A ccommodative esotropia is the most common form of childhood esotropia. Although full hyperopic correction often restores binocular alignment, approximately one-third of patients exhibit residual distance esotropia despite optimal refractive correction, a condition known as partially accommodative esotropia (PAET). In this situation, strabismus surgery is indicated, usually consisting of medial rectus (MR) muscle recession, but the question of appropriate surgical dosing is a conundrum.

The standard surgical formula for MR recession in PAET often yields suboptimal outcomes, with undercorrection rates approaching 20% in some series. ^, Alternative targeting strategies for determining the amount of MR recession have been proposed, including operating for the near deviation, prism adaptation, addition of posterior scleral fixation, and augmented surgical dosing. ^,,,, Several strategies have addressed which deviation should be targeted. Wright et al suggested calculating the surgical dose based on the average of the near deviation with and without correction. In contrast, Jotterand et al suggested dosing on the average of the distance deviation with and without correction. Del Monte described another approach, recommending surgical dosing based on the average of the near deviation with correction and the distance deviation without correction.

However, many surgeons approach augmentation of MR recession in PAET with caution due to concern about overcorrection. This concern is understandable, as significant overcorrections have been reported even with standard-table surgery, with rates up to 44%. ^, Moreover, prior studies evaluating averaging-based dose augmentation have been limited to relatively small cohorts and short-term follow-up, leaving uncertainty regarding the reproducibility and long-term stability of this approach. Given these risks, and because prior studies of dose augmentation have been limited to cohorts of no more than 40 patients followed for only short intervals, the present study aimed to apply the distance-based averaging strategy described by Jotterand et al to a substantially larger group of patients, aiming to obtain robust long-term outcome data.

This study reviewed consecutive patients with PAET who underwent strabismus surgery by one of two surgeons (JLD, SYS) using identical technique at the Stein Eye Institute, University of California, Los Angeles, between January 2014 and January 2025. The study was conducted in accordance with the Declaration of Helsinki, complied with the U.S. Health Insurance Portability and Accountability Act, and received prior approval from the UCLA Institutional Review Board for Protection of Human Subjects.

Eligible patients were ≤18 years, had PAET defined as distance esotropia of at least 10Δ in full cycloplegic spectacle correction, with at least 10Δ larger distance esotropia without correction. Patients with less than 10Δ residual esotropia at distance in full correction were also included if they demonstrated a significant near deviation and were intolerant of bifocal spectacles. Patients were required to wear the full hyperopic spectacle correction for at least 6 weeks preoperatively, demonstrated stable alignment within 5Δ on two visits at least 2 weeks apart, and complete at least 6 weeks follow-up after strabismus surgery. Amblyopia was permitted if treated to plateau acuity, and had severity designated as follows: mild amblyopia-best-corrected visual acuity (BCVA) 20/25 to 20/40; moderate amblyopia—worse than 20/40 to 20/80; and severe amblyopia—worse than 20/100. Patients with prior ocular surgery, other ocular diseases, restrictive or paralytic strabismus, or neurological disorders were excluded.

Demographic data, medical and ophthalmic histories, and pre- and postoperative alignment measurements were recorded. Visual assessments included cycloplegic refraction and BCVA, measured with linear Snellen charts with logarithmic progression at 4 m and converted to LogMAR. For nonverbal children, visual acuity was assessed using central, steady, maintained fixation; younger verbal children were evaluated with Allen figures. In cooperative children, stereopsis was measured with the Titmus fly test while wearing their prescribed spectacle correction. At the final follow-up, testing was performed with full correction or reduced plus correction when indicated, after confirming that near visual acuity and stereopsis were not adversely affected by reduction in hyperopic correction.

Strabismus angles were assessed using the cover-uncover test followed by prism alternate cover testing in five gaze positions (primary, sursumversion, infraversion, dextroversion, and levoversion) at distance (4 m) and near (33 cm). In small, noncooperative children, measurements were limited to primary gaze at distance and near. The term “primary gaze” is used herein for consistency with clinical terminology, but refers to “central gaze,” which is not equivalent to kinematic primary position.

