Review

Authors: Savleen Kaur, Shipra Sharda, Himshikha Aggarwal...

The optimal method of treatment for a child depends on the patient's age at the time of diagnosis, the onset and type of amblyopia, and the degree of compliance attainable. In deprivation amblyopia, the cause of visual impairment (e.g., cataract, ptosis) needs to be treated first, and then the disorder can be treated such as other types of amblyopia. Anisometropic amblyopia needs glasses first. In strabismic amblyopia, conventionally amblyopia should be treated first, and then strabismus corrected. Correction of strabismus will have little if any effect on the amblyopia, although the timing of surgery is controversial. Best outcomes are achieved if amblyopia is treated before the age of 7 years. The earlier the treatment, the more efficacious it is. In selected cases of bilateral amblyopia, the more defective eye must be given a competitive advantage over the comparatively good eye. Glasses alone can work when a refractive component is present, but occlusion might make the glasses work faster. The gold standard therapy for amblyopia remains occlusion of the better eye although penalization is also evidenced to achieve equal results. Pharmacotherapy has been shown to achieve suboptimal outcomes. Newer monocular and binocular therapies based on neural tasks and games are adjuncts to patching and can also be used in adults.

Topics: Child; Adult; Humans; Amblyopia; Visual Acuity; Sensory Deprivation; Strabismus; Refraction, Ocular; Treatment Outcome

PubMed: 37417105
DOI: 10.4103/IJO.IJO_338_23

Review

Authors: Angeles R Bort-Martí, Fiona J Rowe, Laura Ruiz Sifre...

BACKGROUND

The use of botulinum toxin as an investigative and treatment modality for strabismus is well reported in the medical literature. However, it is unclear how effective it is in comparison with other treatment options for strabismus.

OBJECTIVES

The primary objective was to examine the efficacy of botulinum toxin therapy in the treatment of strabismus compared with alternative conservative or surgical treatment options. This review sought to ascertain those types of strabismus that particularly benefit from the use of botulinum toxin as a treatment option (such as small angle strabismus or strabismus with binocular potential, i.e. the potential to use both eyes together as a pair). The secondary objectives were to investigate the dose effect and complication rates associated with botulinum toxin.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS and three trials registers on 6 July 2022, together with reference checking to identify additional studies. We did not use any date or language restrictions in the electronic searches for trials.

SELECTION CRITERIA

We planned to include randomized controlled trials (RCTs) comparing botulinum toxin with strabismus surgery, botulinum toxin alternatives (i.e. bupivacaine) and conservative therapy such as orthoptic exercises, prisms, or lens therapy for people of any age with strabismus. All relevant RCTs identified in this update compared botulinum toxin with strabismus surgery.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane and assessed the certainty of the body of evidence using GRADE.

MAIN RESULTS

We included four RCTs with 242 participants that enrolled adults with esotropia or exotropia, children with acquired esotropia, and children with infantile esotropia. The follow-up period ranged from six to 36 months. Two studies were conducted in Spain, and one each in Canada and South Africa. We judged the included studies to have a mixture of low, unclear and high risk of bias. We did not consider any of the included studies to be at low risk of bias for all domains. All four studies reported the proportion of participants who improved or corrected strabismus, defined as ≤ 10 prism diopters (PD) at six months (two studies) or ≤ 8 PD at one year (two studies). Low-certainty evidence suggested that participants treated with the surgery may be more likely to improve or correct strabismus compared with those who treated with botulinum toxin (risk ratio (RR) 0.72, 95% confidence interval (CI) 0.53 to 0.99; I² = 50%; 4 studies, 242 participants; low-certainty evidence). One study, which enrolled 110 children with infantile esotropia, suggested that surgery may reduce the incidence of additional surgical intervention required, but the evidence was very uncertain (RR 3.05, 95% CI 1.34 to 6.91; 1 study, 101 participants; very low-certainty evidence). Two studies conducted in Spain compared botulinum toxin with surgery in children who required retreatment for acquired or infantile esotropia. These two studies provided low-certainty evidence that botulinum toxin may have little to no effect on achieving sensory fusion (RR 0.88, 95% CI 0.63 to 1.23; I² = 0%; 2 studies, 102 participants) and stereopsis (RR 0.86, 95% CI 0.59 to 1.25; I² = 0%; 2 studies, 102 participants) compared with surgery. Three studies reported non-serious adverse events. Partial transient ptosis (range 16.7% to 37.0%) and transient vertical deviation (range 5.6% to 18.5%) were observed among participants treated with botulinum toxin in three studies. In one study, 44.7% participants in the surgery group experienced discomfort. No studies reported serious adverse events or postintervention quality of life.

