Surgical outcomes for esotropia in children with high accommodative convergence/accommodation ratio

Purpose: To assess if high accommodative convergence/accommodation (AC/A) ratio impacts surgical outcomes in children with esotropia (ET), and evaluate the appropriate target angle in surgical dosing in the presence of high AC/A ratio. Methods: A retrospective chart review identified patients who underwent primary bilateral medial rectus (BMR) recessions for ET. Patients were excluded if follow-up was ≤2 months. Basic demographic information, visual acuity, stereopsis, alignment, and target angle for surgery were collected. High AC/A was defined as ≥10 prism diopter (Δ) deviation at near compared to distance. Outcome parameters were near and distance deviations ≤10Δ within orthophoria, and/or stereopsis postoperatively. Yates' continuity correction, unpaired t-test, regression analysis, and one-way ANOVA were used. Results: We identified 103 patients, 23 with high AC/A and 80 with normal AC/A, preoperatively. Mean age was 4.0 ± 2.5 years. Surgical success measured by postoperative alignment was 48% and 45% in the high AC/A and normal AC/A groups, respectively (P = 1.0). There was a statistically significant difference in preoperative near deviation between high AC/A and normal AC/A groups (P = 0.0015); however, there was no significant difference in preoperative distance deviation (P = 0.061). In addition, there was not a significant difference in preoperative or postoperative stereopsis between high AC/A and normal AC/A groups (P = 0.88 and P = 0.44, respectively). There was a significant difference in the normal AC/A and high AC/A groups when target angle was directed toward preoperative near deviation as determined by one-way ANOVA (F = 170.88, P < 0.0001 and F = 14.61, P = 0.0010, respectively). Conclusion: In the setting of ET treated with BMR recession, the presence of high AC/A does not affect surgical success as measured by alignment and stereopsis. In addition, when high AC/A is present, surgical dosing with a target angle toward near deviation was found to yield the best surgical outcomes in our patient population.