Surgeries were performed with dosing of MR recession according to Parks tables, with the surgical target angle calculated as the average of the esotropia measured at distance with full hyperopic spectacle correction, and the esotropia measured at distance without correction. Total MR recession represents the sum of recession performed on both MR muscles, as measured from the anatomic muscle insertion. The operative technique was applied universally. Patients with a “high accommodative convergence to accommodation (AC/A) ratio,” defined as more than 10Δ greater esotropia at near than distance but near angle reduced by bifocal add, were managed either with bifocal spectacles or with MR recession combined with pulley posterior fixation, according to the surgeon’s preference. Undercorrection was defined as persistent esotropia within 3 weeks postoperatively, and recurrence was defined as esotropia following at least 4 weeks of satisfactory alignment. The primary outcome was the change in deviation angle (Δ) from preoperative to final follow-up, along with the proportion of patients who were orthophoric, esotropic, or exotropic at their last examination. Surgical success was defined as alignment within 5Δ of orthophoria at distance while wearing hyperopic correction at the final follow-up visit. For patients who subsequently underwent reoperation, alignment outcomes were recorded at the final visit immediately preceding reoperation. Secondary outcomes included improvement in stereopsis and reoperation rates. In patients with high AC/A ratio, bifocal requirement was specifically assessed 2 to 6 weeks postoperatively to minimize the confounding by natural reduction in hyperopia over time.

Statistical analyses were performed using GraphPad Prism version 10 (GraphPad Software). Two-sample t test, chi-square test, Fisher’s exact test, and one-way ANOVA were used as appropriate. Linear regression analysis was performed with unconstrained slopes and intercepts, and statistical significance was taken at the 0.05 level.

A total of 110 patients met inclusion criteria. Mean age at esotropia onset was 2 ± 1 years (range, birth to 6 years), and mean age at surgery was 5 ± 3 years (range, 0.5-16 years). Fifty-two patients (47%) were female. The first postoperative follow-up visit occurred at a mean of 2.5 ± 2.2 days (range, 1-7 days) after surgery. The mean follow-up period was 2.8 ± 2.6 years (range, 6 weeks to 10 years). Final follow-up occurred at less than 3 months in 5 patients (5%), 3 to 6 months in 6 (6%), 6 to 12 months in 18 (16%), 1 to 3 years in 38 (35%), and more than 3 years in 43 (39%). Eighty-one patients (74%) had at least 1 year follow-up. A total of 57 patients (52%) had follow-up exceeding 2 years, and 26 patients (24%) were followed for over 5 years. The mean cycloplegic spherical equivalent refraction was +4.0 ± 1.7 D (range, +1.25 to +9.75 D). Without correction, mean preoperative esotropia measured 43 ± 13Δ at distance and 46 ± 17Δ at near. With full hyperopic correction, these values decreased to 26 ± 11Δ at distance and 30 ± 12Δ at near. Amblyopia was present in 52 patients (47%). A detailed summary of these characteristics is provided in Table .

All procedures were conducted under general anesthesia without the use of adjustable sutures, and there were no intraoperative complications. Total MR recession averaged 9.5 ± 1.5 mm (range, 6-14 mm). Compared with the standard dose calculated based on the esotropia measured with hyperopic correction, this represents 1.7 mm average augmentation (increasing mean recession from 7.8 to 9.5 mm). Posterior pulley fixation for high AC/A ratio was performed in 23 patients.

At the last follow-up visit, postoperative esotropia measured in prescribed hyperopic correction (full cycloplegic correction or reduced plus when clinically indicated) decreased from 26 ± 11Δ (range, 6-70Δ) to 3 ± 6Δ (range, −20 to 20Δ) at distance ( P <.0001), and from 30 ± 12Δ (range, 10-70Δ) to 4 ± 9Δ (range, −25 to 40Δ) at near ( P <.0001). The surgical effect correlated positively with preoperative esotropia at distance, with nearly identical regression slopes and intercepts at first and last follow-up ( Figure 1 ). Despite this overall stability at the group level, the proportion of orthophoric patients decreased over time, with a corresponding esotropic shift in some individuals. At the final follow-up, 45 patients were orthophoric, 23 had esotropia less than 5Δ, 33 had esotropia of 5Δ or greater, 6 had exotropia less than 10Δ, and 3 had exotropia exceeding 10Δ, corresponding to an overall success rate of 67% ( Figure 2 ). In total, 82% of patients achieved alignment within 10Δ. Mean follow-up duration was 2.9 years in patients with satisfactory alignment, 3.5 years in those with consecutive exotropia, and 4.4 years in those with residual esotropia, without statistically significant difference between groups (one-way ANOVA, P =.21).

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