Acute acquired comitant esotropia of childhood: a classification based on 48 children

Purpose To identify characteristics of pediatric patients who develop acute acquired comitant esotropia ( AACE ) with and without intracranial disease. Methods We reviewed the charts of 48 children consecutively referred to the hospital with AACE during a 13‐year period. Inclusion criteria were acute onset of comitant esotropia, available data on ophthalmologic, orthoptic and neurologic examinations. Children with neurological signs, AACE recurrence or hyperopia <+3 dioptres (D) underwent brain computed tomography or magnetic resonance imaging. Patients without imaging were followed. Results In all, 48 cases were recorded. The mean age at onset was 4.7 years, being significantly higher among children with intracranial disease. Seven cause‐specific types of AACE in childhood were identified: The acute accommodative ( n  = 15, 31%), decompensated monofixation syndrome or esophoria ( n  = 13, 27%), idiopathic ( n  = 9, 19%), intracranial disease ( n  = 3, 6%), occlusion related ( n  = 3, 6%), AACE secondary to different aetiologic disease ( n  = 3, 6%) and cyclic AACE ( n  = 2, 4%). Intracranial disease included hydrocephalus, pontine and thalamic glioma. Of the children with intracranial disease, 2 of 3 had no obvious neurological signs at onset. Four significant risk factors for intracranial disease were identified as follows: larger esodeviation at distance, recurrence of AACE , neuro signs (papilledema) and older age at onset (>6 years). Conclusion In a large case series of children with AACE and by review of literature, we identified seven cause‐specific types of AACE . Intracranial disease was present in 6%, and four risk factors were identified to guide clinicians when to perform brain imaging. Findings suggest AACE of childhood to be differentiated from AACE of adulthood.