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Intermittent Esotropia in an Adult

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 33-year-old woman was referred for evaluation of intermittent esotropia. When playing video games at a distance or when reading, she developed oscillopsia with eyestrain and noted that her right eye turned up and in. She had undergone strabismus surgery for crossed eyes as a young child and more recently had laser in situ keratomileusis performed. She was medically healthy and neurodevelopmentally normal but had been born 4½ weeks premature. There was no family history of strabismus, and she denied diplopia.

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Dissociated horizontal deviation

C. Reversed fixation test

The term dissociated horizontal deviation (DHD) was originally used to describe a unique form of intermittent exotropia in which the measured exodeviation was larger with 1 eye fixating than the other.14 In some cases, the exodeviation resolves or converts to a large esodeviation when the patient fixates with the nonpreferred eye. Associated clinical findings include latent nystagmus, dissociated vertical divergence, and sensorial suppression of the nonfixating eye, indicating that DHD develops only when binocular visual input is preempted early in life.36 Some cases arise spontaneously, but most patients have undergone previous bimedial recessions.5

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Article Information

Corresponding Author: Michael C. Brodsky, MD, Department of Ophthalmology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (brodsky.michael@mayo.edu).

Published Online: April 15, 2021. doi:10.1001/jamaophthalmol.2020.4929

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Zubcov  AA , Reinecke  RD , Calhoun  JH .  Asymmetric horizontal tropias, DVD, and manifest latent nystagmus: an explanation of dissociated horizontal deviation.   J Pediatr Ophthalmol Strabismus. 1990;27(2):59-64.PubMedGoogle ScholarCrossref
2.
Raab  EL .  Discussion: asymmetric horizontal tropias, DVD, and manifest latent nystagmus.   J Pediatr Ophthalmol Strabismus. 1990;27(2):65.Google Scholar
3.
Quintana-Pali  L .  Desviacion horizontal disociada.   Bol Hosp Oftalmol. 1990;42:91-94.Google Scholar
4.
Wilson  ME , McClatchey  SK .  Dissociated horizontal deviation.   J Pediatr Ophthalmol Strabismus. 1991;28(2):90-95.PubMedGoogle ScholarCrossref
5.
Romero-Apis  D , Castellanos-Bracamontes  A .  Dissociated horizontal deviation: clinical findings and surgical results in 20 patients.   Binocul Vis Strabismus Q. 1992;7:173-178.Google Scholar
6.
Wilson  ME .  The dissociated strabismus complex.   Binocul Vis Strabismus Q. 1993;8:45-46.Google Scholar
7.
Gräf  M . Dissociated horizontal deviations (DHD): terminology, diagnosis, and etiology. In Faber TJ, ed. Transactions: 27th Meeting, European Strabismological Association, Florence, Italy, 2001. Swets & Zeitlinger; 2001:105-108.
8.
Gräf  M , Becker  R , Kloss  S .  Dissociated near reflex and accommodative convergence excess.  Article in German.  Ophthalmologe. 2004;101(10):1017-1019. doi:10.1007/s00347-003-0948-2PubMedGoogle Scholar
9.
Brodsky  MC , Gräf  MH , Kommerell  G .  The reversed fixation test: a diagnostic test for dissociated horizontal deviation.   Arch Ophthalmol. 2005;123(8):1083-1087. doi:10.1001/archopht.123.8.1083 PubMedGoogle ScholarCrossref
10.
Brodsky  MC , Fray  KJ .  Dissociated horizontal deviation after surgery for infantile esotropia: clinical characteristics and proposed pathophysiologic mechanisms.   Arch Ophthalmol. 2007;125(12):1683-1692. doi:10.1001/archopht.125.12.1683 PubMedGoogle ScholarCrossref
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