Decompensated Esophoria As A Benign Cause of Acute, Adult Onset Esotropia
Muhammad Hassaan Ali, MD; Joseph L. Demer, MD, PhD
Stein Eye Institute and Department of Neurology, University of California, Los Angeles
Los Angeles, California 90095. U.S.A.
Introduction: Adult onset esotropia confronts the strabismologists with the potential for serious underlying neurological pathologies that have been described, yet the alternative benign possibility of decompensated esophoria has received scant attention. We conducted this study to determine the clinical and magnetic resonance imaging (MRI) characteristics of patients with symptomatic adult onset esotropia due to decompensated esophoria.
Methods: We reviewed cases of patients who presented with esotropia to the Stein Eye Institute between 2015 – 2017.
Results: Seven cases were identified of mean age 28.5 ± 10.2 (range: 20-48) years having gradually progressive intermittent horizontal, binocular diplopia for 10 months to 3 years. Mean pre-operative esotropia was 31.4±12.9D for distance and 30.7±12.3D for near, although this was intermittent in five patients who exhibited markedly enhanced fusional divergence. Neurological evaluation and MRI of brain, orbits, and extraocular muscles were uniformly unremarkable. Orthotropia was successfully restored in all by standard or enhanced doses of bimedial recession, improving mean stereoacuity from 200 to 73 arc sec, although five patients exhibited 2-14 asymptomatic residual esophoria.
Discussion: Patients with decompensated esophoria slowly deteriorate and present with esotropia when their enhanced divergence fusional amplitudes no longer suffice. This contrasts with acute adult comitant esotropia (ACE) developing suddenly without history of phoria or intermittent diplopia. This makes decompensated esophoria progressing to esotropia a generally benign diagnosis distinct from ACE, yet occasionally difficult to distinguish clinically when decompensation is rapid. Mild surgical undercorrections are common yet ususally asymptomatic due to enhanced divergence fusional amplitudes.
Conclusion: Decompensated esophoria is a benign clinical entity causing acquired adult esotropia treatable by enhanced medial rectus recession.
References: 1. Erkan Turan K, Kansu T. Acute acquired comitant esotropia in adults: Is it neurologic or not? J Ophthalmol. 2016:2856128. doi: 10.1155/2016/2856128.
- Lyons CJ, Tiffin PA, Oystreck D. Acute acquired comitant esotropia: A prospective study. Eye. 1999 ;13:617-20.