Effectiveness of treatment modalities for childhood esotropia: a systematic review

Esotropia has several types that commonly manifest in early childhood, with numerous treatment options described in the literature. The aim of this systematic review is to synthesize recent research findings on the management of childhood esotropia (ET) to clarify the relative success rates and specific indications for each treatment option, providing guidance for eye care professionals in selecting the most effective interventions.

A comprehensive search was conducted across multiple databases, including PubMed, Web of Science, ProQuest, Scopus, Google Scholar, EBSCO, and Medline, following PRISMA 2020 guidelines. The search was restricted to articles published between 1990 and 2023 that examined various treatment modalities for different types of childhood esotropia (ET). In this study, success was defined as a post-treatment deviation of less than 10 prism dioptres (PD). The study protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42024589042.

The final systematic review included 34 studies from 14 countries, encompassing 3,877 children with a mean age of 4.72 ± 2.08 years. The reviewed studies indicated that optical correction had the highest effectiveness rate at 79.31% after an average follow-up of 5.57 years. Extraocular muscle surgery demonstrated an effectiveness rate of 71.4% with a follow-up period of 2.89 years, while botulinum toxin (BT) injections showed a lower effectiveness rate of 61.24% after a follow-up of 3.15 years.

The review concluded that substantial evidence supports full cycloplegic hyperopic correction as the most effective first-line treatment for childhood accommodative esotropia (AET). However, surgery may be required for some children with AET if their deviation remains over 15 PD after full cycloplegic hyperopic correction. Prismatic correction was highly successful in managing residual deviation in partial AET. Bilateral BT injections proved effective as a first-line treatment for acute-onset ET and infantile ET without a vertical component. Timely surgical intervention enhances sensory outcomes in infantile ET; however, no surgical technique has demonstrated a distinct advantage.