AUTHORS' CONCLUSIONS

It remains unclear whether botulinum toxin may be an alternative to strabismus surgery as an independent treatment modality among certain types of strabismus because we found only low and very low-certainty evidence in this review update. Low-certainty evidence suggests that strabismus surgery may be preferable to botulinum toxin injection to improve or correct strabismus when types of strabismus and different age groups are combined. We found low-certainty evidence suggesting botulinum toxin may have little to no effect on achievement of binocular single vision compared with surgery in children with acquired or infantile esotropia. We did not find sufficient evidence to draw any meaningful conclusions with respect to need for additional surgery, quality of life, and serious adverse events. We identified three ongoing trials comparing botulinum toxin with conventional surgeries in the varying types of strabismus, whose results will provide relevant evidence for our stated objectives. Future trials should be rigorously designed, and investigators should analyze outcome data appropriately and report adequate information to provide evidence of high certainty. Quality of life and cost-effectiveness should be examined in addition to clinical and safety outcomes.

Topics: Adult; Child; Humans; Botulinum Toxins; Esotropia; Strabismus; Canada

PubMed: 36916692
DOI: 10.1002/14651858.CD006499.pub5

Authors: Mikael Hofsli, Tobias Torp-Pedersen, Claes Sepstrup Lønkvist...

Strabismus is a common condition affecting both children and adults. Strabismus patients may experience double vision, abnormal head position and loss of stereovision. The psychosocial negative impact of strabismus may be severe, affect self-esteem, social relationships, and job opportunities. Strabismus is a congenital condition or a result of an illness in later life and surgical treatment should be considered as reconstructive surgery and not downrated as just »a cosmetic procedure«. Strabismus surgery is safe, effective and addresses functional as well as psychosocial problems.

Topics: Adult; Child; Humans; Strabismus; Oculomotor Muscles; Plastic Surgery Procedures; Interpersonal Relations

PubMed: 36760141
DOI: No ID Found

Review

Authors: Daniela Cioplean, Lăcrămioara Nitescu Raluca

Age related binocular vision disorders (age related strabismus) could include all types of spontaneous strabismus appearing along the lifetime, which are directly connected with the aging process. Neurological strabismus is excluded. Functional and structural changes related to the aging process can induce phoria decompensation, convergence insufficiency decompensation and new onset strabismus as distance esotropia or vertical strabismus induced by the sagging eye syndrome. MRI studies sustain the hypothesis of age related structural changes of extraocular muscles pulleys and their influence on the eye position and motility nominated as sagging eye. Age Related Distance Esotropia, Age Related Divergence Insufficiency Esotropia are probably different names for the same type of strabismus. All types of age related binocular disorders require treatment because of the accompanying diplopia. Prisms or/ and surgery can improve the patients' life quality by eliminating diplopia in primary position and main gazes.

Topics: Aging; Humans; Magnetic Resonance Imaging; Oculomotor Muscles; Ophthalmologic Surgical Procedures; Strabismus; Vision Disorders; Vision, Binocular

PubMed: 29450323
DOI: No ID Found

Review

Authors: Mehmet Cem Mocan, Aishwarya Pastapur, Lawrence Kaufman...

BACKGROUND

Pediatricians are regularly involved in the initial examination of children presenting with strabismus, a common ocular condition occurring in 3% of children. The objective of this review was to gain insight into pediatric residents, fellows and attendings` understanding of strabismus, and to propose an etiology-based strabismus classification scheme to aid this understanding.

METHODS

A survey was conducted in a single Department of Pediatrics in a university academic institution in order to assess the degree of understanding of the classification, etiology and nomenclature of strabismus. A targeted literature review, pertinent to our classification scheme for strabismus in the pediatric age group, is provided to clarify the various underlying etiological conditions for pediatricians.

