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Controversies in ophthalmology
Controversy in the management of convergence excess esotropia
  1. A J Vivian1,
  2. C J Lyons2,
  3. J Burke3
  1. 1West Suffolk Hospital, Bury St Edmunds and Addenbrooke’s Hospital, Cambridge, UK
  2. 2British Columbia Children’s Hospital, Vancouver, Canada
  3. 3Royal Hallamshire Hospital, Sheffield, UK
  1. Correspondence to: Dr AJ Vivian

https://doi.org/10.1136/bjo.86.8.923

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    What is the clinical problem? Children with a significant esotropia for near but a smaller or no deviation for distance.

    What is the controversy? There are two treatment strategies. Patients may be managed either with optical correction (bifocal glasses) or with surgery.

    What are the important issues? Are we treating a homogeneous group? What are the objectives of treatment? What are the outcome measures? Is one treatment strategy more effective than the other? What are the complications of each treatment strategy? Can we create an evidence based treatment strategy?

    Much of the controversy that has arisen in the management of convergence excess esotropia results from differences in definition. A review of the literature reveals a number of studies concerning the management of convergence excess esotropia which are clearly dealing with different, although related, conditions. This makes comparison of outcomes difficult. The major difference in management is the use of optical treatment in North America (mainly bifocal glasses), whereas in Europe the same condition is more likely to be treated with surgery. Miotics are no longer used to treat this condition.

    The objective of this review is to determine whether there is evidence to suggest one form of treatment is more effective than the other. Does it depend on definition? Are some patients with convergence excess esotropia more effectively managed with optical correction and some with surgical correction? What are we trying to achieve with treatment and at what point do we concur that a treatment has been a success or failure? Does the method of bifocal management affect the outcome? Are some surgical strategies more effective than others?

    SETTING THE SCENE

    Convergence excess esotropia is a condition characterised by an esotropia which is greater for near fixation than for distance fixation. It was first described by Donders in 1864.1 Most consider that, …

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