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Divergence insufficiency-type ET is a common cause of distance diplopia in elderly adults. A recent prospective multicenter data collection study has provided additional guidance on management. Either base-out prism glasses or strabismus surgery were found to have high success rates, based on patient report of diplopia, and health-related quality-of-life domain scores. It was concluded that either prism or surgery were reasonable initial treatment strategies. Although allocation bias precluded formal comparison of prism versus surgery (evident in baseline differences between groups), there were hints that surgery may yield superior outcomes. For surgery, the most common approach was bilateral medial rectus recession, which was highly successful when assessed 10 weeks and 12 months postoperatively. It was unclear whether adjustable sutures were helpful, but in the vast majority of adjustable cases, additional recession at the time of adjustment was performed, suggesting that larger than standard surgical doses are needed.

Evaluation and Management of Divergence Insufficiency-Type Esotropia