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Background: Acute acquired comitant esotropia (AACE) is a rare subtype of esotropia that occurs after infancy. The exact pathogenesis of AACE remains unknown with aetiologies ranging from benign conditions to serious underlying neurological diseases being reported. Given the elusive characteristic of AACE, diagnostic and management guidelines remain unclear. This systematic review aims to contribute to this field by summarising the risk factors for AACE reported thus far. Methods: A systematic review was conducted with papers found in CINAHL, MEDLINE, Cochrane library, PubMed databases and other sources. Eligible studies investigating the risk factors for, and clinical features of, AACE in children and young adults were critically appraised before relevant data were extracted and discussed via a narrative summary. Results: Twelve studies were included in the final review, of which six and eight papers reported on benign and non-benign risk factors for AACE respectively. Identified benign risk factors varied among studies, while non-benign risk factors were associated with intracranial pathologies, multiple sclerosis and head trauma. Conclusion: Given the low generalisability of study findings, no definitive conclusions can be drawn on the significance of each risk factor on AACE development. Further prospective research with more objective measurements of 'near work', larger sample sizes and control groups is required to better ascertain any cause-effect relationship, refine the diagnostic criteria for each AACE subtype and advise on appropriate management guidelines for AACE.

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CLINICAL RELEVANCE: Acute acquired comitant esotropia (AACE) is becoming increasingly common in young children. Understanding clinical characteristics and treatment outcomes can inform future practice. BACKGROUND: To evaluate clinical characteristics of myopic children and adolescents with AACE, and the outcomes of varying treatments. METHODS: A retrospective review of medical records was conducted to identify patients diagnosed with AACE and diplopia between 2016 and 2020. The duration of smartphone use, angle of deviation, refractive error, stereopsis, and treatment options were analysed. The motor outcomes were evaluated at the earliest 6-month postoperative visit (6-30 months), and orthotropia or esodeviation ≤10 prism dioptres (PD) was defined as success. Successful sensory outcomes were defined as the elimination of diplopia in primary gaze or the presence of stereoacuity. RESULTS: Twelve patients diagnosed with AACE were identified. Ages were between 9 and 19 years (15.6 ± 3.3 years). All patients showed convergent and comitant esotropia ranging from 12 to 40 PD at distance fixation that was nearly equivalent for distance and near fixation. The mean age at the initial visit was 15.6 ± 3.3 years. Post-treatment esodeviations were significantly lower at both distance and near compared to pretreatment (p < 0.001, for both). Eight patients required surgery and were treated with bilateral medial rectus muscle recession, two patients were treated with botulinum toxin, and two patients were followed with prismatic glasses. Nine of 10 patients (%90) treated with either surgery or botulinum toxin had successful motor and sensory outcomes. CONCLUSIONS: Surgery is the most efficient treatment option; botulinum toxin and prismatic glasses could be useful treatment options in patients who refuse to have surgery or for whom the amount of deviation is small and variable.

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PURPOSE: To compare the distance of the medial rectus muscle insertion to the limbus (DMIL) between patients with acute acquired comitant esotropia (AACE) associated with excessive digital device usage (EDDU) and exotropic patients. STUDY DESIGN: Retrospective study. METHODS: The medical records of 72 eyes of 44 patients with EDDU were retrospectively analyzed. The DMIL was measured from the anterior part at the midpoint of the medial rectus muscle insertion into the anterior limbus using a caliper after dissecting the medial rectus muscle with two control sutures at 12 o'clock and 6 o'clock. The DMIL in the non-fixation eye was compared between 44 patients with AACE and 23 patients with exotropia. RESULTS: The mean daily EDDU was 6.5 ± 3.1 h. The mean cycloplegic refractive errors (spherical equivalent: SE) were - 3.18 ± 2.52 diopters (D) OD and - 3.03 ± 2.42 D OS. The mean DMIL in the 72 eyes of 44 patients with AACE associated with EDDU was 4.30 ± 0.66 mm. The difference in DMIL of non-fixation eyes between 44 AACE patients and 23 exotropic patients was significant (4.28 ± 0.65 mm vs. 5.28 ± 0.50 mm, p < 0.0001). However, the SE in 44 non-dominant eyes of AACE was - 3.08 ± 2.56 D, significantly stronger than - 1.22 ± 1.93 D in the 23 exotropic eyes (p = 0.008). CONCLUSION: DMIL in patients with AACE associated with EDDU was significantly shorter. This anatomical anomaly may be an etiology of AACE associated with EDDU.

