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Shirabe et al concurred with such findings but added that it was necessary to confirm a stable angle of deviation with accurate preoperative evaluation and to maintain good postoperative eye alignment throughout the follow-up period to achieve and maintain the binocular visual function resulting from early corrective surgery. [ 28 ] Birch et al explained that better stereopsis is achieved with early surgical alignment because the duration of misalignment is shortened and not because alignment is achieved during an early critical period of visual maturation. [ 29 ] Surgery for infantile esotropia is most likely to result in measurable stereopsis if patient age alignment is not more than 16 months. [ 30 ]

Several techniques for making a wider canalicular opening have been reported, including anchoring of the anterior lacrimal sac flap to the periosteum [ 18 ], lacrimal diaphragm and periosteum suturation [ 19 ], bicanalicular double silicone intubation [ 20 ], the sleeve technique (., sustaining the sleeve at the opening site) [ 21 ], and the use of mitomycin C [ 22 ]. It is thought that anchoring the anterior flap to the periosteum and the sleeve technique might especially help prevent the newly formed anterior mucosal flap from collapsing because the sac flaps are physically tented [ 18 , 21 ]. We expected to achieve a similar mechanical tenting effect by placing the absorbable packing materials at the site of the newly-formed anastomosis before the suturing of the anterior flaps ( Fig. 1 ).

Smaller angles of deviation may be addressed with prism lenses with or without occlusion therapy, depending on the existence of amblyopia. Perform a good refraction with full cycloplegia on all esotropic infants. A common cycloplegic combination is % phenylephrine and 1% cyclopentolate. It is necessary to occlude one eye at a time during retinoscopy to make sure that the examiner maintains accurate alignment with the visual axis. The average cycloplegic refraction of a child with infantile esotropia with no other developmental or systemic problem is a mild hyperopic spherical equivalent with mild astigmatism, which is relatively stable in the first decade of life.

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