Am Orthopt J  49: 75-85  (1999).

Treatment of Excess Accommodative Convergence (High Gradient AC/A Esotropia) with Medial Rectus Fadenoperation

Edward G. Buckley, M.D.

Objective: The surgical management of esotropia which is significantly greater at near than distance (high AC/A ratio) presents a therapeutic challenge. In those patients who have an excess convergence secondary to accommodation (high gradient AC/A ratio), a procedure which effectively returns the AC/A ratio to normal would be advantageous. The medial rectus fadenoperation, which theoretically should have a greater effect at near would seem to be ideal for this purpose. We evaluated the effectiveness of this operation on reducing the near/distance disparity and AC/A ratio in this patient population.

Methods: We reviewed 28 consecutive patients who had bilateral medial rectus recessions combined with a fadenoperation for high AC/A esotropia as determined by the gradient method. Ocular motility and sensory evaluations were performed pre and postoperatively. All patients were followed for at least two years.

Results: The preoperative mean distance deviation, near deviation, near/distance disparity, and AC/A ratio were 25PD, 47PD, 27A and 8.7, respectively. Postoperatively the mean distance deviation was 2PD, the near deviation was 7PD, the near/distance disparity was 5PD and the mean AC/A ratio was 2.4. Eighty-two percent (23/28) had a manifest deviation less than 10PD at distance and near. The average follow up was 36 months (range 24-64). Stereopsis of greater than 400 arc seconds was present in 27% of patients preoperatively and 64 percent postoperatively. Eighty-nine percent of patients were able to maintain adequate near alignment without bifocals.

Conclusions: The fadenoperation appears to be successful in normalizing the abnormal near response in patients with a high gradient AC/A ratio esotropia.

© 1999 The Board of Regents of the University of Wisconsin System