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BACKGROUND: Acute acquired comitant esotropia caused by prolonged near work, such as the use of digital devices, has been frequently reported in recent years. However, intracranial examination is necessary even for patients with nonparalytic comitant esotropia. Lhermitte-Duclos disease is a rare tumor that grows in layers in the cerebellum. Among those with this disease, cases of esotropia have been reported due to abduction limitation of the eye, but there have been no reports of comitant esotropia. Here, we report the case of a young woman with acute acquired comitant esotropia who was found to have Lhermitte-Duclos disease. CASE PRESENTATION: A 16-year-old Japanese female patient, whose ethnicity was Asian, was referred to our hospital for acute acquired comitant esotropia. Fundus examination revealed papilledema in both eyes, and magnetic resonance imaging of the head revealed a cerebellar tumor in the right cerebellum with obstructive hydrocephalus. She underwent partial tumor resection, and a histopathological diagnosis of Lhermitte-Duclos disease was obtained. However, comitant esotropia status remained unchanged, and she underwent strabismus surgery. Finally, diplopia disappeared completely. CONCLUSION: Neurological and intracranial imaging examinations are essential when acute acquired comitant esotropia is observed. Acute acquired comitant esotropia by Lhermitte-Duclos disease did not improve with partial tumor resection and required strabismus surgery, but good surgical results were obtained.

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Acute acquired comitant esotropia (AACE) is mainly characterized by sudden onset, accompanied by diplopia, without extraocular muscles paralysis or ocular motility disorders. In recent years, the incidence of AACE has been increasing, researchers have found that this phenomenon may be related to the widespread use of electronic devices and the increase in the number of people working from home during the COVID-19 pandemic. However, its neural mechanisms have not been fully elucidated. This article primarily reviews the latest developments in the diagnosis and treatment of AACE from the perspectives of etiology and treatment methods, aiming to provide direction for future in-depth exploration of the pathogenesis and treatment approaches of this disease.

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AIM: To investigate botulinum toxin A (BTXA) efficacy on small-angle (≤25Δ) acute acquired concomitant esotropia (AACE) in early-stage patients. METHODS: The electronic medical record data of AACE patients during March 2019 and June 2023 were collected in this retrospective and hospital-based cohort study. A total of 72 small-angle AACE patients received BTXA extraocular muscle injection. Patients were grouped by onset-to-treatment time (Group A: ≤6mo, Group B: >6mo). Deviation of esotropia, eye alignment and stereopsis were analyzed at the period of pre/post-injection (1wk, 1, 3, and 6mo). Orthophoria rate at 6mo (horizontal deviation <10Δ and binocular single vision) were considered as outcome index. RESULTS: There were no significant baseline differences (P>0.05) between two groups except onset-to-treatment time (2mo vs 11mo, P<0.001). Higher orthophoria rates were in Group A at last follow-up (94.74% vs 73.53%, P=0.013). Post-BTXA deviations of two groups at 1mo showed no difference (P>0.05); while in 3 and 6mo Group A was significantly smaller than group B (all P<0.001). No statistically significant differences were observed among all post-BTXA deviations of near and distance in Group A. In Group B, deviation at 3mo (near: 2Δ vs 0, P<0.001; distance: 4Δ vs 0, P<0.001) and 6mo (near: 6Δ vs 0, P<0.001; distance: 6Δ vs 0, P<0.001) was significant increased compared to deviation at 1wk after treatment. Group A showed better stereopsis recovery in last follow-up compared to Group B (80″ vs 200″, P=0.002). Both groups obtained improved stereopsis after treatment (Group A: 80″ vs 300″, P<0.001; Group B: 200″ vs 300″, P=0.037). CONCLUSION: BTXA is effective for AACE with small deviation (≤25Δ) in early stage. Delayed treatment (>6mo) may reduce BTXA efficacy. Early BTXA intervention benefits long-term eye alignment and stereopsis recovery.

