The Accommodative Element in Accommodative Esotropia

Purpose

To evaluate the effect of reducing the hyperopic correction on the state of binocular accommodative response in fully accommodative esotropia and to determine the “comfortable” amount of reduction in hyperopic correction.

Design

A cohort study.

Methods

Hyperopic corrections of children with a baseline refractive error of +1.50 to +5.0 diopters were gradually reduced in 0.50-diopter increments. Binocular accommodative ability was assessed by dynamic retinoscopy (monocular estimate method). Similar binocular accommodative responses were ascertained among patients with a baseline hyperopic correction of ≤3.0 of hyperopia and >3.0 of hyperopia, and patients were divided into two groups, group 1 (13 patients) and group 2 (18 patients), accordingly.

Results

After a reduction of 2.0 diopters in group 1 and 1.0 diopter in group 2, there was a decrease in accommodative response initially in the nondominant eye, accompanied by the dominant eye with a further reduction of 0.50 diopter. To overcome the bilateral accommodative lag, a reinstatement of a 0.50-diopter stronger hyperopic correction was required. Patients in group 1 tolerated a mean undercorrection of 2.37 diopters, and 77% were weaned from their spectacles. All of the children in group 2 were dependent upon spectacles at the completion of the study period. The final spectacle worn was a median of −1.67 diopters less than their full cycloplegic refraction.

Conclusions

A complete binocular accommodative ability seems to be a prerequisite for the establishment of “comfortable” hyperopic undercorrections. It does not seem to be a reasonable approach to consider further reductions in hyperopic correction in the presence of a bilateral decreased accommodative performance.