of +3.06 D hyperopia. The mean final postoperative SEQ was +0.06 D. Preoperative BSCVA was 0.04 logarithm of the minimum angle of resolution (logMAR), and did not change postoperatively. Mean UCVA significantly improved from 0.30 logMAR preoperatively to 0.08 logMAR post-operatively. Mean pre-operative esotropia at distance and near was 18.6 prism D. All patients were orthophoric without correction at the 1 month, 1 year and final postoperative evaluations. Visual acuity, refractive error and alignment remained stable after the 1 year postoperative examination. Stereoacuity was unchanged in 80% of patients postoperatively. There were no complications., Conclusion: PRK can be used to treat low to moderate hyperopia associated with purely refractive accommodative esotropia in young adults.

Objective: Infantile esotropia, a common form of strabismus, is treated either by bilateral recession (BR) or by unilateral recession-resection (RR). Differences in degree of alignment achieved by these two procedures have not previously been examined in a randomised controlled trial., Design: Controlled, randomised multicentre trial., Setting: 12 university clinics., Participants and Intervention: 124 patients were randomly assigned to either BR or RR. Standardised protocol prescribed that the total relocation of the muscles, in millimetres, was calculated by dividing the preoperative latent angle of strabismus at distance, in degrees, by 1.6., Main Outcome Measure: Alignment assessed as the variation of the postoperative angle of strabismus during alternating cover., Results: The mean preoperative latent angle of strabismus at distance fixation was +17.2 degrees (SD 4.4) for BR and +17.5 degrees (4.0) for RR. The mean postoperative angle of strabismus at distance was +2.3 degrees (5.1) for BR and +2.9 degrees (3.5) for RR (p = 0.46 for reduction in the angle and p = 0.22 for the within-group variation). The mean reduction in the angle of strabismus was 1.41 degrees (0.45) per millimetre of muscle relocation for RR and 1.47 (0.50) for BR (p = 0.50 for reduction in the angle). Alignment was associated with postoperative binocular vision (p = 0.001) in both groups., Conclusions: No statistically significant difference was found between BR and RR as surgery for infantile esotropia.

Background/aims: To evaluate the effectiveness and dose-effect relationship of unilateral medial rectus advancement to the original insertion and lateral rectus recession in the surgical management of consecutive exotropia., Patients/methods: The charts of 62 patients operated on for consecutive exotropia in a single-surgeon paediatric ophthalmology practice with a minimum follow-up time of 6 weeks were reviewed., Results: Fifty-two patients were managed with unilateral surgery involving medial rectus advancement and lateral rectus recession. The medial rectus was advanced to the original insertion, and the lateral rectus was recessed by the amount of millimetres it had originally been resected for patients with precise records on previous surgery (within one millimetre of the above). The mean age at surgery for exotropia was 12.86 years. The mean postoperative follow-up time was 2.5 years. The mean preoperative distance exodeviation was 33.4 prism dioptres (PD), and the mean reduction in the angle of strabismus was 33.5 PD. A successful surgical outcome, defined as ocular alignment within 10 PD of orthophoria, was obtained in 41 patients (78.8%) at final follow-up. The mean dose-effect relationship between the reduction in the angle of deviation and the sum of millimetres of the reoperation was 2.9 PD/mm. It varied widely among patients and was strongly correlated with the amount of preoperative exodeviation, that is the patients tended to respond more per millimetre of surgical intervention the greater the preoperative exodeviation., Conclusion: The standard reversal of unilateral medial rectus recession and lateral rectus resection is a simple and effective means for correcting secondary exotropia. The dose-effect relationship varied widely among patients and tended to correlate with the amount of preoperative exodeviation.

Aims: To evaluate the postoperative alignment drift following traditional strabismus surgery utilizing direct attachment of muscle to sclera., Methods: The ocular alignment drift (change from the first postoperative week) of 106 patients who underwent scleral fixation strabismus surgery at age 0.5 to 35 years with 5 years' maximal follow-up was analysed., Results: There was a mean undercorrection drift of 4.6 (SD 8.9) prism dioptres (PD) at distance fixation (p = 0.025) and 3.4 (7.6) PD at near (p = 0.053) for all subjects, and 11.3 (8.6) PD distance (p = 0.008) and 10.6 (6.0) PD near (p = 0.016) for exotropic patients. Recession surgery produced an undercorrection drift of 5.3 (8.8) PD (p = 0.021) at distance fixation. Esotropic patients and those undergoing unilateral recession/resection surgery had no significant drift. Patients overcorrected at the 1-week postoperative visit later developed an undercorrection drift at distance (10.3 (7.9) PD, p = 0.002) and near fixation (5.5 (9.2) PD at 36 months, p = 0.041), while undercorrected patients showed no significant drift and largely stayed undercorrected., Conclusion: Fixed scleral-suture strabismus surgery generally produces a postoperative undercorrection drift, especially following recession surgery, exotropia or overcorrection at the first postoperative week.