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AIM: To explore the risk factors for acute acquired comitant esotropia (AACE). METHODS: A retrospective cohort study was conducted by analyzing 83 patients (case group) with AACE who underwent strabismus correction surgery from January 1, 2021 to June 30, 2022. Totally 73 outpatient volunteers were recruited during the same period as the normal control group. The case group's binocular vision time, near and distance esotropia angle, and near stereo vision function were recorded, and the age, gender, refractive status, and best-corrected visual acuity (BCVA) of both groups were analyzed. Additionally, multiple logistic regression analysis was conducted using an eye usage condition questionnaire to determine the independent risk factors for AACE. RESULTS: In the case group, 61 patients (73.49%) had myopia, with a mean equivalent spherical power (SE) of -3.35±3.31 D (range: +2.75 to -10.62 D) of the right eye and -2.87±3.35 D (range: +2.75 to -11.12 D) of the left eye. The average duration of diplopia in the case group was 29.83±35.72mo, of which 80 patients (96.39%) were primarily with distance diplopia. The near and distance esotropia angle after wearing glasses were 52.36±20.95 prism degree (PD) and 56.71±19.54 PD, respectively, and there was no statistically significant difference between the two (t=1.38, P=0.169). The incidence of improper glasses wearing and unhealthy eye habits in the case group was significantly higher than those in the control group (P<0.05). Close-up work without glasses [ß=2.30, odds ratio (OR)=10, 95% confidence interval (CI) 2.35-42.51, P=0.002] and near work in supine position (ß=1.80, OR=6.02, 95%CI 3.29-11.02, P<0.001) were independent risk factors for AACE. CONCLUSION: Patients with AACE mainly present with distance diplopia, and there is a high degree of variation in myopia. Near work without wearing glasses and in supine position are independent risk factors for AACE.

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Introduction: Acute acquired comitant esotropia (AACE) is an acquired strabismus with uncrossed sudden-onset diplopia due to esodeviation, comitant esotropia without accommodation factor, or paretic eye movement. The diagnosis of AACE entails differentiation from incomitant esotropia caused by abnormalities in the central nervous system. We present 2 pediatric patients with AACE as the first symptom of brainstem tumor. Case Presentation: The 2 patients were aware of their diplopia and had no other neurological abnormalities. There were no special findings in the anterior segment, ocular media, or fundus. Esotropia with a difference of no more than 10Δ between distant and near fixations was observed. Eye movements were normal, and Hess red-green test under prism neutralization did not reveal abduction restriction. The presumed cause of AACE in both patients was excessive use of digital displays, and brain magnetic resonance imaging (MRI) was performed to confirm the absence of neurological abnormality. Using MRI, a definitive diagnosis of AACE was made based on comitant esotropia associated with diffuse median glioma and medullary pilocytic astrocytoma without abducens nerve palsy. Conclusion: Although the incidence of AACE caused by brainstem tumors may be low, it is necessary to perform head imaging to confirm etiology. Furthermore, Hess red-green test under prism neutralization is considered important for the differentiation of abducens nerve palsy.

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Aim: To compare the long-term efficiency of botulinum toxin type A (BTXA) injection and surgery on acute acquired comitant esotropia (AACE). Methods: This retrospective study enrolled patients with AACE from January 2020 to August 2022. The horizontal angle of deviation pre- and post-treatment was measured. Deviations in BTXA and surgical treatment were compared. The BTXA group was divided into adequate treatment (AT) and inadequate treatment (inAT) subgroup based on the deviation of no more than 4 prism diopters (at near and distance) or temporary exotropia at the 2 week follow-up. The two subgroups were compared to determine the long-term efficacy of BTXA treatment. Results: Ninety-two patients with AACE were included. Follow-up was 6 months. The deviations of the surgery and BTXA group were significantly smaller at the 6 month follow-up than at pre-treatment (p < 0.001). The deviation before treatment in the surgery group was larger than in the BTXA groups (p < 0.001) but smaller at the 6 month follow-up (p < 0.001). The deviation was similar in the AT-BTXA and inAT-BTXA subgroups before treatment (p = 0.322 for distance and p = 0.051 for near) but smaller in the AT-BTXA subgroup at 6 month follow-up (p < 0.001 for near and distance). Conclusion: Surgery and BTXA successfully treat AACE. Surgery has a more precise and lasting therapeutic effect than BTXA. AACE patients adequately treated with BTXA and with deviations of no more than 4 prism diopters at 2 weeks follow-up had better outcomes.

