Intermittent and Accommodative Esotropia*

I N T E R M I T T E N T AND ACCOMMODATIVE ESOTROPIA* A STUDY OF 74 CASES JOHN

P. L U H R ,

M.D.

Buffalo, New York AND ABRAHAM SCHLOSSMAN,

M.D.

New York

This report represents an analysis of 74 cases of intermittent and accommodative esotropia. We have used the term intermit­ tent esotropia for those cases which show both esophoria and esotropia. They may have an esophoria for distance and an esotropia for near, or they may be intermittent both for distance and near. There were 30 cases of this type. In contrast, the average case of ac­ commodative esotropia is a uniocular ob­ ligatory squint which is converted by cor­ rective lenses to intermittent esotropia, to esophoria, or to orthophoria. With few exceptions the cases of inter­ mittent esotropia are accommodative and would seem to be an intermediate group be­ tween the true accommodative esotropias and the esophorias. Because these two types of squint are so closely related and have al­ most interchangeable features, we have grouped them together. In excluding patients whose strabismus is not significantly corrected by the wearing of glasses, and those requiring surgical correc­ tion for improvement, we have focused our attention on patients who show both eso­ phoria and esotropia in the hope that we might obtain some information about the pathogenesis of esotropia in general. At the first examination of a patient with a constant esotropia, the ophthalmologist can­ not foretell whether this case may be cor­ rected by nonsurgical methods alone. We have attempted to find some clues which would enable us to predict the ultimate suc-

cess of nonsurgical treatment in any particu­ lar case. With this in mind, a survey revealed the following factors to be the most signifi­ cant: 1. Age of onset 2. Visual acuity 3." Refractive error 4. Near-point of convergence 5. Fusional status 6. Progress of the cases While the patients displayed a great deal of uniformity, many showed wide variations from the group average in one or more of the above-mentioned factors. AGE OF ONSET

In 77 percent of the cases the parents re­ ported that *the strabismus began between two and six years of age. In 14 percent the onset was before the age of two, and in nine percent the parents noted the squint after the age of six years (table 1). VISUAL ACUITY

While most of the cases were uniocular, 15 percent were classified as so-called alterTABLE 1 AGE OF ONSET

* From the Department of Motor Anomalies, New York Eye and Ear Infirmary. Presented in part before the Section of Ophthalmology, New York Academy of Medicine, April 20, 1953, 19V

Age (years)

Number of Cases

Birth to 1 year 1 to 2 2 to 3 3 to 4 4 to 5 5 to 6 Over 6

3 7 11 16 13 10 5

192

JOHN P. LUHR AND ABRAHAM SCHLOSSMAN TABLE 2 VISUAL ACUITY

Both eyes equal to 20/20 or 20/30 One line difference between eyes (20/20 in one eye and 20/30 in other) Two lines difference between eyes (20/20 and 20/40) Difference between eyes three lines or more

·. 36 21 9 5

nators. Contrary to findings in most patients with obligatory uniocular strabismus, very few in this group showed any marked degree of amblyopia (table 2 ) . In 80 percent of the cases, the vision was equal (20/20 or 20/30) in both eyes or there was but one line of difference on the Snellen chart; 13 percent had two lines of difference; and another seven percent showed three or more lines of difference. The visual acuity in the amblyopic eyes of most of these patients improved as the eyes became straight. In most cases this improve­ ment occurred without the benefit of or­ thoptic training, whereas others required patching of the fixing eye. Only three pa­ tients retained an amblyopia of 20/50 or less despite improvement in the angle of squint. REFRACTIVE ERROR

Under atropine all of the patients, with but one exception, had hyperopia greater than one diopter (table 3) ; 23 percent of them TABLE 3 REFRACTIVE ERROR*

Refractive Error Oto +1.00 + 1.2S t o + 2 . 0 0 +2.25 t o + 3 . 0 0

N u g b g of 1 9 12 22(29.7%)

+3.25 t o + 4 . 0 0 +4.25 t o + 5 . 0 0

20 16 36(48.7%)

Other +5.00

16(21.6%

) * Cases of astigmatism were included by using their spherical equivalents.

had astigmatism of one diopter or more and were included in the total statistics by using their spherical equivalents. Of these cases, 48.7 percent had hyperopia between 3.25 and 5.00 diopters, while 29.7 percent showed a greater, and 21.6 percent a lesser refractive error. Three patients had anisometropia greater than 2.75 diopters. There was no relationship between the amount of hyper­ opia and the degree of strabismus. NEAR-POINT OF CONVERGENCE

It is interesting that 42 percent of the pa­ tients had a near-point of convergence more remote than 29 mm. It would seem that this is a large percentage in a group of cases with convergent strabismus. Nevertheless, the near-point had no relation to the progress of the condition and patients with a more re­ mote near-point did as well as those whose near-point was unlimited. FUSIONAL STATUS

As one would expect, the patients in this group showed a very high degree of fusion as compared to other types of convergent strabismus (table 4 ) . In every case where the retinal correspondence was determined it was normal. When possible, the major amblyoscope was used and 47.3 percent showed first, second, and third-grade fusion. Another 24 percent reported fusion with the Worth four-dot test although they were not examined with the amblyoscope; 9.4 percent appeared to have intermittent fusion; and only nine percent failed to show evidence of fusion by the tests used. TABLE 4 FUSIONAL STATUS

Amount of Fusion

Number of Cases

Per­ centage

First, second and third grade First and second or second and third grade Fusion with Worth 4-dot test Intermittent fusion No fusion