Aim: To measure the drift of ocular alignment following strabismus surgery utilising adjustable sutures., Methods: 106 patients, aged 12 to 84 years, underwent adjustable suture strabismus surgery with a follow-up of 0.5-4 years (mean 24.3 months)., Results: For all subjects measured on distant fixation, there was a mean undercorrection drift of 8.3 (SD 2.3) prism dioptres (PD) from week 1 to 48 months postoperatively (p = 0.005). Patients with exotropia demonstrated an undercorrection drift on distant fixation from week 1 to 2 years (mean 10.1 (3.5) PD, p = 0.023). Patients who underwent recession surgery developed a mean 9.1 (3.3) PD undercorrection drift from week 1 to 3 years (p = 0.031). Patients who had unilateral recession and resection surgery showed a mean 6.8 (2.9) PD undercorrection drift from week 1 to 18 months (p = 0.049). Patients with constant or intermittent postoperative stereopsis had a statistically significant undercorrection drift (

Aims: This prospective study explores the effect of reduction in hypermetropic refractive correction on the angle and control of fully accommodative esotropia., Methods: 30 childhood cases with fully accommodative esotropia were recruited. The angle of deviation with and without full hypermetropic correction (near and distance) was measured. The overall effect of reduction of the correction by one and two spherical dioptres (DS) on the angle and control of the deviation was identified., Results: With the full hypermetropic correction in place, the angle of deviation for near was less than 10 prism dioptres (pd) in 73% of the participants, and the distance deviation was less than 10 pd in 93%. When the prescription was reduced by 1.00 DS, the percentage of those with a near deviation of less than 10 pd fell to 30% and 57% for the distance. Twenty per cent immediately decompensated to manifest esotropia with reduction of 1 dioptre of spectacle correction., Conclusion: Children with fully accommodative esotropia who are given the full hypermetropic correction demonstrate smaller, more controllable angles of deviation than those who are undercorrected by as little as only one dioptre. This supports the practice of providing the maximum hypermetropic correction for childhood esotropes.

Background: /aims: Paediatric squint surgery appears to be declining. This study aims to identify if this is so and, if so, why., Methods: Retrospective review of (1) episodes of paediatric squint surgery in Scotland and Tayside, 1986-2001, (2) presentations to orthoptists (Tayside) during 1986 and 1996., Results: (1) Overall, a 58% fall in surgery in Scotland and 59% in Tayside. For esotropia, a reduction of 63% (Scotland) and 69% (Tayside). (2) Incidence of esotropia was unchanged; surgery for these esotropes fell (from 55% to 30%) (p = 0.013). More children received maximum hypermetropic correction (p <0.001) and more developed stereopsis (p = 0.003)., Conclusion: Childhood strabismus surgery, particularly for esotropia, is declining. The maximum hypermetropic correction has improved the functional results.

Background: Strabismus surgery for congenital esotropia can be complicated by the development of a postoperative head tilt., Purpose: To determine the pathophysiology of acquired head tilting following horizontal realignment of the eyes in children with congenital esotropia., Materials and Methods: Retrospective analysis of nine children with congenital esotropia who developed unexplained head tilts following horizontal realignment of the eyes., Results: Shortly after strabismus surgery, each child developed a head tilt in association with asymmetrical dissociated vertical divergence (DVD). Five children maintained a head tilt toward the side of the fixing eye (group 1), which did not serve to control the DVD. Four children maintained a head tilt toward the side of the hyperdeviating eye, which served to control the DVD (group 2). Children in group 2 had earlier horizontal muscle surgery and developed better stereopsis than those in group 1, suggesting that the higher degree of single binocular vision and stereopsis in these children may have led to a compensatory torticollis to control an asymmetrical DVD., Conclusions: The onset of an unexpected head tilt after congenital esotropia surgery is usually a postural manifestation of asymmetrical DVD. In this setting, a head tilt toward the side of the fixing eye corresponds with a postural manifestation of the underlying central vestibular imbalance that produces DVD, while a head tilt toward the side of the hyperdeviating eye serves to counteract the hyperdeviation and stabilise binocular vision.