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BACKGROUND: Acute acquired comitant esotropia (AACE) is an uncommon subtype of esotropia characterized by sudden and usually late onset of a relatively large angle of comitant esotropia with diplopia in older children and adults. METHODS: A literature survey regarding neurological pathologies in AACE was conducted using databases (PubMed, MEDLINE, EMBASE, BioMed Central, the Cochrane Library, and Web of Science) in order to collect data for a narrative review of published reports and available literature. RESULTS: The results of the literature survey were analyzed to provide an overview of the current knowledge of neurological pathologies in AACE. The results revealed that AACE with unclear etiologies can occur in many cases in both children and adults. Functional etiological factors for AACE were found to be due to many reasons, such as functional accommodative spasm, the excessive near work use of mobile phones/smartphones, and other digital screens. In addition, AACE was found to be associated with neurological disorders, such as astrocytoma of the corpus callosum, medulloblastoma, tumors of the brain stem or cerebellum, Arnold-Chiari malformation, cerebellar astrocytoma, Chiari 1 malformation, idiopathic intracranial hypertension, pontine glioma, cerebellar ataxia, thalamic lesions, myasthenia gravis, certain types of seizures, and hydrocephalus. CONCLUSIONS: Previously reported cases of AACE with unknown etiologies have been reported in both children and adults. However, AACE can be associated with neurological disorders that require neuroimaging probes. The author recommends that clinicians should perform comprehensive neurological assessments to rule out neurological pathologies in AACE, especially in the presence of nystagmus or abnormal ocular and neurological indications (e.g., headache, cerebellar imbalance, weakness, nystagmus, papilloedema, clumsiness, and poor motor coordination).

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Aim: This report aims to discuss and review the diagnosis and management of acute acquired comitant esotropia (AACE) in children and to add several cases to the limited literature available on this unusual condition in the pediatric population. Materials and methods: We present two cases of AACE with large-angle deviations that were investigated and followed-up according to current recommendations. Both cases required strabismus surgery for AACE, but different procedures were chosen, with good postoperative results. Results: Unilateral recession of the medial rectus and resection of the lateral rectus (R&R) were performed in one case and bilateral medial rectus (MR) recession in the other, with resolution of the diplopia and full recovery of binocular vision. Discussion: Although isolated AACE is usually benign, studies have reported the presence of intracranial disease in up to 10% of cases, making it a potential first sign of an underlying serious pathology. Therefore, AACE should be investigated as a medical emergency and neuroimaging should be performed in all patients with unclear onset of AACE, as well as in those with associated neurological symptoms, such as headache, cerebellar imbalance, weakness, or nystagmus. Conclusion: Acute acquired comitant esotropia (AACE) is an infrequent type of esotropia that usually appears in older children. It is characterized by esotropia and diplopia with acute onset. Neurological examinations and neuroimaging should be performed to exclude any potential intracranial disease. Treatment of AACE without underlying neurological disease is focused on managing the diplopia and resolving the esotropia. Strabismus surgery has good motor and sensory results and can successfully restore good binocular function. Abbreviations: AACE = Acute acquired comitant esotropia, LR = lateral rectus, MR = medial rectus, PD = prism diopters, R&R = recession and resection, BSV = binocular single vision, PAT = prism adaptation test.