RESULTS

The surveyed cohort (n=26) consisted of 10 (38.5%) attendings and 16 (61.5%) pediatricians-in-training. Although 69% of survey participants felt comfortable performing an ocular motility evaluation, only 19% had a clear understanding of the underlying etiology of strabismus, 8% had a clear understanding of strabismus nomenclature and none of the participants had clear knowledge of a classification scheme of strabismus. We propose an etiologic-based strabismus classification scheme with streamlined nomenclature geared towards Pediatricians to facilitate the management of pediatric patients with various ocular misalignments. Eight major categories of this classification scheme include (1) physiologic, (2) comitant, (3) paralytic, (4) sensory, (5) syndromic, (6) orbital, (7) supranuclear and (8) pseudostrabismus.

CONCLUSIONS

Pediatricians at all levels of professional experience have a limited command of strabismus. An etiology-based classification scheme of strabismus may assist in understanding the underlying causes and facilitate the management of strabismus in the pediatrician`s office.

Topics: Child; Cohort Studies; Humans; Pediatricians; Strabismus; Surveys and Questionnaires

PubMed: 35611422
DOI: 10.24953/turkjped.2020.2372

Comparative Study

Authors: E M Helveston

Topics: Age Factors; Esotropia; Follow-Up Studies; Humans; Infant; Strabismus; Vision, Binocular; Visual Acuity; Visual Perception

PubMed: 2979026
DOI: No ID Found

Review

Authors: Pradeep Sharma, Nripen Gaur, Swati Phuljhele...

Strabismus is one of the most challenging subspecialties encountered in the field of ophthalmology. The concept of etiology of strabismus is being advanced with the development of newer imaging modalities and increased understanding of the genetics of strabismus. Imaging is also being used to aid in the planning of strabismus surgery. Newer horizons are being explored in the amblyopia management. The good old eye-pad is being replaced with the iPad. Early detection of loss of stereopsis is being used to decide the timing for strabismus surgery. Improvement of binocular summation has been discovered as a benefit of corrective strabismus surgery. Newer surgical techniques such as new transposition procedures are being developed to correct complex strabismus. Strabismus surgeries aided by adjustable sutures have increased the precision of a strabismologist. A new light has been thrown on the psychosocial impact of strabismus. A present-day strabismologist has advanced from the goal of ocular alignment to a bigger perspective "to regain the paradise lost: stereopsis."

Topics: Congresses as Topic; Eye Movements; Humans; Oculomotor Muscles; Strabismus; Vision, Binocular; Visual Acuity

PubMed: 28440246
DOI: 10.4103/ijo.IJO_867_16

Observational Study

Authors: Vidya S Mooss, V Kavitha, H N Ravishankar...

PURPOSE

To study the presence and development of strabismus in children with telecanthus, epicanthus, and hypertelorism.

METHODS

This is a prospective, longitudinal, and observational study. Sixty children aged between 6 months and 18 years with telecanthus, epicanthus, and hypertelorism in isolation or in combination were recruited. A detailed analysis of the history, determination of best corrected visual acuity, complete evaluation of strabismus, and ocular examination were carried out. The presence of telecanthus, epicanthus, and hypertelorism and associated strabismus, if any, was noted. All children were followed up for a minimum and maximum period of 12 and 18 months, respectively, to analyze the strabismus (previously present) and for detection of strabismus in those who did not have. The data were analyzed descriptively with mean and standard deviation. Chi square test and Fishers exact test were used to analyze the data between the groups. A P value less than 0.05 was considered to be statistically significant.

RESULTS

Telecanthus was the most common lid feature (55%). At baseline, ten (16.66%) children had strabismus (six: esotropia; four: exotropia). Two (3.33%) children underwent surgery. One child developed exotropia at the third follow-up (18 months). At the end of the study, 11 (18.33%) children had strabismus. No significant association was seen between lid characteristics and the type of strabismus.

CONCLUSION

Children with telecanthus, epicanthus, and hypertelorism in isolation or in combination may or may not have associated strabismus. These features can pose difficulty in strabismus diagnosis, which mandates a careful examination, especially in younger age groups and small-angle strabismus. On the other hand, children without strabismus need longer follow-up to detect the development of strabismus and to initiate further management at the earliest.

Topics: Child; Craniofacial Abnormalities; Esotropia; Exotropia; Eyelids; Humans; Hypertelorism; Infant; Prospective Studies; Retrospective Studies; Strabismus; Visual Acuity

PubMed: 36190058
DOI: 10.4103/ijo.IJO_776_22

Meta-Analysis Review

Authors: Yudi Yang, Chao Wang, Yong Gan...

