intermittent esotropia pediatric - Eye & Vision Message Board

MDMc · 09-15-2003, 08:45 AM

I have a 7 yr old son who has been having intermittent esotropia (closest term that applies) for 4 years. He has had apx. 10 episodes of crossing that last for anywhere from a few hours to a few days. He has near perfect vision in both eyes whether they are crossed or not. He does though experience double vision while both eyes are open during the crossing times. There is no pattern or common circumstances during these episodes. He has had all the battery of tests (visual and brain scans), and they show nothing unusual.
We have seen several Ped. Opt. and all have said they have never seen this occurance in this manner.Most recently a former Chief of Ped. Opt. at Childrens Mercy Opt. Dept.
Has anyone ever heard of this? Seen this? We are trying to at least find another case of this so we can get ideas on prognosis, treatment, progression, etc.
Any help would be greatly appreciated.

Shaman · 09-15-2003, 04:12 PM

Your description actualy made me think of a few different possibilities. First off, you may have more luck searching for information using "acquired esotropia" which is what your son has. The treatments and outcomes for congenital and acquired esotropia are not always the same.

Just out of curiousity does your son have any sinus problems? Has he been screened for them? A couple of the "intermittent esotropia" cases I have read about were actually traced to sinus problems. When the sinus problem got bad the eyes would cross, when it was better, they would return to normal.

Another thing that came to mind was a decompensating phoria. Has your son been diagnosed with a phoria? Sometimes when children get older and more demands are made on there visual system for close work like reading and writing, a phoria that was previously controled will begin to decompensate. It doesn't happen overnight and at first it is intermittent.

The other thing that came to mind was "Cyclic Esotropia" Although cyclic esotropia usually has a 24 hr cycle, that is 24 hours straight, 24 hours crossed, there have been documented cases of cycles that are much different i.e.1 week, 3 months and variable. Cyclic esotropia is EXTREMELY rare, and most POs will go their entire careers and never see one single case. Of the two articles I found regarding this, one PO has passed away and the other retired a few years back. I did manage to pull up a couple of "personal stories", so I encourage you to read up on cyclic esotropia because some of them sound similar to your son.

Prognosis? Well, all intermittent tropias, exo or eso, tend to become more constant over the years. For some people it happens by the time the are in grade school, some as teens, and some later in life. Treatment? Since there is very little information out there on cyclic esotropia (if that is what it is) there is also a lot of contraversy about what should be done and when. Some POs believe that you should operate sooner rather than later when proper fusion is present during "straight" periods because over time the patient will begin to surpress the deviated eye to avoid double vision when the eye turns. Some POs think that press on prisms should be used during "turned" periods to avoid double vision and taken off during straight periods. Some say do nothing until the deviation becomes constant so that you will know what deviation to correct for.

I encourage you to contact Dr. David Guyton at John Hopkins in Baltimore, MD. He is THE authority on strabismus. He works exclusively with difficult and unusual cases. He may be willing to review your sons medical records and give his opinion as regards what to do. If I had such an unique case, Dr. Guyton is the person I would trust.

I hope that you find some answers. Also, just so you know, none of the cases that I pulled up turned out to be some awful undiagnosed disease. ALL of the parents expressed concerns that despite all of the tests their children had been through some horrible thing had been missed, but I couldn't find one instance where that was the case. I know this doesn't cure the strabismus, but I hope it helps to put your mind at ease a little regarding long term outcome!

MDMc · 09-16-2003, 10:14 AM

Thank you so much for your reply.

As far as this being cyclic, we have not found any patterns. Some episodes last a few hours, some a few days. Between episodes can be a few days, or several months. His most recent crossing was a few days ago, and the time before that was 7 months ago. As of now the episodes are happening farther apart. I know that can (and probably will) change.
Acquired eso was one almost diagnosis, but was dismissed because they can't find any cause. ie: any syndrome, damage, etc. He did in fact aquire eso, but why, and why it comes and goes is the problem. It is intermittent, but not cyclic. Sudden, but not acute. Hurry up and wait

So far, no PO has wanted to do surgery, and I agree (at this time). I've tried to contact several PO's out of our area, to see if they have ever seen this, or anything similar. So far, the only response I've recieved is that they would have to examine him to form an opinion. Very frustrating as I am not able to travel thousands of miles for an office visit and exam....If I could find someone who has seen this, or even heard of this I would be willing to go anywhere. We are trying to exhaust all of our resources in our immediate area (a few hundred miles). I will contact John Hopkins, and Dr. Guyton. Hopefully they will be willing to help, or at least point us in the right direction.
Mentioning sinus problems did set off a light for me, as my son does have allergies, and is very nasaly, and "drippy" most of the time. I have told all POs this but none have said that this could be related. This I will pursue also.
My son has not been diagnosed with any phoria ( has not been diagnosed with ANYTHING, that's the problem!!!!

) All Dr.'s have had ideas, but with further testing become dumbfounded. His vision is near perfect in each eye (whether crossed or not) MRI was normal, no pattern or common circumstance. He doesn't fit for Duanes syn. any nerve palsy, Arnold Chiari I, nothing I or the PO's can find. It's like he's a little of this, some of that, a pinch of something else, but not enough to be this, or too much to be that.
We will be going to Childrens Mercy next week, and will push for retesting of everything, including MRI. I believe a lot can change over a few years, and will put my mind at ease as far as any neuro. problems that may exist. (After many late nights doing internet research, you read so many terrible things that MAY be the cause, your mind can get carried away!)
Thank you again for your reply. Any information could be helpful.

Shaman · 09-16-2003, 02:19 PM

If you are interested in pursuing the sinus aspect, Dr. Albert Biglan in Cranberry Township, PA is the one who has lectured on the connection between accute sinusitus and ocular motor dysfunction.

Although you don't think his case sounds like cyclic esotropia, your story sounds a whole lot like the stories told by other parents who ended up with that diagnosis to me. At first, cyclic esotropia has no pattern and eventually degenerates in to the "cycle". What sets these kids apart from "normal" acquired esotropia is that 1)they do not have high hyperopia i.e. their is little to no "accomadative" portion to the eso; little to no rx as opposed to rx of +6 or more you see in most acquired eso 2) They have no sensory defect, that is the have excellent fusion/binocularity on their straight days; "normal" acquired esos have binocular disfunction due to their sensory problems

Here's a short excerpt from a story I found:

My 7 year old developed strabismus...and soon thereafther noticed his right eye turning in occasionaly, and then more frequently. It is now in a pattern where his right eye will turn every other day, and both eyes are straight the other days. Our optometrist...found the following:
- low hyperopia - .5 diopter dry, 1.25 wet
- comitant intermittent alternating non-accomodative esotropia
- stereoscopic perception to 70 seconds of arc

Sound at all familiar? They did turn out finding a sinus component to the problem which they treated, and the strabismus went away. It did return and they started looking for other answers. Started a HUGE debate as to correct diagnosis i.e. continuing sinus problem, decompensated phoria or cyclic esotropia.

I hope Dr. Biglan is able to offer you some guidance regarding the need for further testing. Good luck.

Torre · 09-16-2003, 07:34 PM

I believe Dr. Guyton answers e-mails, too. Some digging on the net might turn up his address.

Torre