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PURPOSE: The number of patients with acute acquired comitant esotropia (AACE) has been increasing in Japan. The purpose of this study was to investigate the changes in the number and characteristics of patients with AACE examined in our institution during a 12-year period. METHODS: We retrospectively reviewed the medical records of patients with AACE aged < 30 years who suddenly developed diplopia or esotropia and were examined in Hyogo College of Medicine Hospital from January 2008 to December 2021. We investigated the association of the yearly changes in the number of patients with the age category, refractive error category, AACE type, esotropia type, and use or nonuse of smartphones. RESULTS: The total number of patients with AACE was 171, and this number significantly increased each year (Pearson correlation coefficient, 0.9450; p < 0.0001). Significant increases were found among students in junior high school and beyond, patients with myopia, patients with Bielschowsky type AACE, and patients with basic esotropia (p < 0.0001 for all). We compared two age groups, elementary school students and below versus junior high school students and above, and found that the rate of increase was significantly higher in the junior high school students and above (estimate, 1.951; p < 0.0001), and the non-myopia group and myopia group and found that the rate of increase was significantly higher in the myopia group (estimate, 1.891; p < 0.0001). Excessive use of smartphones was confirmed in 82 of 133 patients, and the rate of the increase in the number of patients with AACE was significantly greater among patients with than without excessive use of smartphones (estimate, 1.098; p = 0.0009). CONCLUSION: This study confirmed a significant increase in the number of patients with AACE in recent years. The excessive use of smartphones may be associated with the increase in AACE.

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Purpose: To analyze surgical results of 32 cases with acute acquired comitant esotropia (AACE) related to prolonged use of digital devices (DDs). Patients and Methods: Medical records of cases with AACE related to prolonged use of DDs that had undergone surgery were retrospectively revised. Complete medical history and full ophthalmological examinations before and surgery were obtained for all cases. All cases also underwent neurological examinations using brain and orbital imaging. Motor success was considered as alignment within 10 prism diopters (Δ) at both near and distance. Sensory success was defined as stereopsis ≤60 arcsec. Nineteen cases (Group S) underwent surgery alone and 13 cases were treated with surgery and prism adaptation (Group S+P). Motor and sensory outcomes were compared between groups. Results: Mean age at first visit was 22.0 ± 9.0 years and mean daily use of DDs use was 6.3 ± 3.4 hours. Mean angle of preoperative alignment for distance and near were 26.5 ± 13.0Δ and 24.6 ± 16.4Δ, respectively. Surgery was performed at a mean of 23.3 ±3.5 years old and mean angle of alignment at final examination for distance and near were 5.8 ± 7.7Δ and 3.5 ± 5.7Δ, respectively. Final motor and sensory success rate were 84% and 53%, respectively. No significant differences in motor or sensory outcomes were evident between groups at initial or last visit. Conclusion: Favorable motor and sensory outcomes were achieved with surgical intervention with and without prism adaptation for AACT related to prolonged use of DDs.

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The management of acute acquired comitant esotropia (AACE) is controversial, and no clear guidelines exist to guide its treatment options. Therefore, the author proposes his idea that treatment options for AACE should be prioritized to achieve optimal outcomes with fewer potential complications for this type of esotropia. In this manner, treatment should be started with less invasive, muscle-sparing procedures while the patient is regularly checked for improvement in esotropia and diplopia. This is also a good scheme because the patient can go through vital neurological and ophthalmological assessments while he/she is spared from invasive interventions in the beginning.

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PURPOSE: This study investigated the possibility of neurological etiologies causing acute acquired comitant esotropia (AACE) and to evaluate the differences in clinical features between younger children, older children, and adults. METHODS: In this retrospective analysis, patients who had been diagnosed with AACE between July 2017 and June 2021 were included. Data on clinical findings, medical history, brain or orbital imaging, and ophthalmological and orthoptic examinations were retrieved from medical records and analyzed. Patients were divided into three groups based on their age: younger children (<10 years), older children (10-18 years), and adults (>18 years). RESULTS: Overall, 41 patients with AACE (15 females and 26 males) were examined. Most patients were children. Mild hyperopia was observed in children, while adults had moderate to high myopia. The mean angle of esotropia at a distance fixation was 43.57 ± 9.77, 51.54 ± 8.75, and 30.14 ± 12.39 prism diopters (PD) in younger children, older children, and adult groups, respectively. The mean angle of esotropia at a near fixation was 43.57 ± 9.37, 51.15 ± 9.39, and 31.43 ± 12.15 PD in younger children, older children, and adult groups, respectively. Significant differences were found in the mean angles of esotropia in patients with AACE at both near and far distances according to their age (all p < 0.001). Among 36 patients with previous neuroimaging data, none had AACE secondary to intracranial lesions. Over 2 years, five patients who were under continuous observation did not develop any neurological abnormalities. CONCLUSIONS: AACE was more common in children than in adults. The angle of deviation was larger in children than in adults. Coexisting or underlying neurological diseases were not present in patients with isolated AACE, which eliminated the need for neuroimaging. Continuous follow-up evaluations are warranted when signs of intracranial disease are observed in patients who have not undergone an imaging investigation.

