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Constant Deviation in a Child after Surgery for Cyclic Esotropia | OMICS International
ISSN: 2165-7920
Journal of Clinical Case Reports
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Constant Deviation in a Child after Surgery for Cyclic Esotropia

Kadriye Erkan Turan*, Hande Taylan Sekeroglu and Ali Sefik Sanac
Department of Ophthalmology, Hacettepe University School of Medicine, Ankara, Turkey
Corresponding Author : Kadriye Erkan Turanco
Department of Ophthalmology
Hacettepe University School of Medicine
Ankara, Turkey
Tel: 90-312-3053133
Fax: 90-312-3094101
E-mail: [email protected]
Received September 25, 2014; Accepted December 10, 2014; Published December 12, 2014
Citation: Turan KE, Sekeroglu HT, Sanac AS (2014) Constant Deviation in a Child after Surgery for Cyclic Esotropia. J Clin Case Rep 4:467. doi:10.4172/2165-7920.1000467
Copyright: © 2014 Turan KE, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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A 28-month-old boy presented with a 3-week history of intermittent left esotropia with a 48 hour cycle. The decision to perform surgery was made after treatment with patching and full refractive correction of the hyperopia. Bilateral medial recession with recession of both inferior oblique muscles was performed. Follow up examination postoperatively showed that the cyclic pattern resolved but a constant esotropia occurred.

Cycli esotropia; Ophthalmology; Bilateral medial recession
Cyclic strabismus is an uncommon disorder, of unclear etiology, in which strabismus presents in an alternate day pattern [1-3]. Although technically an intermittent form of strabismus, cyclic strabismus differs from typical intermittent strabismus [4]. Cyclic esotropia has been reported more commonly than cyclic exotropia or cyclic vertical deviations, most cases occur in children [5,6]. Cyclic esotropia was first described by Costenbader and Mousel in 1964 [1]. Most common pattern is the 48-hour type, in which the eyes are straight one day and esotropic the next. It is not related to visual acuity, fatigue, accommodation, disruption of sensory fusion. A relation with the biological clock, the location of which is unknown, mechanism is suspected. If untreated, cyclic esotropia may progress to a constant deviation [7]. Surgical correction of the maximum deviation generally corrects the esotropia [2]. Treatment is based on the amount of the tropia measured on the strabismic days. After surgical correction, the deviation disappears and recurrence of esotropia is very infrequent [8].
Case Report
A 28-month-old boy presented at Hacettepe University Faculty of Medicine, Department of Ophthalmology with a 3-week history of intermittent left esotropia with a 48 hour cycle. The patient was otherwise healthy and neurologically normal. Orbit and brain magnetic resonance imaging was normal. He had not suffered from head trauma. There was no family history of strabismus or amblyopia.
At the first visit an orthophoria was noted with overacting inferior oblique muscles on ocular version testing (Figure 1A). We were unable to perform binocular vision tests at this visit. Anterior segment and fundus examination was normal. Cycloplegic refraction was +3.50 in each eye. After 1 week, the patient was seen again. The patient had an esotropia of the left eye of 20° with a clear V-pattern and overacting inferior oblique muscles (Figure 1B). He was treated with 2 hours patching of right eye and full refractive correction of the hyperopia. Bimonthly examinations for the next 8 months revealed the same results and the decision to perform surgery were made.
A 5.5 mm Bilateral Medial Recession (BMR) with recession of both inferior oblique muscles was performed. Follow up examination 4 months postoperatively showed that the cyclic pattern and the bilateral over elevation in adduction and V-pattern resolved. Uncorrected visual acuity was 20/125 in both eyes, improving to 20/25 with refraction (+3.00 spheres bilateral). The patient had an esotropia of the left eye of 12 prism dioptri (pd) with hyperopic correction and 15 pd without correction at all distances (Figure 1C). Fusion was demonstrated at near on Worth 4-dot testing, and the patient achieved 400 seconds of arc of stereopsis on Titmus stereo test. The patient was followed for 18 months, and there were no significant clinical changes.
Cyclic strabismus differs from typical intermittent strabismus in that a significant heterophoria is not present during the orthotropic phase [4]. The etiology and pathogenesis of this rare form of strabismus are unknown [1-3]. However, it is rarely associated with optic atrophy, trauma, strabismus surgery, retinal detachment surgery, or central nervous system disease [7,9-11].
Cyclic esotropia is typically spontaneous with an average age of onset of 3 to 4 years. The cyclic nature of the strabismus may last from a few weeks to years [4]. The fusion and binocularity are usually defective on the strabismic days; in contrast it remains normal during the straight days [12]. Binocular vision is not absolutely necessary because the disorder has also been reported in patients with monocular blindness [5,10,13]. Bilateral over-elevation in adduction and V-pattern are common in cyclic esotropia [14]. Surgery is almost always curative for the condition, however, recurrence of cyclic esotropia and consecutive cyclic exotropia after surgical correction have been reported [2,11,15,16].
We present a well-documented case who was treated with bilateral medial recession and recession of both inferior oblique muscles for cyclic esotropia. After surgery, fusion was present and, the V pattern and over elevation in adduction were resolved, but esotropia became constant with smaller angle. Cyclic esotropia is a rare and poorly understood form of strabismus. There is no response to conservative treatment. The cycles become irregular in time until the deviation becomes constant. Although successful results of muscle surgery have been highlighted in the literature, surgical correction for cyclic esotropia may not correct the problem and may result in constant esotropia.
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