Indian Journal of Ophthalmology

: 2008  |  Volume : 56  |  Issue : 2  |  Page : 168--169

Author's reply

Mihir Kothari 
 Department of Pediatric Ophthalmology and Strabismus, Bombay City Eye Institute and Research Centre, 5 Victor Villa, Babulnath Road, Mumbai - 400 007; Jyotirmay Eye Clinic for Children and Squint, 205 Ganatra Estate, Pokhran Road No 1, Khopat, Thane West - 400 601, Maharashatra, India

Correspondence Address:
Mihir Kothari
Jyotirmay Eye Clinic, 205 Ganatra Estate, Pokhran Rd 1, Khopat, Thane (W) - 400 601, Maharashatra

How to cite this article:
Kothari M. Author's reply.Indian J Ophthalmol 2008;56:168-169

How to cite this URL:
Kothari M. Author's reply. Indian J Ophthalmol [serial online] 2008 [cited 2020 Jul 9 ];56:168-169
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Full Text

Dear Editor,

We thank Pandey et al . for their interest and comments. [1] We request the readers to refer to our reply to the letter to editor [2] where they will find some clarifications.

We have encountered accommodative esotropes presenting with spontaneous late-onset comitant esotropia. However, our study was to report clinical characteristics of spontaneous late-onset comitant acute non-accommodative esotropia in children (ANAET). We included only those patients in whom atropine-based refractive correction did not significantly reduce esotropia and the esodeviation did not increase more than 10 prism diopter for near. There are several recent studies [3],[4],[5] that report ANAET as a common cause of esotropia (second only to accommodative esotropia) confirming our perception of the high incidence of ANAET as real. Accommodative component can play a significant causative role in esotropia and needs to be ruled out in every esotrope and should not be confused with ANAET.

We certainly caution the clinicians to be aware of an underlying neurological lesion in patients with ANAET. There is one subtype mentioned in our article (Type 5 of ANAET) where ANAET is caused by a central nervous system (CNS) lesion. A careful neuro-ophthalmic and systemic neurological examination is mandatory. However, in the absence of any systemic or ocular neurological sign, in the presence of a long history of strabismus and in the absence of other ocular features we do not recommend routine neuroimaging for every patient with ANAET. The positive predictive value of having a CNS lesion with isolated ANAET is very low. A study by Simon et al. , quoted by the readers states, if no other neurological signs are present, underlying intracranial disease is unlikely. The case mentioned above by the readers was an obvious case for neuroimaging as the patient had skew deviation.

It is advisable for those who are fraught with the dangers of missing an underlying neurological lesion to know the Good Clinical Criteria [6],[7] for use in the selection of those patients with ANAET who require immediate neuroimaging. Use of the mnemonic, DON'T PANIC would be useful in systematic analysis of the problem and analysis of the seriousness of the situation. [8]

History Examination

D = Diplopia P = Papilledema

O = Ophthalmic symptoms A = Anisocoria

N = Neurological symptoms N = Nystagmus

T = Trauma I = Incomplete visual Fields

C = Corneal Hypaesthesia

We do not check the divergence amplitudes of patients with manifest esodeviation. It does not help in the diagnosis or treatment. Cycloplegic refraction and ocular deviation for near and distance are already mentioned; [9] AC/A ratio and anisometropia can be easily calculated. None of the patients had high AC/A ratio and anisometropia >1.25 diopter, this is mentioned in the results section. [9] Evaluation of binocular single vision was possible in some patients. [9] Possibility of decompensation of a preexisting microtropia is mentioned but it could have been confirmed only by demonstrating the preexisting absence of bifoveal fusion.

We are aware of the limitations of photographic evidence in the evaluation of the ocular alignment. Nevertheless, once the esotropia is manifest, what sign can a clinician rely on to confirm prior absence of esotropia other than the medical history from the parents and photographic evidence? Whenever possible we elicited the history from the individual parents separately and looked at several photographs taken at different ages, time and eye positions.

The classification that we mentioned using the term ANAET was based on the reports of several investigators. [8] Nevertheless, ANAET is neither a new term coined by us nor should it confuse the clinicians. The term ANAET was in use previously. [3],[10],[11] We found the term useful and descriptive and would not mind taking the credit for making it popular.


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