Aim: To describe the development and treatment of V-pattern and bilateral over-elevation in adduction in patients with cyclic esotropia., Methods: Three patients with cyclic esotropia are described in retrospect. All patients underwent bilateral medial recession, while one patient additionally had a weakening procedure of both inferior oblique muscles., Results: All patients developed a V-pattern and bilateral over-elevation in adduction. After strabismus surgery, normal eye alignment with some signs of binocularity was reached in all three patients. Moreover, the over-elevation in adduction and V-pattern completely resolved., Conclusions: V-pattern and bilateral over-elevation in adduction was seen in all patients with cyclic esotropia in the stage that fusion was disrupted. Possible explanations for the origin of these patterns are discussed. Strabismus surgery aimed to correct the horizontal esotropic angle restored fusion and eliminated the vertical incommitancies in lateral gaze, and the V-pattern.

Aim: To investigate the postoperative eye alignment and binocular visual function after early surgery for infantile esotropia., Methods: Both the postoperative eye position and stereopsis were reviewed using the Titmus stereo test in nine patients who received uniocular medial rectus recession and lateral rectus resection under general anaesthesia before 8 months of age and were followed up for a minimum of 4 years., Results: Orthophoria was attained in three cases, whereas esotropia was found in four patients. Dissociated vertical deviation was noted in two other cases at the final examination. Static stereoacuity was achieved in five cases. These results also showed that most infants in whom stereopsis was attained had satisfactory eye alignment during the follow up period and at the final examination. Infants who did not achieve stereopsis still had deviation throughout the follow up period., Conclusions: It was concluded that early surgery in infantile esotropia is beneficial to achieve binocular visual function, but it is necessary to confirm a stable angle of deviation with accurate preoperative evaluation, and to maintain good postoperative eye alignment throughout the follow up period.

Aim: To compare the efficacy of reoperation and botulinum toxin injection in treating infantile esotropes early after unsatisfactory surgical alignment., Methods: 55 strabismic children who had been unsuccessfully operated for infantile esotropia were randomised to reoperation (28 patients) or botulinum toxin injection (27 patients). The motor outcomes (percentage of successful motor outcome and percentage change in deviation) were compared at 6 months, 1 year, and 3 years after retreatment, and the sensory outcomes (percentage with fusion ability and stereo perception) at the 3 year follow up visit., Results: The motor and sensory outcomes and the stability of motor results were similar in patients reoperated and treated with botulinum injection. At the 3 year visit 67.8% and 59.2% of children were, respectively, within 8 prism dioptres of orthotropia (p=0.72). The frequency of fusion ability was, respectively, 60.7% and 51.8% (p=0.71), and the frequency of stereo perception (

Background: The Early vs Late Infantile Strabismus Surgery Study Group investigates whether early or late surgery is preferable in infantile convergent strabismus, in a non-randomised, prospective, multicentre clinical trial. The current state of the study after end of recruitment is reported here, focusing on the question of possible sources for bias in this non-randomised trial., Method: The prognostic factors were analysed at baseline in order to check for imbalances between the two treatment groups. Reasons for possible differences are discussed., Results: There is no evidence for clinically relevant inhomogeneities between the two groups concerning the distribution of the three prognostic factors spherical equivalent, degree of amblyopia, and limitation of abduction. The fourth prognostic factor, horizontal angle of squint, differs significantly between the two groups., Conclusion: In the analysis of the final results we may have to account for differences in angle of squint at baseline by its inclusion as a covariate or by stratification.

Aims: Two viable options were compared, reoperation and botulinum toxin injection, in the management of children who need retreatment after surgery for acquired esotropia., Methods: 47 strabismic children previously operated to correct an acquired esotropia were randomised to reoperation or botulinum toxin injection. Reoperation was undertaken in 24 of these patients and botulinum toxin injection in 23 of them. The percentage net change in distance deviation, the percentage of patients with successful motor outcome, detectable fusion, and stereopsis were compared 1 year after retreatment and at last visit (average follow up: 2.9 years in reoperation group, and 2.7 years in botulinum group). The motor success rate relative to time elapsed from initial surgery was evaluated., Results: There was no significant difference in the motor and sensory outcomes between patients reoperated and treated with botulinum injection. The frequency of correction to within 8 prism dioptres of orthotropia was, respectively: 75% versus 69.56% at 1 year; 70.83% versus 60.86% at last visit. Botulinum injection could be more effective when performed within 3 months of initial surgery., Conclusions: Botulinum injection is a rapid and safe procedure that may be as effective as reoperation in the management of children who need a secondary procedure after surgery for acquired esotropia.

