Subtype-Specific Macular Microvascular Changes in Accommodative Esotropia Assessed by Optical Coherence Tomography Angiography

Purpose: The purpose of this study was to evaluate macular microvascular alterations in children with accommodative esotropia (AE) using optical coherence tomography angiography (OCTA) and to determine whether these changes differ across AE subtypes independent of refractive and biometric confounders. Methods: This prospective cross-sectional study included 34 children with AE (68 eyes) and 35 age-matched healthy controls (70 eyes). AE was classified into refractive (n = 8), high accommodative convergence to accommodation (AC/A) ratio (n = 10), and partially accommodative (n = 16) subtypes. All participants underwent comprehensive ophthalmic examination and OCTA imaging. Vessel density (VD) was measured in the superficial capillary plexus (SCP), deep capillary plexus (DCP), choriocapillaris (CC), and outer retina (OR) across five macular regions. Generalized estimating equation models adjusted for spherical equivalent and axial length (AL) were used for comparisons. Results: The AE and control groups were age-matched (9.2 ± 2.3 vs. 9.8 ± 2.8 years, P = 0.356). No significant differences were found in SCP between groups. CC analysis revealed significantly reduced VD confined to the superior quadrant in high AC/A ratio (P = 0.005, q = 0.03) and partially accommodative (P < 0.0001, q < 0.001) AE subtypes compared with controls. OR analysis showed superior quadrant reductions in high AC/A ratio AE (P = 0.010, q = 0.04). DCP reductions in partially accommodative AE (P = 0.027, q = 0.09) and CC reductions in refractive AE (P = 0.041, q = 0.12) did not survive false discovery rate (FDR) correction. All other quadrants showed no significant differences. Conclusions: Children with AE exhibit significant, layer-specific microvascular alterations predominantly confined to the superior quadrant, with distinct patterns across AE subtypes. After FDR correction, CC findings in high AC/A ratio and partially accommodative subtypes, and OR findings in high AC/A ratio subtypes, remained significant. These findings suggest that chronic accommodative effort and convergence stimulation may influence retinal microvasculature, providing new insights into the pathophysiology of AE.