Infantile esotropia: preferred postoperative alignment.

Wagner: This is a case of infantile esotropia. Six weeks following a 6-mm recession of the right and left medial rectus muscles in a 7-month-old infant with typical infantile esotropia findings and no vertical deviation at all, you find a residual esotropia of 12 prism diopters. Dr. Wang, what is your management at this time? Wang: Is the 12 diopters distance, near, or both? Wagner: We’ll say it’s accommodative. It’s pretty much distance and near. Wang: The first thing I would ensure is that I have his cycloplegic refraction. If he had more than 2.5 diopters of plus I probably would try spectacles. If not, I think 12 diopters is a satisfactory position to leave him in and see him back in a month or so. Wagner: I’ll assume that in this case it was alternating. Would that change your opinion, if he had a preferred fixation in one eye that you could determine from your examination? Wang: If he had a preferred fixation of one eye, you would start patching but I’m still satisfied with his alignment result. Wagner: Dr. Ruttum? Ruttum: I certainly agree. I think you have to make sure he doesn’t have amblyopia because that can make it worse over time. I agree that at 7 months I probably wouldn’t put him in glasses unless it was really high. I think that in most children that’s a pretty reasonable result. I would imagine the parents would be happy about it and I would be happy if he saw well in each eye and the alignment was stable. Wagner: Dr. Duss? Duss: I agree as well. I think a 12-diopter residual is acceptable. I would double check the cycloplegic refraction and I would prescribe anything over 2 or 2.5. Wagner: Dr. Ruttum, what would be an acceptable range for postoperative deviation in a case like this? And let’s go both ways, exotropia and esotropia. Ruttum: I would not like any exotropia at this stage because I don’t find that they tend to come back and there are parental concerns. Parents are good at spotting a little overcorrection and not so good at spotting a little undercorrection. But I think 12 diopters is starting to get to a gray zone where they might look okay and they might not. But more than that, I would consider additional surgery if the patient didn’t have any refractive issue that I could address it with. Wagner: Dr. Duss? Duss: I agree. I think my limit would be 15. I think 12 is pushing it. Anything over 15 I would probably consider reoperating. And I agree, I think parents are aware of converting an esotropia to an exotropia. I believe they prefer to see a little residual esotropia and they are more understanding if you need a second surgery than if you flip the child and end up going exotropic. Wagner: Dr. Wang, anything to add on that? Wang: No, I agree. I assume that this is a healthy child who has no other problems. There are children who I’ll let be even a little more esotropic than that, such as children who have high toned cerebral palsy and albinos who have positive angle kappas. There are some children in whom I’ll accept up to almost 20 diopters of esotropia. A lot depends on what their face looks like. It’s a bit hard to tell at 6 or 7 months of age, but that’s more of a consideration later on. Frederick M. Wang, MD, is from New York, New York.