Background: Patients with 'A' or 'V' pattern esotropia without vertical muscle overaction have traditionally been treated with medial rectus recession and vertical transposition of the muscle insertions., Method: Seven cases are presented treated by slanting muscle insertions, whereby the lower margin of the medial rectus is preferentially recessed more than the upper margin in esotropia, and the upper margin is recessed more than the lower margin in A esotropia., Results: All seven patients had their A or V patterns eliminated, with six achieving good alignment in all positions of gaze., Conclusion: The slanting muscle insertion should be considered as an alternative technique in all cases of A or V pattern esotropia.

Sixteen patients with large angle infantile esotropia with deviations of 80-90 prism dioptres were operated at the age of about 2 years. All patients underwent 8 mm bilateral medial rectus recessions. At the last follow up examination, 6 to 48 months postoperatively (average 16.3 months), successful horizontal alignment was achieved in 12 patients (75%). Four patients (25%) were undercorrected. Clinically significant limitation of adduction or convergence was not observed postoperatively in any of the patients. Consecutive exotropia was not encountered in this series but a longer follow up is probably needed in order to assess its delayed appearance. These results suggest that 8 mm recession of the medial recti is an effective procedure for the correction of large angle infantile esotropia of 80-90 prism dioptres and can be considered as an acceptable alternative to operations on three or four muscles.

A characteristic pattern of dissociated eye movements was observed in a large proportion of our patients with a variety of craniosynostosis syndromes. These anomalies simulate overaction of the inferior oblique and underaction of the superior oblique muscles which, however, cannot fully explain the abnormalities. In a number of cases, excyclorotation of the muscle cone was observed, with the upper pole of the eye tilted away from the midline. It is postulated that such excyclorotation of the eyes will lead to dissociated eye movements which can be explained on physiological grounds according to Hering's law. This paper presents a review of our patients and evidence to support this hypothesis.

Monozygous twins who developed typical acute late onset esotropia are described. Neither had evidence of other neurological disease and both responded well to bimedial rectus muscle recessions. This twin presentation suggests a hereditary basis for the development of late onset esotropia in at least some cases. It provides further support for a policy of avoiding invasive CNS investigations in those patients who have binocular potential and are otherwise normal.

Convergence excess esotropia has been treated with bifocals, miotics, medial rectus recession(s), fadenoperation, or a combination of these. However, comparatively few studies on the sensory status of these patients exist. We present the sensory findings in 31 children treated surgically. Twenty-one had fadenoperations combined with bimedial rectus recessions, one had a fadenoperation alone, and nine had augmented bimedial rectus recessions. Five children (16%) achieved bifoveal fusion, 22 (71%) had varying degrees of peripheral fusion, and four (13%) had no detectable binocularity after a mean postoperative follow-up of 2.4 years.

Binocularity was assessed in children who developed large, constant esotropia following bilateral lateral rectus recessions for intermittent exotropia. Nine such patients were identified who warranted medical rectus recession. Seven were finally aligned within 6 prism dioptres after secondary surgery. Stereopsis measured 50 seconds or better in six of these patients and 200 seconds of arc in the seventh. Two patients had residual deviations: one child with 30 prism dioptres of residual esotropia had 400 arc seconds and the remaining patient, with 12 prism dioptres of exotropia and marked anisometropia, did not show stereopsis. Children with constant acquired esotropia for as long as two years may still have normal stereopsis after surgical alignment. The risk of losing binocularity because of a large overcorrection following exotropia surgery may be smaller than previously assumed.

Of 50 cases of strabismus having surgical operations designed on the basis of A scan ultrasonography 45 (90%) had less than 10 dioptres eso- or exodeviation two months postoperatively; 22 eso-, 25 exo-, and 3 vertical deviations were included in the series. A scan ultrasonography is done preoperatively to find the diameter and thus the circumference of the globe. This is used with the angle of deviation to estimate the amount of recession and/or resection necessary to correct the deviation. Attention is drawn to the oculomotor axis, which is 10-12 degrees divergent to the anteroposterior axis and around which the recti muscles act. The oculomotor equator is at right angles to this axis and is closer to the limbus medially than laterally, so that excessive recession of the medial rectus is more likely than of the lateral rectus.

