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Diagnosis: sensory esotropia
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Expert Commentary
Comments of David A. Plager, MD
This gentleman developed a slowly progressive esotropia over a number of years following trauma to the right eye. The time course suggests that the esodeviation was not precipated directly by the trauma, but is likely a sensory esodeviation caused by the poor vision due to the cataract. In the absence of any coincidental systemic or neurologic signs or symptoms, no further work up is necessary. The diplopia became apparent after good vision was restored to the eye by the cataract surgery, making the patient aware of the ocular misalignment.
Surgery is not difficult; he needs bimedial rectus recessions or a monocular recess/resect procedure on the pseudophakic eye. I would normally favor the bilateral procedure when there are two good seeing eyes, but this patient would likely feel more comfortable with the idea of operating only on the "bad" eye. Adjustable sutures could be used, but for me, they offer no advantage over fixed suture surgery on such straightforward cases.
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| Comments of Bradley C. Black, MD
Decreased visual acuity in one eye results in unequal inputs to visual cortex. This in turn will cause disruption of fusion and eventually will often cause strabismus. Because the traumatic cataract occurred in teenage years, this patient did not develop suppression or amblyopia as a result of the esotropia. Poor visual acuity in the right eye as well as the significant deviation probably allowed him to ignore the horizontal diplopia. Following cataract surgery as an adult, he has good visual acuity but is unable to ignore the diplopia.
In the photos, the esotropia appears comitant with full abduction of the right eye. Preoperative evaluation must determine the patient's ability to fuse with prism neutralization. If single vision can be obtained with prism neutralization, then surgery is indicated.
Goals of treatment are: 1) Eliminate diplopia 2) Obtain fusion 3) Improve visual field 4) Improve appearance. If the patient is able to obtain single vision with prism, the chances to achieve these goals with surgery are excellent. Depending on forced ductions, I would do a right medial rectus recession on an adjustable suture and a right lateral rectus resection. Forced ductions should be done following the lateral rectus resection before the suture is permanently tied. If forced ductions are at all positive, the lateral rectus should be recessed slightly to prevent an incomitant postoperative result. I would aim for orthophoria at the time of adjustment on the first postoperative day. Because this patient has good visual acuity in each eye and his esotropia developed after the age of visual maturity, I think he has an excellent chance of restoration of some binocular function and has an excellent chance of a stable result. Visual field will always improve when adult esotropia is corrected. As always, the patient should understand that further surgery may be necessary and that there may be persistent diplopia, especially in extremes of gaze.
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Comments of Daniel E. Neely, MD
This patient most likely has sensory esotropia induced by his reduced visual acuity OD and secondary disruption of his fusional mechanism. Despite the traumatic nature of his cataract, there is no evidence of either a restrictive process nor a sixth nerve palsy, as evidenced by his excellent ability to abduct the eye.
His potential for single binocular vision can be evaluated by placing either a 25 PD loose prism or spectacle mounted Fresnel prism before the deviated eye and observing his subjective response and Worth four dot responses. While not absolute, this will better enable the surgeon to counsel the patient regarding possible persistent postoperative diplopia.
Surgical correction would be recommended, with recession of the right medial rectus and resection of the right lateral rectus. If desired, the medial rectus could be done on an adjustable suture.
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