Laser In Situ Keratomileusis for the

Treatment of Refractive Accommodative

Esotropia
Ofelia M. Brugnoli de Pagano, MD,1,2 Gabriela L. Pagano, MD2,3

Purpose: To demonstrate the effectiveness of refractive surgery with an excimer laser to correct hyperopia
and convergent strabismus caused by compensatory accommodation of refractive error.
Design: Prospective, interventional, noncomparative case series.
Participants: Forty-six eyes of 23 patients with hyperopia and fully or partially refractive accommodative
esotropia.
Methods: Patients were treated with an excimer laser and the LASIK technique between 2000 and 2010.
Main Outcome Measures: Preoperative and postoperative refractive spherical equivalent and ocular
alignment.
Results: Mean agestandard deviation [SD] was 2512.6 years. Mean hyperopiaSD was 3.671.28
diopters (D) before surgery and 0.210.59 D after surgery (P0.001). The mean angle of deviation without
correction was 21.0 prism diopters () before surgery and 3.7 after surgery (P0.001).
Conclusions: Refractive surgery with excimer laser is a promising option for the treatment of refractive
accommodative esotropia.
Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed
in this article. Ophthalmology 2012;119:159 163 2012 by the American Academy of Ophthalmology.

Patients with moderate hyperopia may seek treatment with
a convergent deviation produced by the increased accom-
modation needed to focus on the image. This strabismus can
be fully or partially corrected with glasses or contact lenses
to compensate for hyperopia. Without optical correction, the
eyes remain deviated.1 In partially or fully accommodative
esotropia, refractive surgery is another treatment option that
allows for the correction of both the hyperopia and strabis-
mus in a single procedure. This article presents a series of
23 hyperopic patients with fully or partially accommodative
esotropia treated with LASIK in whom full or partial ocular
alignment was achieved without the need for glasses or
contact lenses after surgery.
Patients and Methods
This prospective study included a total of 46 eyes of 23 patients
with hyperopia and fully or partially refractive accommodative
esotropia treated with an excimer laser and LASIK technique in
the Centrovision Mendoza Eye Clinic, Mendoza, Argentina, be-
tween 2000 and 2010. Patients with fully or partially refractive
accommodative esotropia, with or without previous strabismus
surgery, were included. Patients with partially accommodative
esotropia with at least 40% improvement of their angle of esotro-
pia with optical correction were included in the study. Individuals
younger than 10 years or with severe amblyopia (best spectacle-
corrected visual acuity [BSCVA] 0.2 in decimals) were ex-
cluded. Other exclusion criteria were nonaccommodative strabis-
mus, paralytic strabismus, presence of systemic or local pathologic
features interfering with the corneal repair process, presence of
active posterior segment pathologic features and neuromuscular
disorders, and an estimated postoperative corneal curvature of
more than 48 diopters (D). All patients wore either glasses or
contact lenses to achieve partial or total orthophoria.
Written informed consent was obtained from all subjects or
their guardians before surgery. This study was approved by the
Institutional Review Board of the Centrovision Mendoza Eye
Clinic and adhered to the tenets of the Declaration of Helsinki.
Twenty patients underwent conventional LASIK and 3 patients
underwent wavefront-guided LASIK to correct the refractive de-
fect. All surgeries were performed by the same surgeon (OMBdP)
on both eyes simultaneously to minimize the disruption of binoc-
ularity. All procedures were performed with the use of topical
anesthesia. The target correction of refractive surgery was em-
metropia or the maximum tolerated cycloplegic refraction (maxi-
mum tolerated hyperopic correction that would not decrease dis-
tance visual acuity [VA] when the patient was not cycloplegic).
The superior hinged flap was created using a Moria M2 micro-
keratome (Moria, Antony, France). The lasers used were the VISX
S2 Star Smoothscan (Abbott Laboratories, Inc., Abbott Park, IL)
between 2000 and 2004 and the VISX S4 Wavescan Wavefront
(Abbott Laboratories, Inc.) between 2004 and 2010. Treatment
centration was achieved by self-centration of the patient and the
eye tracker. Corticosteroid and antibiotic eye drops were admin-
istered in combination both before and after surgery.