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Previously reported cases of acute acquired comitant esotropia (AACE) with unknown etiologies have been reported in both children and adults. However, AACE can be associated with neurological disorders that require neuroimaging probes. The author recommends that clinicians should perform comprehensive neurological assessments to rule out neurological pathologies in AACE, especially in the presence of A or V pattern esotropia, nystagmus, or abnormal ocular and neurological indications (e.g. headache, cerebellar imbalance, weakness, nystagmus, papilloedema, clumsiness, and poor motor coordination).

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Purpose: To compare the success rate of extraocular muscle surgery and botulinum toxin injection for treatment in patients with acute acquired comitant esotropia (AACE). Patients and Methods: This is a retrospective cohort study in which we treated 34 patients of AACE with botulinum toxin compared with 80 patients who had been treated with surgery. The data included angle of deviation in prism diopter (PD) at baseline and one, three, and six months after treatment. The main outcome was the success rate in each treatment group. Results: In the surgery group, mean esodeviation angles at baseline and one, three, and six months after treatment were 50.8 ± 18.3 PD, 4.9 ± 8.3 PD, 4.6 ± 9.5 PD, and 5.5 ± 10.3 PD, whereas those in the botulinum toxin group were 51.2 ± 14.3 PD, 13.9 ± 17.4 PD, 22.0 ± 19.3, and 31.3 ± 23.8 PD, respectively. There was a statistically significant difference in the deviation angles between the two groups (p < 0.001). The success rate in the surgery group at one, three, and six months was 81%, 84%, and 79%, whereas that in the botulinum toxin group was 50%, 27%, and 27%. Conclusion: Botulinum toxin injection was not as effective as conventional extraocular muscle surgery in AACE patients. However, the treatment is safe, fast-acting, and improves both cosmetic appearance and quality of life. This may be considered as a chance for patients not preferring surgery.

