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      Two Pediatric Patients with Acute Acquired Comitant Esotropia as the First Symptom of Brainstem Tumor: A Case Report


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          Acute acquired comitant esotropia (AACE) is an acquired strabismus with uncrossed sudden-onset diplopia due to esodeviation, comitant esotropia without accommodation factor, or paretic eye movement. The diagnosis of AACE entails differentiation from incomitant esotropia caused by abnormalities in the central nervous system. We present 2 pediatric patients with AACE as the first symptom of brainstem tumor.

          Case Presentation

          The 2 patients were aware of their diplopia and had no other neurological abnormalities. There were no special findings in the anterior segment, ocular media, or fundus. Esotropia with a difference of no more than 10Δ between distant and near fixations was observed. Eye movements were normal, and Hess red-green test under prism neutralization did not reveal abduction restriction. The presumed cause of AACE in both patients was excessive use of digital displays, and brain magnetic resonance imaging (MRI) was performed to confirm the absence of neurological abnormality. Using MRI, a definitive diagnosis of AACE was made based on comitant esotropia associated with diffuse median glioma and medullary pilocytic astrocytoma without abducens nerve palsy.


          Although the incidence of AACE caused by brainstem tumors may be low, it is necessary to perform head imaging to confirm etiology. Furthermore, Hess red-green test under prism neutralization is considered important for the differentiation of abducens nerve palsy.

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          Most cited references15

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          Acute acquired comitant esotropia related to excessive Smartphone use

          Background To describe the clinical characteristics and outcomes of acute acquired comitant esotropia (AACE) related to excessive smartphone use in adolescents. Methods The medical records of 12 patients with AACE and a history of excessive smartphone use were retrospectively reviewed, and the duration of smartphone use, angle of deviation, refractive error, stereopsis, and treatment options were analyzed. Results All patients showed convergent and comitant esotropia ranging from 15 to 45 prism diopters (PD; average: 27.75 ± 11.47 PD) at far fixation. The angle of deviation was nearly equivalent for far and near fixation. Every patient used a smartphone for more than 4 h a day over a period of several months (minimum 4 months). Myopic refractive errors were detected in eight patients (average:−3.84 ± 1.68 diopters (D]), and the remaining four patients showed mild hyperopic refractive error (average: +0.84 ± 0.53 D). Reductions in esodeviation were noted in all patients after refraining from smartphone use, and bilateral medial rectus recession was performed in three patients with considerable remnant esodeviation. Postoperative exams showed orthophoria with good stereoacuity in these patients. Conclusion Excessive smartphone use might influence AACE development in adolescents. Refraining from smartphone use can decrease the degree of esodeviation in these patients, and remnant deviation can be successfully managed with surgical correction.
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            Comitant convergent strabismus with acute onset.

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              Acute acquired comitant esotropia.

              Acute acquired comitant esotropia has been used to describe a dramatic onset of a relatively large angle of esotropia with diplopia and minimal refractive error. We describe six children aged 5 to 11 years who developed an acute non-accommodative esotropia with diplopia. Neurological examination, including CT scan, in each of these children gave negative results. We suggest that this is an unusual presentation of esotropia of undetermined aetiology. The diagnosis, clinical characteristics, and management are discussed.

                Author and article information

                Case Rep Ophthalmol
                Case Rep Ophthalmol
                Case Reports in Ophthalmology
                S. Karger AG (Basel, Switzerland )
                8 November 2023
                Jan-Dec 2023
                8 November 2023
                : 14
                : 1
                : 613-619
                [a ]Department of Ophthalmology, Gifu Prefectural General Medical Center, Gifu, Japan
                [b ]Department of Ophthalmology, Graduate School of Medicine, Gifu University, Gifu, Japan
                [c ]Yagasaki Eye Clinic, Ichinomiya, Japan
                [d ]Department of Neurosurgery, Gifu Prefectural General Medical Center, Gifu, Japan
                [e ]Department of Pediatrics, Gifu Prefectural General Medical Center, Gifu, Japan
                Author notes
                Correspondence to: Ayaka Yagasaki, yagasakiayaka@ 123456gmail.com
                © 2023 The Author(s). Published by S. Karger AG, Basel

                This article is licensed under the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC) ( http://www.karger.com/Services/OpenAccessLicense). Usage and distribution for commercial purposes requires written permission.

                : 3 January 2023
                : 17 October 2023
                : 2023
                Page count
                Figures: 3, References: 15, Pages: 7
                There was no funding for this article.
                Case Report

                acute acquired comitant esotropia,hess red-green test,magnetic resonance imaging,brainstem tumor


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