The effect of maternal smoking during pregnancy on strabismus in offspring remains unclear. We conducted a meta-analysis to summarize epidemiological evidences on the association between maternal smoking during pregnancy and the risk of offspring strabismus. Eligible studies were searched from the PubMed, Ovid, Embase and CNKI databases up to May 2018. The qualities of included articles were assessed with the Newcastle-Ottawa Scale and the assessment scale recommended by the Agency for Healthcare Research and Quality. Odds ratios (ORs) corresponding with its 95% confidence intervals (CIs) were pooled to estimate the effects of maternal cigarette smoking on the risk of offspring strabismus. Subgroup analyses and meta-regression were performed to explore the potential sources of heterogeneity. The Begg's test and Egger's test were used to assess the publication bias. Eleven articles involving 4,833 patients with strabismus were included. The pooled OR showed that maternal smoking during pregnancy was significantly associated with strabismus in offspring (OR = 1.46, 95% CI = 1.32-1.60). Compared with less than 10 cigarettes per day (OR = 1.17, 95% CI = 1.06-1.29), maternal smoking 10 cigarettes or more per day during pregnancy significantly increased the risk of offspring strabismus (OR = 1.79, 95% CI = 1.39-2.31). The risk of developing esotropia and exotropia for smoking pregnant women, respectively, increased by 65% (OR = 1.65, 95% CI = 1.31-2.09 and OR = 1.65, 95% CI = 1.24-2.19) than those who did not smoke during pregnancy. Additionally, the increased risk of maternity smoking associated with offspring strabismus was stable across all subgroup analyses. Overall, maternal smoking during pregnancy was associated with a significantly increased risk of offspring strabismus and the result was persistent in subgroup analyses, suggesting the importance in changing smoking habit or smoking cessation for women who are pregnant or preparing to.

Topics: Female; Global Health; Humans; Incidence; Infant, Newborn; Pregnancy; Prenatal Exposure Delayed Effects; Risk Factors; Smoking; Strabismus

PubMed: 30402966
DOI: 10.1111/aos.13953

Review

Authors: Saif Saleh AlObaisi, Bashair Nasser Alnasser, Hana Abdulaziz Almuhawas...

BACKGROUND

Many ophthalmological complications have been associated with hydrocephalus (HC), including ocular motility disorders, visual field defects, optic atrophy, and loss of visual acuity. No studies have investigated the prevalence of strabismus and visual outcomes of children with congenital HC after ventriculoperitoneal (VP) shunt in Saudi Arabia.

OBJECTIVES

Estimate the frequency of strabismic children diagnosed with HC who underwent a VP shunt procedure.

DESIGN

Medical record review SETTING: Tertiary care center PATIENTS AND METHODS: We reviewed the files of all pediatric patients diagnosed with hydrocephalus before the age of 2 years and treated with shunts during the period 2010 to 2020 at our institution.

MAIN OUTCOME MEASURES

Strabismus types and ophthalmic assessment (visual state, outcomes, and ocular motility state).

SAMPLE SIZE AND CHARACTERISTICS

190 children; 98 (51.5%) males.

RESULTS

Eighty-nine (46.8%) had congenital HC followed by intraventricular hemorrhage 36 (18.9%); 74 (38.9%) patients had regular follow-ups in ophthalmology. Sixty-five (34.2%) patients had no ophthalmic assessment or fundus examination records, while 63 (33.1%) were diagnosed with strabismus. At the initial assessment, 26 (13.6%) patients had exotropia (XT). At the final assessment, 7 (3.6%) patients had XT. The association between VP shunt and strabismus was statistically significant, (χ=6.534, df=1, <.01).

CONCLUSION

More than one-third of children diagnosed with HC who had surgical treatment in a tertiary hospital did not have any records of ophthalmic assessment, which highlights the need to implement a specific ophthalmological examination protocol in patients with HC. Further studies are needed to analyze the association between VP shunt and strabismus.

LIMITATIONS

Evaluating the ocular state and visual function before and after VP shunt was not possible.

CONFLICT OF INTEREST

None.

Topics: Male; Humans; Child; Child, Preschool; Female; Ventriculoperitoneal Shunt; Prevalence; Hydrocephalus; Strabismus; Fundus Oculi; Medical Records

PubMed: 36444928
DOI: 10.5144/0256-4947.2022.391