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PURPOSE: To compare the surgical amount of unilateral medial rectus recession and lateral rectus resection (RR) in patients with acute acquired comitant esotropia (AACE) versus common forms of esotropia and to provide dose-response reference for surgical planning in AACE. DESIGN: Retrospective study. PARTICIPANTS: Consecutive patients who underwent unilateral RR for AACE or common forms of esotropia correction from January 2018 to January 2022. Only patients who achieved motor and sensory success with a minimum follow-up of 3 months were analyzed. METHODS: Group differences in the amount of medial rectus (MR) recession and lateral rectus (LR) resection were analyzed using multivariate regression models. Surgical dose responses in AACE were analyzed using multivariable regression models. Regression models were performed with and without adjustment for clinical confounders. Piecewise analysis was used to detect segmented results. MAIN OUTCOME MEASURES: Group difference in surgical amount and dose responses of unilateral RR in AACE. RESULTS: Fifty-four patients with AACE and 98 patients with common forms of esotropia were included. To correct comparable deviations, surgical amount performed was significant larger in AACE patients, with the adjusted group differences of 0.49 mm (95% confidence interval [CI], 0.34-0.65 mm; P < 0.001) in MR recession and 1.68 mm (95% CI, 1.25-2.11 mm; P < 0.001) in LR resection in patients with deviation < 40 prism diopters (Δ) and with a group difference of 1.22 mm (95% CI, 0.76-1.68 mm; P < 0.001) in LR resection in those with deviation ≥ 40 Δ. In AACE patients, in the adjusted model taking into account the intercept, dose responses of MR recession and LR resection in patients with deviation < 30 Δ were 5.11 Δ/mm (95% CI, 0.98-9.23 Δ/mm; P = 0.02) and 2.51 Δ/mm (95% CI, 0.57-4.45 Δ/mm; P = 0.02), respectively, and for those with deviation ≥ 30 Δ, the dose response of additional LR resection was 5.48 Δ/mm (95% CI, 4.56-6.40 Δ/mm; P < 0.001) to correct remaining deviation beyond 30 Δ. CONCLUSIONS: These findings provide quantitative evidence that augmented-dose unilateral RR should be performed in AACE for favorable surgical outcomes. The new surgical dose calculation proposed provides reference for surgical planning. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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AIM: To investigate the effects of micro-injection of botulinum toxin A (BTXA) on acute acquired comitant esotropia (AACE). METHODS: A total of 33 AACE patients who underwent BTXA micro-injection at Renmin Hospital of Wuhan University from September 1st, 2019 to July 1st, 2021 were retrospective analyzed. Esotropia, eye alignment, stereopsis, and complications were examined at baseline (except complications), 1wk, 1, 3, and 6mo after injection. RESULTS: The average angle of deviation before injection was (+20.24±6.80)Δ at near and (+24.76±6.43)Δ at distance, while (+5.15±5.85)Δ at near and (+7.30±6.17)Δ at distance 6mo after treatment (P<0.05). Six months after injection, the stereopsis of patients had improved. The number of patients having no stereopsis (>800 seconds of arc) decreased from 11 to 3. The number of patients having peripheral stereopsis (300-800 seconds of arc), macular stereopsis (70-200 seconds of arc) and central concave stereopsis (≤60 seconds of arc) increased from 10 to 11, 10 to 12, and 2 to 7, respectively. At the follow-ups at 1wk, 1, 3, and 6mo after injection, success rates were 96.97%, 96.97%, 93.94% and 87.88%, respectively. One week after injection, two patients (6.07%) showed subconjunctival hemorrhage; three patients (9.09%) showed limited eye movement and one patient (3.03%) showed mild vertical strabismus. All the symptoms disappeared by the final follow-up. CONCLUSION: Micro-injection of BTXA can reduce diplopia and improve binocular vision function of AACE patients. Furthermore, the operation is relatively safe with few complications, making it an ideal treatment modality for AACE.

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BACKGROUND: Acute acquired comitant esotropia induced by excessive digital device usage, especially smartphones (SAACE), has been increasing over the past few years. One suggested mechanism is convergence spasm induced by excessive near work, with refraining from digital device use considered to be an effective method for decreasing the degree of esodeviation. However, if symptoms persist and are untreated over time, recovery becomes more difficult. The present study evaluated the effects of topical cycloplegics on persistent SAACE untreated for over 1 year. METHODS: Patients with sustained SAACE that was untreated for over 1 year were evaluated. Digital device usage was discouraged and a topical cycloplegic, 0.4% tropicamide, was prescribed at bedtime. After obtaining informed consent, the 14 out of 23 enrolled patients who agreed to eye drop administration were defined as the study group, with the others serving as the controls. After a 3-month follow-up, patients who elected to undergo surgery were analyzed as the surgery group. Changes in esotropia angles, stereoacuity and diplopia complaints were evaluated after a 3-month follow-up. RESULTS: Esotropia angles decreased and stereoacuity improved after a 3-month treatment in the study group (P < 0.01). Diplopia disappeared in 13 patients (92.9%, totally disappeared or disappeared when using glasses with built-in prisms). Among 11 patients with untreated esotropia ranging from 1-3 years, decreases in esotropia angles were correlated to untreated esotropia duration (near: R = -0.6; distance: R = 0.7; both P < 0.05). Esotropia angles in the control group exhibited a tendency to increase while stereoacuity tended to deteriorate after the 3-month follow-up. As diplopia did not disappear in any patients, 7 elected to undergo surgery and were enrolled as the surgery group. While esotropia angles decreased in the study group, they were lower than the surgery group (P < 0.01), but higher than the control group (P < 0.01). Stereoacuity was worse in the control versus the study and surgery groups (both P < 0.05). CONCLUSION: Results suggest short-acting topical cycloplegics are effective in SAACE patients with long untreated periods. Decreases in esotropia angles were negatively correlated to untreated esotropia duration, which suggests the necessity of early treatment.

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