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Monofixation Syndrome Treatment & Management

  • Author: Balaji K Gupta, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Apr 27, 2016
 

Medical Care

Monofixation syndrome is often the desired result of strabismus surgery.

If a manifest strabismus is present, it is small and cosmetically acceptable.

Monofixation syndrome allows for a higher likelihood of diplopia-free long-term alignment.

Monofixation syndrome with esotropia of less than 8 prism diopters is more stable than monofixation syndrome with exotropia of less than 8 prism diopters.

Associated amblyopia

Treatment is given for any associated amblyopia in accordance with standard ophthalmic principles.

Amblyopia in children should be treated with appropriate spectacle correction. A careful cycloplegic refraction should be performed to check for anisometropia.

Occlusive patching or optical penalization should be considered as the clinical situation warrants. The amount of occlusive patching is dependent upon many factors, including age, density of amblyopia, and underlying etiology. In cases of mild amblyopia secondary to anisometropia, part-time occlusion may be all that is needed.

Optical penalization is a method of amblyopia treatment. Optical penalization relies on optically blurring the image of the preferred eye. The most common method relies on using atropine 1% ophthalmic solution in the preferred eye.

Decompensated monofixation syndrome

Older patients with monofixation syndrome may develop double vision if their fusional status decreases. This is termed decompensated monofixation syndrome.

This is less likely in patients treated earlier in childhood, those with no manifest strabismus, and patients with monofixation due to anisometropia.

Decompensated subjects have demonstrated worse horizontal fusional amplitudes, greater torsional fusional amplitudes, and a higher likelihood of having small vertical strabismus than patients with stable monofixation syndrome.[7]

In symptomatic patients, treatment ranges from correcting refraction, orthoptic exercises, prisms, and strabismus surgery. The majority of patients can be successfully returned to a monofixation state.

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Surgical Care

Heterotropia is cosmetically acceptable, so patients rarely need surgery. Monofixation syndrome tends to stabilize the alignment, thereby decreasing the need for further surgery, with over 90% of patients having stability of alignment over the first 2 decades of follow up.[2]

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Contributor Information and Disclosures
Author

Balaji K Gupta, MD Clinical Assistant Professor, Department of Ophthalmology and Visual Sciences, University of Chicago

Balaji K Gupta, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

J James Rowsey, MD Former Director of Corneal Services, St Luke's Cataract and Laser Institute

J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Sigma Xi, Southern Medical Association, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Gerhard W Cibis, MD Clinical Professor, Director of Pediatric Ophthalmology Service, Department of Ophthalmology, University of Kansas School of Medicine

Gerhard W Cibis, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Ophthalmological Society

Disclosure: Nothing to disclose.

References
  1. Tychsen L. Can ophthalmologists repair the brain in infantile esotropia? Early surgery, stereopsis, monofixation syndrome, and the legacy of Marshall Parks. J AAPOS. 2005 Dec. 9(6):510-21. [Medline].

  2. Ing MR. Roberts KM. Lin A. Chen JJ. The stability of the monofixation syndrome. Am J Ophthalmol. 2014 Jan. 157 (1):248-253. [Medline].

  3. Botet RV, Calhoun JH, Harley RD. Development of monofixation syndrome in congenital esotropia. J Pediatr Ophthalmol Strabismus. 1981 Mar-Apr. 18(2):49-51. [Medline].

  4. Kushner BJ. The Occurrence of Monofixational Exotropia After Exotropia Surgery. Am J Ophthal. Mar 13 2009. [Medline].

  5. Scott MH, Noble AG, Raymond WR 4th, Parks MM. Prevalence of primary monofixation syndrome in parents of children with congenital esotropia. J Pediatr Ophthalmol Strabismus. 1994 Sep-Oct. 31(5):298-301; discussion 302. [Medline].

  6. Cibis GW. Video vision development assessment in diagnosis and documentation of microtropia. Binocul Vis Strabismus Q. 2005. 20(3):151-8. [Medline].

  7. Siatkowski RM. The decompensated monofixation syndrome (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2011 Dec. 109:232-50. [Medline]. [Full Text].

  8. Hunt MG, Keech RV. Characteristics and course of patients with deteriorated monofixation syndrome. J AAPOS. 2005 Dec. 9(6):533-6. [Medline].

  9. Choi DG, Isenberg SJ. Vertical strabismus in monofixation syndrome. J AAPOS. 2001 Feb. 5(1):5-8. [Medline].

  10. Parks MM. The monofixation syndrome. Trans Am Ophthalmol Soc. 1969. 67:609-57. [Medline].

  11. Tomac S. Monofixation syndrome and anisometropia. Ophthalmology. 2002 Jan. 109(1):3-4. [Medline].

  12. Wright K. Visual development, amblyopia, and sensory adaptations. Pediatric Ophthalmology and Strabismus. St Louis, Mo: Mosby; 1995. 119-138.

 
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