35

47.3

8 17 7 7

10.9 23 9.4 9.4

ESOTROPIA PROGRESS OF T H E CASES

The degree of strabismus varied a great deal among the cases. The patient with the smallest amount of strabismus measured orthophoria for distance and an intermittent esotropia of eight prism diopters for near, while the one with the largest amount of squint had an esotropia of 30 prism diopters for distance and an esotropia of 55 prism diopters for near. The majority, 45 cases, measured less than 35 prism diopters of eso­ tropia for near with the screen and prism test. In accommodative strabismus one would expect the amount of strabismus to be greater for near than for distance. This was true in all but eight patients. The most inter­ esting of these exceptions was a patient with an esotropia of 25 prism diopters for dis­ tance and orthophoria for near. After wear­ ing full hyperopic correction for two years and three months, this patient measured four prism diopters of esophoria for distance and orthophoria for near. Taken as a group, these patients responded promptly and well to their full corrections re­ gardless of the amount of squint. In some cases the strabismus was converted to eso­ phoria or orthophoria within two to three months, while in other cases it took over a year before the strabismus was fully cor­ rected. Since the response to the correction of refractive errors is so uniform only three examples will be given to show the typical course in the average case. CASE REPORTS CASE 1

A. S., aged four years, was first seen in May, 1950. At this time she had an esotropia of 20 prism diopters for distance and 50 prism diopters for near without correction. After wearing a +1.25 D. sph. C +1.0D. cyl. ax. 90°, O.U., for six months, the stra­ bismus was reduced to orthophoria for dis­ tance and a variable intermittent esotropia of about four prism diopters for near. Sixteen

193

months later, with hyperopic correction, she was orthophoric for both distance and near. CASE 2

M. C , aged four years, was first examined in May, 1949. He had an esotropia measuring 15 to 20 prism diopters for distance and near. After wearing his full correction, +4.5D. sph., O.U., for three months he was orthophoric with his glasses. CASE 3

J. M. was first seen at the age of five years. Her strabismus measured 30 diopters of eso­ tropia for distance and near. After wearing: R.E., +1.5D. sph. C +1.0D. cyl. ax. 90°; L.E., +2.0D. sph., for 11 months, her devia­ tion measured six prism diopters of eso­ phoria for distance and near with correction. Concurrent with the decrease in the de­ gree of squint, it was noted that whatever initial amblyopia was present frequently disappeared and many patients showed evi­ dence of an improvement in fusion. Im­ provement occurred in many patients without orthoptics or even patching of the fixing eye. Only three cases were felt to warrant or­ thoptic training, indicating that the great ma­ jority of these cases need only removal of the accommodative element in order to im­ prove. Corrective surgery was not performed on any of these patients. In seven patients, the strabismus for dis­ tance improved to orthophoria but a small amount of esotropia remained for near even after the patients wore their full corrections for some length of time. Bifocals were pre­ scribed for these children, with beneficial results. The bifocal prescribed is that amount with which the patient reads 20/30 on the Lebensohn chart. It could be as much as an add of +5.00 diopters. One child who originally measured 20 prism diopters of esotropia for both distance and near, wore a correction of + 3.00, O.U., for five months. He then measured ortho-

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STANLEY MASTERS

phoria for distance but still retained an esotropia of 12 prism diopters for near. H e was advised to wear bifocals and his esotropia for near was improved to esophoria of four prism diopters. W e believe that bifocals should be used only by patients whose glasses fully correct the esotropia for distance but who still have a small residual constant or intermittent eso­ tropia for near. The bifocal should be strong enough to correct the strabismus for near. The diameter of the segment must be large enough to be situated at the border of the pupil. T h e strength of the segment can gradually be diminished over a period of sev­ eral years. If the child is old enough, the orthoptist can treat him in an attempt to dissociate the faulty accommodation-con­ vergence linkage.

CONCLUSION

F r o m this study, it would seem that a case of convergent strabismus with the following characteristics has a reasonable chance of correction by nonsurgical means : 1. Onset between four and six years of age 2. Relatively equal vision in both eyes 3. Hyperopia under atropine between three and five diopters 4. Evidence of a well-functioning fusion faculty. 40 North Street (2). 667 Madison Avenue (21). We wish to acknowledge the help of Miss Dorothy Parkhill and Miss Leta Counihan of the Orthoptics Department in preparing this study.

TOXOPLASMOSIS* A REPORT OF T H E LITERATURE A N D C L I N I C A L STUDIES BASED ON FIVE CASES STANLEY MASTERS,

M.D.

Brooklyn, Neiv York INTRODUCTION

Since the early descriptions of toxoplasmo­ sis, many clinical and investigative reports have appeared concerning the disease. P r a c ­ tically all of these have given cognizance to the presence of ophthalmic pathologic condi­ tions. It is the purpose of this paper primar­ ily to review toxoplasmosis from the ophthal­ mic standpoint, to review the literature, 1 " 25 and to present five cases which had pre­ viously been undiagnosed. DISCOVERY

Nicolle and Manceaux, in 1908, demon­ strated the protozoan parasite, Toxoplasma, in the North African Gondi. Splendor, work* From the Department of Ophthalmology, The Long Island College Hospital.

ing independently, in the same year, de­ scribed the organism in the Brazilian rabbit. MORPHOLOGY

T h e organisms 2 are crescentric, oval, or pyriform in shape, and vary in size from two to seven microns in length and from two to four microns in width. T h e y may be pointed at the ends or one end may be blunted. T h e nuclear chromatin (there is no nuclear mem­ brane) stains deep purple and the cytoplasm, pale blue, with W r i g h t ' s stain. 14 I n fixed tis­ sues, the organisms appear smaller and rounder and may exhibit features in common with ultramicroscopic viruses. T h e organisms may occur in clusters forming cysts or pseudocysts. REPRODUCTION

Multiplication occurs by binary fission in the longitudinal axis and is possible only