Esotropia caused by low-dose atropine for rapidly progressive myopia in a 15-year-old boy

Aman S, Guyton DL

JAAPOS 2025:29:104122

Review: In the current myopia pandemic, this case report caught my eye. A 15-year-old myopic boy had been prescribed increasing concentrations of atropine drops to slow myopia progression. This started at 0.01%, but increased to 0.05%, then to 0.1% and finally to 0.2%. He had grown accustomed to taking his glasses off to read. Nine months after starting the 0.2% preparation he developed a comitant esotropia with diplopia. A CT head scan to eliminate sinister causes was normal.

The atropine was stopped, but the esotropia and diplopia persisted. He underwent bilateral medial rectus recessions, which successfully restored his orthophoria and stereopsis. Postoperatively, he was prescribed two pairs of glasses: one with full cycloplegic correction for far distance (right -8.50/+1.50x90, left -9.25/+1.50x80) and another for everyday wear. These were bifocals, with the top segment undercorrecting his myopia by 1.0D and the lower segment undercorrecting it by 2.50D. The authors postulate the esotropia developed for the same reason that early presbyopes, with increased effort to accommodate for near, tend to overconverge, resulting in loss of sarcomeres, shortening of the medial recti and eventual esotropia. Likewise, the increasing doses of atropine and the removal of glasses to read increased this patient’s accommodative effort and convergence tonus, both of which led to his esotropia.

Comment: This case highlights the possible unwanted consequences of increasing concentrations of low-dose atropine and of reading binocularly unaided in the presence of high myopia.

Comparative analysis of clinical features following inferior oblique recession surgery for unilateral congenital superior oblique palsy

Kang E, Ha S-G

JAAPOS 2025:29:104169

Review: In this paper, researchers compare the clinical features following inferior oblique recession surgery for unilateral congenital superior oblique palsy. They analysed the changes in hypertropia in primary position, in head tilt and in fundus excyclotorsion. The retrospective study included 81 patients with a mean age of 8.1+/-2.6 years (range 3-14) and with follow-up of at least 12 months (mean 15.4+/-2.2 months). Patients with a preoperative hypertropia in primary position of >20 dioptres were excluded from the study, as were cases of bilateral superior oblique palsy or those in which the aetiology was felt to be due to previous head injury, cerebrovascular disease, or neurological causes.

The mean surgical reduction of hypertropia in primary position was 77.3%, while that of head tilt was 57.6% and that of fundus excyclotorsion was 75%. The degree of reduction in hypertropia and excyclotorsion, which are both measured under dissociated conditions, were strongly correlated. The reduction in head tilt, which is measured under binocular conditions, was not. The authors concluded that inferior oblique recession for unilateral congenital superior oblique palsy was more effective at reducing the hypertropia in primary position and fundus excyclotorsion than the abnormal head tilt. The residual torticollis could reflect factors such as older age at surgery and residual sternocleidomastoid muscle tightness.

Comment: One of the main motivators to operate on this type of strabismus is to alleviate an abnormal head posture. Therefore, it is disappointing when there is residual torticollis, even if it is successful in reducing the hypertropia and excyclotorsion.

Baseline and outcome stereoacuity of children with anisometropic amblyopia undergoing dichoptic amblyopia treatment

Birch EE, Jost RM, Kelly KR

JAAPOS 2025:29:104116

Review: Unlike conventional amblyopia treatments, which primarily address the monocular visual acuity deficit, dichoptic treatments primarily address the binocular function and secondarily the improvement in visual acuity. A total of 185 children with anisometric amblyopia, aged 3–12 years, were pooled from eight separate randomised or pilot clinical trials assessing contrast-rebalance dichoptic treatments. The treatments utilised varying levels of contrast to the fellow eye to reduce suppression of the amblyopic eye by the fellow eye while subjects watched a video or played a game.

Better baseline stereoacuity and binocular function were associated with better baseline BCVA in the amblyopic eye, less suppression and anisometropia of <4.0 D. With the dichoptic treatment 84% of the participants had improved BCVA in the amblyopic eye, 43% had improved stereoacuity and 48% had improved binocular function. Greater improvement of outcome stereoacuity and binocular function was associated with better baseline stereoacuity, with more improvement in BCVA, with anisometropia of <4.0 D and with astigmatic anisometropia (compared to spherical or combined anisometropia). No significant differences in outcomes were found in children aged 3–6 vs 7–12, or between those without prior amblyopia treatment.

The authors concluded that dichoptic amblyopia treatment did not provide a significant advantage over previously reported traditional treatments, such as patching or Bangerter filters, in promoting binocular function or stereopsis.

Comment: This paper did not demonstrate that binocular dichoptic treatment for anisometropic amblyopia was superior to traditional amblyopia treatment in improving visual acuity or stereopsis. Until there is proven superiority, I would rather persevere with patching, which is inexpensive, doesn’t require a virtual headset (which makes social interaction impossible during treatment) and doesn’t risk inducing myopia with yet another digital device.

Dr Julia Escardό-Paton is a consultant in paediatric ophthalmology and strabismus with Eye Doctors and Te Whatu Ora Auckland Counties Manukau.