The influence of refractive error management on the natural history and treatment outcome of accommodative esotropia (an American Ophthalmological Society thesis).

Purpose: To evaluate the effect of refractive error management on resolution of accommodative esotropia, deterioration of accommodative esotropia, and the natural history of hypermetropia in accommodative esotropia.

Methods: Retrospective cohort study and nested case-control study of patients with accommodative esotropia untreated prior to diagnosis by the author. Eligibility criteria included esodeviation of >/=10 prism diopters (PD) on distance and near fixation on initial examination, hypermetropia, distance esodeviation <10 PD with full cycloplegic refraction correction on first follow-up examination, and at least 2 years of follow-up.

Results: The study included 285 patients with mean follow-up of 102 months. After age 7 years, mean annual decrease in hypermetropia was .24 D for patients wearing full cycloplegic refraction and for patients in whom hypermetropia was undercorrected by 1.00 D or more. Age at diagnosis (P < .0001), oblique muscle dysfunction (P < .0001), and abnormal distance-near relationship (P = .007) were associated with deterioration of accommodative esotropia. Of 51 patients with an intermittent abnormal distance-near relationship, 19 (37%) had increased hypermetropia on cycloplegic refraction, and prescription of the increased correction normalized the distance-near relationship.

Conclusions: The possibility that undercorrecting hypermetropia speeds its resolution is not supported by this study. Accommodative esotropia is usually stable, but younger age at diagnosis, oblique muscle dysfunction, and abnormal distance-near relationship are associated with deterioration. Undercorrection of hypermetropia can cause an abnormal distance-near relationship, which in turn can cause deterioration of accommodative esotropia. Aggressive undercorrection of hypermetropia should be pursued carefully, because the risk may outweigh the potential advantages.