Acute acquired comitant esotropia of childhood: a classification based on 48 children

PURPOSE: To identify characteristics of pediatric patients who develop acute acquired comitant esotropia (AACE) with and without intracranial disease.

METHODS: We reviewed the charts of 48 children consecutively referred to the hospital with AACE during a 13-year period. Inclusion criteria were acute onset of comitant esotropia, available data on ophthalmologic, orthoptic and neurologic examinations. Children with neurological signs, AACE recurrence or hyperopia <+3 dioptres (D) underwent brain computed tomography or magnetic resonance imaging. Patients without imaging were followed.

RESULTS: In all, 48 cases were recorded. The mean age at onset was 4.7 years, being significantly higher among children with intracranial disease. Seven cause-specific types of AACE in childhood were identified: The acute accommodative (n = 15, 31%), decompensated monofixation syndrome or esophoria (n = 13, 27%), idiopathic (n = 9, 19%), intracranial disease (n = 3, 6%), occlusion related (n = 3, 6%), AACE secondary to different aetiologic disease (n = 3, 6%) and cyclic AACE (n = 2, 4%). Intracranial disease included hydrocephalus, pontine and thalamic glioma. Of the children with intracranial disease, 2 of 3 had no obvious neurological signs at onset. Four significant risk factors for intracranial disease were identified as follows: larger esodeviation at distance, recurrence of AACE, neuro signs (papilledema) and older age at onset (>6 years).

CONCLUSION: In a large case series of children with AACE and by review of literature, we identified seven cause-specific types of AACE. Intracranial disease was present in 6%, and four risk factors were identified to guide clinicians when to perform brain imaging. Findings suggest AACE of childhood to be differentiated from AACE of adulthood.