Surgical treatment of teenagers with high AC/A ratios

The surgical approach to esotropia with a high AC/A ratio in teenagers should be dichotomized based on whether or not there is satisfactory alignment at distance with the cycloplegic correction in place. If there is not, surgery should target the near angle with glasses on. If there is good alignment at distance, bifocals should be used, and surgery deferred until the patient is approximately 18 years of age. At that time, surgery could be entertained to eliminate the need of a bifocal, by targeting the near angle measured through the distance correction. Surgery for the purpose of eliminating a bifocal in younger teenagers may be unnecessary as 99% of those who maintained satisfactory distance alignment outgrew the need of a bifocal by 18 years of age. However, many still needed a bifocal in their early teenage years.