A Data-Driven Approach to the Management of Accommodative Esotropia

PurposeTo determine if key findings on initial examination are predictive of ability to achieve and maintain functional alignment (residual esotropia of less than 8 prism diopters) with single-vision spectacles, bifocals, or surgery in children with accommodative esotropia.DesignRetrospective, observational case series.MethodsInstitutional review of 68 consecutive accommodative esotropia patients. Exclusion criteria included previous spectacles use, other ocular pathologic features or surgery, or follow-up of less than 2 years. The main outcome measure was the ability to achieve functional alignment.ResultsMean age at the time of single-vision spectacle prescription (P = .02), mean cycloplegic refractive error (P = .016), amblyopia (P = .02), uncorrected near deviation (P < .001), and uncorrected distance deviation (P < .001) differed significantly between children who achieved functional alignment with single-vision lenses and those who did not. The most parsimonious prediction model revealed that presence of amblyopia (P = .113; odds ratio [OR], 0.138; 95% confidence interval [CI], 0.012 to 1.59), uncorrected distance deviation (P = .004; OR, 1.156; 95% CI, 1.049 to 1.274), mean cycloplegic refractive error (P = .008; OR, 0.300; 95% CI, 0.123 to 0.732), and age at time of single-vision lens prescription (P = .007; OR, 0.259; 95% CI, 0.097 to 0.690) were the best predictors of ability to achieve orthotropia with single-vision spectacles with a sensitivity of 94% (95% CI, 71% to 99%) and specificity of 91% (95% CI, 75% to 98%).ConclusionsSignificant differences exist in the clinical presentations of children who achieve functional orthotropia with single-vision spectacles and those who require bifocals or surgery. An evidence-based algorithm may help practitioners predict which intervention is most likely to benefit an individual child.