Patients were evaluated according to a protocol that included
preoperative and postoperative uncorrected visual acuity (UCVA) and
BSCVA, automatic keratometry, objective refraction (spherical

2012 by the American Academy of Ophthalmology ISSN 0161-6420/12/$see front matter 159
Published by Elsevier Inc. doi:10.1016/j.ophtha.2011.07.003
 Ophthalmology Volume 119, Number 1, January 2012
equivalent [SE]) with an automatic refractor with and without cyclo-
plegia (cyclopentolate hydrochloride 1%), subjective refraction, cor-
neal topography with Orbscan II (Bausch & Lomb, Rochester, NY)
before and after surgery, and ultrasonic and optical corneal
pachymetry. Aberrometry (Custom Vue, VISX; Abbott Laboratories,
Inc.) was performed in 17 patients. Postoperative assessment was
performed 1 month after surgery and every 6 months afterward.
A detailed sensorial eye evaluation was performed before and
after refractive surgery (synoptophore, red-glass test, Bagolini
striated glass). Stereopsis was evaluated using the Random Dot
Stereo Butterfly (Stereo Optical Co., Inc., Chicago, IL) with
glasses before LASIK and without correction afterward. Ocular
alignment was assessed using prisms and cover testing in all 9
gaze positions both before and after surgery. The angle of stra-
bismus was measured in prism diopters (). The accommodative
convergence-to-accommodation ratio was measured using the gra-
dient method. The protocol included a photographic register of the
preoperative ocular deviation with and without optical correction
and the ocular alignment achieved without correction after surgery.
Sensorimotor evaluation was performed after surgery at 1 month
and then annually. Fourteen patients (65.2%) had undergone pre-
vious strabismus surgery in infancy, 1 had been treated with
botulinum toxin, and 8 had no previous surgeries.
Statistical assessment of the data was performed using Excel
2007 (Microsoft, Redmond, WA). Hyperopia and esotropia mea-
surements were subjected to paired t tests. A P value of less than
0.01 was considered statistically significant. Statistical analyses
were performed using a confidence level of 99%.
Results
Twenty-three patients (46 eyes) were included in the study. Patient
results are summarized in Table 1 (available at http://aaojournal.
org). There were 14 females and 9 males. Mean agestandard
deviation (SD) was 2512.6 years, ranging from 11 to 52 years.
Nine patients from this series were younger than 16 years. After
laser surgery, the meanSD follow-up was 3.372.62 years,
ranging from 6 months to 10.5 years.
MeanSD hyperopia was 3.671.28 D before surgery,
0.020.65 D at the 1-month postoperative evaluation
(P0.001), and 0.210.59 D at the final evaluation (P0.001; Fig
1). MeanSD correction of hyperopia was 3.691.35 D (Fig 2).
The spherical equivalent differed significantly between the
1-month evaluation and the final evaluation (P0.001), with a
mean hyperopic regression of 0.230.40 D at the final evaluation.
Ocular alignment improved without optical correction in all
patients. The meanSD angle of deviation at near vision without
Figure 1. Graph showing preoperative versus postoperative spherical
equivalent in all eyes.
160
Figure 2. Histogram showing diopters of hyperopia corrected with LASIK
in all eyes. This figure demonstrates that in most eyes, hyperopia ranged
between 2 and 5 diopters.
correction was 21.08.1 before surgery and 3.74.5
(P0.001) after surgery (Fig 3). The mean difference between the
preoperative and postoperative deviation was 17.36.2 . Be-
cause this study included patients with fully or partially refractive
accommodative esotropia, the angle of deviation with correction
before surgery was a meanSD of 7.16.6 . In the group with
purely accommodative esotropia, orthophoria was achieved with-
out optical correction after surgery. Ocular alignment also was
achieved in the group with partially accommodative esotropia and
previous strabismus surgery. In the group with partially accom-
modative esotropia without previous strabismus surgery, 1 patient
with a residual nonaccommodative component of 15 esotropia
underwent muscle surgery afterward, and another patient with a
residual angle of 8 was satisfied with her ocular alignment.