We studied 250 patients with consecutive exotropia. The interval between the surgical procedure and the onset of the consecutive exotropia may take many years. Consecutive exotropia occurred with all types of corrective esotropia surgery that we studied. Amblyopia and medial rectus limitation postoperatively seemed to be common factors associated with consecutive exotropia.

The success rate of large (6 and 7 mm) bimedial rectus recessions in 45 congenital esotropes with deviations of 50 prism dioptres or greater was found to be 91%. Judgment of final alignment was made six weeks postoperatively, with an average follow-up of 13 months. Large bimedial rectus recessions are an effective surgical treatment for congenital esotropia. This procedure does not significantly alter adduction, and leaves other muscles available should further surgery be necessary. These findings show that initial surgery on three or more muscles is unnecessary in congenital esotropia.

One-stage adjustable suture for strabismus correction, with the whole operation done under topical anaesthesia and adjustment done on the table, was performed on 45 consecutive patients. The stability of the post-adjustment result was studied by comparing the post-adjustment deviation on the operating table to that at six weeks and three months after operation. The stability was comparable to that following the usual two-stage adjustable suture. The original angle of deviation and the fusion status were found to have no bearing on the stability of the procedure.

Appropriate use of base-out prisms may be useful objective test for detecting persistence of normal binocular vision (4-dioptre prism test). By prolonged observation of prismatic correction of an esotropic patient one may infer the presence of an anomalous sensorial status. This can be done when the prismatic correction is compensated for by an increase of the angle of esotropia (prism adaptation test). The increase in the angle of esotropia induced by base-out prisms, here called anomalous movements, is probably related to a type of anomalous movement fusional in nature. When anomalous movements are present, it is important to realise how powerfully they have developed. This may be inferred by determining what amount of prism overcorrection of the esotropic angle the patient is capable of compensating for (progressive prism compensation test). This has important implications for surgery. It has been statistically demonstrated that esotropia with strong anomalous movements tends to respond less effectively to surgery than esotropia without or with weak anomalous movements.

Ninety-seven patients with congenital esotropia with deviations of 50 prism dioptres or greater underwent large (6 and 7 mm) bimedial rectus recessions. The overall success rate with one operation was 83.5%. Judgment of final alignment was made at the last follow-up examination, six to 61 months (average 23.4 months) postoperatively. Large bimedial rectus recessions for congenital esotropia are an effective surgical treatment which does not significantly alter adduction.

Forty-six children awaiting surgery for concomitant esotropia were placed into two matched groups. One group received bilateral medial rectus recessions, while the second group received augmented bilateral medial rectus recessions. By recession the conjunctiva and subconjunctival tissue in addition to the medial rectus we consistently increased the correction obtained. With bilateral medial rectus recession to correct large angle esotropia application of the augmented technique is more likely to provide a full correction.

In 40 eyes of 20 esotropic subjects in which a 'Fadenoperation' was performed on the medial recti we measured the resistance to ocular rotation in adduction before and after the operation. The difference between the two sets of force measurements demonstrates that the Fadenoperation on medial recti produces a mechanical restriction to adduction which can explain the effect of the surgical procedure on the strabismic deviation.

Acute acquired comitant esotropia has been used to describe a dramatic onset of a relatively large angle of esotropia with diplopia and minimal refractive error. We describe six children aged 5 to 11 years who developed an acute non-accommodative esotropia with diplopia. Neurological examination, including CT scan, in each of these children gave negative results. We suggest that this is an unusual presentation of esotropia of undetermined aetiology. The diagnosis, clinical characteristics, and management are discussed.

Sixteen patients with moderate angle esotropia of 30 to 35 prism dioptres were treated with a unilateral medial rectus muscle recession of 6 or 6.5 mm. Thirteen of sixteen patients (80%) were straight postoperatively or had 12 prism dioptres or less of esotropia. Three of the 16 had greater than 12 prism dioptres of esotropia, and none were exotropic. This procedure should be considered as an alternative approach in the treatment of moderate angle esotropia.

Cyclic esotropia is a rare and poorly understood condition normally treated by correcting the deviation measured on the squinting day. Control in some patients with this condition can be gained by correcting their refractive errors, thereby improving acuity. We report on an adult patient who developed cyclic esotropia after unilateral traumatic aphakia with failed contact lens wear whose squint was corrected by secondary intraocular lens implantation. This may be explained by the reduction in the degree of aneisokonia which subsequently improved steropsis.