• Oct 2014
    AAO Pediatric Ophthalmology/Strabismus PPP Panel, Hoskins Center for Quality Eye Care


    These are summary benchmarks for the Academy's Preferred Practice Patterns® (PPP) guidelines. The Preferred Practice Patterns series of guidelines has been written on the basis of three principles.

    • Each Preferred Practice Pattern should be clinically relevant and specific enough to provide useful information to practitioners.
    • Each recommendation that is made should be given an explicit rating that shows its importance to the care process.
    • Each recommendation should also be given an explicit rating that shows the strength of evidence that supports the recommendation and reflects the best evidence available.

    Preferred Practice Patterns provide guidance for the pattern of practice, not for the care of a particular individual. While they should generally meet the needs of most patients, they cannot possibly best meet the needs of all patients. Adherence to these Preferred Practice Patterns will not ensure a successful outcome in every situation. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. It may be necessary to approach different patients' needs in different ways. They physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice.

    The Preferred Practice Pattern® guidelines are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or other information contained herein.

    For each major disease condition, recommendations for the process of care, including the history, physical exam and ancillary tests, are summarized, along with major recommendations for the care management, follow-up, and education of the patient. For each PPP, a detailed literature search of PubMed and the Cochrane Library for articles in the English language is conducted. The results are reviewed by an expert panel and used to prepare the recommendations, which they rated in two ways.

    The panel first rated each recommendation according to its importance to the care process. This "importance to the care process" rating represents care that the panel thought would improve the quality of the patient's care in a meaningful way. The ratings of importance are divided into three levels.

    • Level A, defined as most important
    • Level B, defined as moderately important
    • Level C, defined as relevant but not critical

    The panel also rated each recommendation on the strength of evidence in the available literature to support the recommendation made. The "ratings of strength of evidence" also are divided into three levels.

    • Level I includes evidence obtained from at least one properly conducted, well-designed randomized controlled trial. It could include meta-analyses of randomized controlled trials.
    • Level II includes evidence obtained from the following:
      • Well-designed controlled trials without randomization
      • Well-designed cohort or case-control analytic studies, preferably from more than one center
      • Multiple-time series with or without the intervention
    • Level III includes evidence obtained from one of the following:
      • Descriptive studies
      • Case reports
      • Reports of expert committees/organizations (e.g., PPP panel consensus with external peer review) 

    PPPs are intended to serve as guides in patient care, with greatest emphasis on technical aspects. In applying this knowledge, it is essential to recognize that true medical excellence is achieved only when skills are applied in a such a manner that the patients' needs are the foremost consideration. The AAO is available to assist members in resolving ethical dilemmas that arise in the course of practice. (AAO Code of Ethics)

    Esotropia - Initial and Follow-up Evaluation

    Initial Exam History (Key elements)

    • Ocular symptoms and signs [A:III]
    • Ocular history (date of onset and frequency of the deviation, presence or absence of diplopia) [A:III]
    • Systemic history (review of prenatal, perinatal and postnatal medical factors) [A:III]
    • Family history (strabismus, amblyopia, type of eyeglasses and history of wear, extraocular muscle surgery, genetic diseases [A:III]

    Initial Physical Exam (Key elements)

    • Fixation pattern and visual acuity [A:III]
    • Binocular alignment (at distance and near) [A:III]
    • Extraocular muscle function [A:III]
    • Monocular and binocular optokinetic nystagmus testing for nasal-temporal pursuit asymmetry [A:III]
    • Detection of latent or manifest nystagmus [A:III]
    • Sensory testing [A:III]
    • Cycloplegic retinoscopy/refraction [A:III]
    • Fundoscopic examination [A:III]

    Care Management

    • Consider all forms of esotropia for treatment and re-establish ocular alignment as soon as possible [A:III]
    • Prescribe corrective lenses for any clinically significant refractive error [A:I]
    • If eyeglasses and amblyopia management are ineffective in aligning the eyes, then surgical correction is indicated [A:III]
    • Start amblyopia treatment before surgery to alter angle of strabismus and/or increase likelihood of binocularity [A:III]

    Follow-Up Evaluation

    • Periodic evaluations necessary because of risk of developing amblyopia losing binocular vision, and recurrence [A:II]
    • Children who are well-aligned and do not have amblyopia may be followed every 4 to 6 months [A:III]
    • Frequency of follow-up visits can be reduced as child matures [A:II]
    • New or changing findings may indicate need for more frequent follow-up examinations [A:III]
    • Hyperopia should be assessed at least annually and more frequently if visual acuity decreases or esotropia increases[A:III]
    • Repeat cycloplegic refraction is indicated when esotropia does not respond to initial prescription of hyperopic refraction or when esotropia recurs after surgery[A:II]

    Patient Education

    • Discuss findings with the patient when appropriate and/or parents/caregivers to enhance understanding of disorder and to recruit them in a collaborative approach to therapy [A:III]
    • Formulate treatment plans in consultation with the patient and/or family/caregivers [A:III]