In 10- to 18-year-olds, meanSD preoperative hyperopia was
4.081.34 D, and in those 19 years of age and older, it was
3.401.19 D (P0.01). MeanSD postoperative hyperopia at the
final evaluation in the younger group was 0.210.70 D and
0.160.58 D in the older group (P0.01). The meanSD angle of
deviation without correction before surgery was 2510 in 10- to
18-year-olds and 196 in older patients (P0.01). After sur-
gery, the meanSD angle of deviation without correction was
46 and 34 (P0.01) in the younger and older groups, respec-
tively. The differences between the 2 groups were not statistically
significant.
Mean UCVA improved after LASIK from 0.70.2 (in decimal
fraction; range, 0.051.0) before surgery to 0.90.1 (range, 0.2
1.0) after surgery (P 0.001). Mean preoperative BSCVA was
0.90.2 (range 0.21.0). Mean BSCVA at the end of the follow-up
Figure 3. Graph showing preoperative versus postoperative ocular align-
ment in prism diopters without optical correction in all patients. ET
esotropia; Pre-op preoperative; Post-op postoperative.
 Brugnoli de Pagano and Pagano Refractive Surgery in Accommodative Esotropia
Figure 4. Bar graph showing change in decimal lines of best spectacle-
corrected visual acuity (BSCVA).
period was 0.90.1 (P 0.012), indicating a tendency toward
higher VA, but the difference was not statistically significant. The
BSCVA improved in 15 (32.6%) of 46 eyes, was unchanged in 26
(56.5%) eyes, and decreased in 5 (10.9%) eyes. Of the 15 eyes
with improved BSCVA, 11 eyes gained 1 line, 2 eyes gained 2
lines, and 2 eyes gained 3 lines. Each of the 5 eyes with decreased
BSCVA lost 1 line (Fig 4). Mean BSCVA before surgery was
0.90.2, and mean UCVA after surgery was 0.90.1, indicating
that patients could forego optical correction.
Eight patients (34.8%) in the series did not have stereopsis
before surgery or after surgery. Of the 15 patients who had
stereopsis, 9 (60%) showed no change in stereoacuity; 5 patients
(33.3%) gained between 660 and 200 seconds of arc, and 1 patient
(6.7%) lost 60 seconds of arc of stereoacuity.
There were no intraoperative or postoperative complications.
There were no infections, decentered ablations, halos, glare, haze,
or unexpected refractive outcomes. None of the patients required
enhancement. All patients reported satisfaction with the functional
and aesthetic results.
Discussion
In patients with accommodative esotropia, partial or total
orthophoria can be achieved with glasses or contact lenses.
Glasses may be considered cosmetically unsatisfactory and
contact lenses may be tolerated poorly. Refractive surgery
performed to correct accommodative esotropia resulting
from hyperopia is well received by patients, freeing them of
the use of spectacles or contact lenses.
Accommodative esotropia appears most often in early
childhood, being more common after the age of 2 years. In
patients older than 20 years, the option of a refractive
procedure generally is accepted. In children, however, it is
a complex and controversial issue because the age at which
refraction becomes stable in hyperopic patients is not well
established.
There are some situations in which the refractive pro-
cedure should be considered in small children to avoid
significant amblyopia before it becomes irreversible. This
occurs most commonly in cases of severe refractive aniso-
metropia or corneal opacities.214 For accommodative es-
otropia, however, hyperopic LASIK is an elective procedure
to eliminate the need for optical correction.
