Further Outpatient Care
The infant typically is seen 3-14 days after the surgery. Visual acuity is checked, an afferent pupillary defect is ruled out, and a good red reflex is elicited from both fundi. Furthermore, conjunctival incisions are inspected with a penlight for dehiscence and infection. Most importantly, alignment is assessed, and eye movements are observed for gross underaction and a slipped muscle. If no excessive inflammation is noted, use of antibiotic-corticosteroid ointments may be stopped at this time.
Surgical correction is the first step in the visual rehabilitation of children with infantile esotropia. Patients who are aligned successfully early in life still need careful postoperative monitoring for amblyopia, nystagmus, inferior oblique overactions, dissociated vertical divergence, and accommodative esotropia.
A follow-up visit usually is scheduled 3-4 months after the initial postoperative consult. At this point, occlusion therapy can be restarted if amblyopia is present. In cases of significant overcorrection or undercorrection, while the patient may be seen earlier, reoperations seldom are performed before the third to fourth month postoperative period. If alignment is optimal (eg, within 8 PD of orthophoria) and acuity is equal in both eyes, subsequent follow-up visits are scheduled every 6-12 months until age 7 years. At this point, the risk of strabismic amblyopia is decreased, and yearly visits are sufficient. After age 10, consultations are performed on an as-needed basis.
Accommodative esotropia may develop following surgical correction of infantile esotropia. In a study by Uretmen et al, it was noted that accommodative esotropia occurred at a mean of 8.8 months (range, 6-24 mo) after the initial surgical alignment, with a mean age of onset of 43.2 months. [35] Correction with the appropriate lenses must be instituted to prevent the adverse effects of accommodative esotropia on sensory and motor functions.
Inpatient & Outpatient Medications
Aside from the antibiotic-steroid ointment used in the immediate postoperative period, no other medications are needed.
Complications
Complications of initial surgical correction of infantile esotropia include the following:
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Marked overcorrection and undercorrection
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Infection
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Scleral perforation
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Foreign body granuloma at the suture site
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Allergic reaction to suture material
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Conjunctival inclusion cyst
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Conjunctival scarring
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Anterior segment ischemia
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Change in eyelid position
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Lost muscle
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Slipped muscle
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Oculocardiac reflex
Prognosis
It is accepted that better ocular alignment and visual prognosis can be achieved if surgical correction is performed before age 2 years. Long-term follow-up studies on esotropic infants who underwent surgical alignment by age 2 years have shown that close to 60% achieve a small angle (< 20 PD) cosmetically acceptable strabismus. Although some binocular vision is achieved, it generally is subnormal, often involving peripheral fusion. Factors contributing to poor ocular alignment and visual prognosis include persistent preoperative amblyopia, latent manifest nystagmus, and myopia from -2.5 to 5.0 D.
Patient Education
Parents and other caregivers must be educated on the various presentations of infantile esotropia to ensure early detection and management.
