We thank Mittelman for his thoughtful comments emphasizing points that he has previously published.1 We agree that the terms divergence paralysis esotropia (DPE) and divergence insufficiency esotropia are misnomers. In our article, we noted the existence of multiple terms for this form of strabismus and that we had used the term DPE to permit convenient reference to the prior literature.2 We further agree with Mittelman that the term age-related distance esotropia (ARDE) is better suited than the foregoing terms to describe small-angle distance esotropia in older patients. However, is ARDE the optimal term for the field to adopt for future use? Changes in nomenclature are difficult owing to factors such as a large existing literature using older terms and the association of older terms with presumed pathophysiological mechanisms that may still be embraced by a large number of clinicians.3 Optimal terminology should be descriptive of findings when pathophysiological mechanisms are unknown but should be related to mechanisms when mechanisms have been clearly demonstrated. The controversial consideration is the level of evidence necessary to persuade a professional field of the correctness of a particular mechanism vs that field's natural reticence to change long-standing practice. Even when there is overwhelming evidence of a particular mechanism, professionals tend to change nomenclature only slowly, often as generational replacement limits the rate of paradigm shift.4
Chaudhuri Z, Demer JL. Divergence Insufficiency Esotropia Is a Misnomer—Reply. JAMA Ophthalmol. 2013;131(4):547–548. doi:10.1001/jamaophthalmol.2013.2412
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