The human eye undergoes changes in refraction with
growth. In hyperopic eyes, the corneal curvature becomes
stable at approximately 10 years of age, the axial length
becomes stable at approximately 11 years of age, and the
dioptric power of the crystalline lens becomes stable at
approximately 12 years of age.15,16 Based on these studies,
significant changes do not occur in the refraction of hyper-
opic patients with refractive accommodative esotropia after
the age of approximately 10 to 12 years.1518 In recent
years, the number of studies published on refractive proce-
dures in children and adults for accommodative esotropia
has rapidly increased.19 28
Visual Acuity Outcomes
Visual acuity outcomes were similar to those obtained by
other authors.20,2328 As expected, in this study, mean
UCVA improved after LASIK, and the patients could elim-
inate optical correction. The mean BSCVA increased
slightly, indicating a tendency toward increased VA. Hoyos
et al20 reported the results of hyperopic LASIK in 9 patients
with refractive accommodative esotropia. Mean UCVA im-
proved significantly, with no significant change in mean
BSCVA. In the study by Farahi and Hashemi,27 15% of 20
eyes lost 1 line of BSCVA, 10% gained 2 lines of BSCVA,
and 75% showed no change. In the current study, BSCVA
improved in 15 (32.6%) of 46 eyes, was unchanged in 26
(56.5%) eyes, and decreased in 5 (10.9%) eyes. Stidham et
al21 reported the effect of hyperopic LASIK on ocular
alignment and stereopsis in 24 patients with both purely and
partially refractive accommodative esotropia. In their study,
23% of the patients lost 1 line or more of BSCVA, which is
a higher rate than in the present study. Hutchinson et al,28 in
a study of 40 patients with purely refractive accommodative
esotropia treated with photorefractive keratectomy (PRK),
also reported a significant improvement in mean UCVA
from 0.5 before surgery to 0.8 after surgery with no change
in the postoperative BSCVA.
Refractive Outcomes
Refractive outcomes also were similar to those obtained by
most authors.20,2326,28 Hoyos et al20 reported a mean SE of
5.01 D before surgery and 0.06 D after surgery, but half of
the eyes required retreatment. In a study by Nucci et al,23
the mean preoperative SE was 3.7 D and the mean postop-
erative SE was 0.7 D. Sabetti et al25 reported a mean
preoperative SE of 6.46 D in a LASIK group and 4.60 D in
a PRK group (after surgery, plano and 0.17 D, respectively).
Hutchinson et al28 reported a mean preoperative SE of 3.06
D and a mean SE of 0.06 D at the end of a 3.4-year
follow-up period. In contrast, some authors reported higher
undercorrection rates.21,22,27 Stidham et al21 reported a
mean SE of 7.36 D before surgery and 2.1 D after surgery.
In the series reported by Phillips et al22 (15 patients between
9 and 18 years of age with fully or partially accommodative
esotropia), the SE was 5.35 D before surgery and 2.43 D
after surgery, showing an undercorrection rate of 34%.
Enhancement was required in almost half of the patients.
None of the patients in the current study required enhance-
ment in the 3.37-year follow-up period, in contrast to some
of the mentioned studies.20,22,27 Although these results are
highly promising for the use of hyperopic LASIK as an
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 Ophthalmology Volume 119, Number 1, January 2012
alternative treatment in accommodative esotropia patients,
hyperopic LASIK has a lower predictability and stability in
outcomes than myopic correction.
Alignment Outcomes
In the present study, all patients reported improved ocular
alignment without optical correction. The alignment out-
comes were comparable with those obtained by other au-
thors.20,2228 The studies by Hoyos et al,20 Nucci et al,23
Sabetti et al,25 and Hutchinson et al,28 which included only
patients with purely refractive accommodative esotropia,
reported that all patients achieved orthophoria after surgery
without optical correction. Some studies, which included
both fully and partially refractive accommodative esotropia,
also reported a significant decrease in the angle of deviation,
but with a residual esotropia that constitutes the nonaccom-
modative component of the strabismus.21,22,24,27 Nucci et
al24 presented a series of 10 adults with partially accommo-
dative esotropia who underwent PRK to correct hyperopia
followed 6 months later by bilateral medial rectus muscle
recessions to treat the accommodative and nonaccommo-
dative components of their esotropia, respectively. These
authors concluded that PRK was useful for treating the
hyperopia and the accommodative portion of partially ac-
commodative esotropia.24 Most of the current partially re-
fractive accommodative esotropia patients underwent a pre-
vious strabismus surgery to correct the nonaccommodative
component of the strabismus. This explains the absence or
small angle of residual esotropia in this group.
Sensory Outcomes
In this study, most patients had no modifications in stere-
opsis after surgery. Interestingly, it improved in 5 of the 15
patients who had stereopsis before surgery. In other studies
where stereoacuity is reported, the results were variable.
Nucci et al23 found that stereopsis was unaffected by PRK
in all patients. In the series presented by Stidham et al,21
gross stereopsis improved in 3 patients and was unchanged
in the remaining patients. Hutchinson et al28 reported that
80% of the patients had no change in stereoacuity, 4 patients
had an increase of between 30 and 60 seconds of arc, and 4
patients had a loss of 30 seconds of arc after refractive
surgery. The authors attributed these results to testing vari-
ability. The current findings, with 33.3% of patients show-
ing improved stereoacuity, may be the result of a coinci-
dental misreading. If not, the most likely explanation is the
achievement of permanent emmetropia and ocular align-
ment that stimulates improvement in binocular vision. Fur-
ther studies are needed to elucidate this point.
Ten- to 18-Year-Olds
This series included 9 patients between 11 and 16 years of
age, because the authors believe that hyperopia in patients
with refractive accommodative esotropia remains stable af-
ter the age of 10 years. The results revealed no difference
between this group and the older patients. Numerous studies
have demonstrated that refractive surgery is effective and
162
safe for accommodative esotropia in children and adoles-
cents.21,22,26,27 Phillips et al22 presented a series of 15
patients between 9 and 18 years of age treated by LASIK
without serious complications. Dvali et al26 studied 46
children and adolescents with accommodative strabismus
and refractive amblyopia and concluded that excimer laser
correction of hyperopia and hyperopic astigmatism has the
potential to correct refractive errors, to improve visual func-
tion in amblyopic eyes, to correct accommodative strabis-
mus, and to improve binocular vision. The present authors
agree with some authors regarding the selection of moti-
vated and collaborative patients who are able to accept
topical anesthetics, because it is an elective procedure and
general anesthesia is an unnecessary and excessive risk.
The present results compare favorably with the standard
management of these patients, which generally consists of
full optical correction of hyperopia using glasses or contact
lenses. In most of these patients, optical correction is re-
quired for life to maintain ocular alignment.29,30 The pa-
tients were able to discontinue the use of optical aids and to
maintain or improve VA. In terms of stereoacuity, these
results are comparable with those of patients treated by
conventional means.29,30
In summary, refractive surgery with an excimer laser is a
promising option for the treatment of refractive accommo-
dative esotropia in patients at least 10 years of age. Because
it is considered an elective procedure, this procedure should
not be performed in younger children because, in addition to
stable refraction, it is also necessary to achieve correct
centration of the refractive procedure, which requires that
the patient be able to accept topical anesthetics and to
cooperate during the surgery. Refractive surgery in patients
with accommodative esotropia allows for ocular alignment,
eliminating the need for optical correction and allowing 1
procedure to achieve 2 goals.
Acknowledgments. The authors thank Maria Lourdes Pagano,
MBA, Austral University, Argentina, for her invaluable expertise
and assistance concerning the statistical analysis and Alejandro
Navas, MD, Department of Cornea and Refractive Surgery, Insti-
tute of Ophthalmology Conde de Valenciana, Mexico, for his
helpful insights and critical review of the manuscript.
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Footnotes and Financial Disclosures
Originally received: August 12, 2010.
Final revision: June 23, 2011.
Accepted: July 1, 2011.
Available online: September 29, 2011. Manuscript no. 2010-1108.
1
Department of Ophthalmology, National University of Cuyo, Mendoza,
Argentina.
2
Centrovision Mendoza Eye Clinic, Mendoza, Argentina.
3
Department of Ophthalmology, Mendoza Central Hospital, Mendoza,
Argentina.
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Presented at: American Academy of Ophthalmology Annual Meeting,
October 2009, San Francisco, California.
Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials
discussed in this article.
Correspondence:
Gabriela L. Pagano, MD, Emilio Jofre 366, Cuidad, CP 5500, Mendoza,
Argentina. E-mail: gabrielapaganomd@gmail.com.
163