UNIVERSITY OF GONDAR

CMHS
School of Medicine
DEPARTMENT OF OPTOMETRY
Advanced pediatric optometry seminar presentation on:
Pediatric strabismus(ET)
Prepared by :Abebizuhan Zigale(Msc 1st year student)

Moderators : 1.Mr.Aragaw Kegne (BSc,Msc in clinical optometrist)

2.Ms.Yezinash Addis (BSc,Msc in clinical optometrist)
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 Objectives
At the end of this presentation you will able to:

Define esotropia

Describe the epidemiology of esotropia

List the different classification of esotropia

Describe the etiology of esotropia

Identify the clinical feature of each esotropia

Evaluate patients clinically presents with esotropia

Manage esotropic patients accordingly

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 Outline
 Introduction

 Definition

 Epidemiology

 Classification

 Etiology

 Clinical feature
 Clinical evaluation
 Differential diagnosis
 Management
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 Introduction
An esodeviation is a latent or manifest convergent misalignment of the visual

axes.
esodeviations are the most common type of childhood strabismus, accounting for

more than 50% of ocular deviations in the pediatric population.

esodeviations and exodeviations are equally prevalent in adults

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 Epidemiology
Esodeviations occur with equal frequency in males and females and are more

common in African Americans and white ethnic groups in USA.

The prevalence of esotropia increases

Age (higher prevalence at 48–72 months compared with 6–11  months)

Moderate anisometropia, and

 Moderate hyperopia

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 Conti…………
Amblyopia develops in approximately 50% of children who have esotropia.

Risk factors for esotropia include

anisometropia

hyperopia

neurodevelopmental impairment

 prematurity

 low birth weight

craniofacial or chromosomal abnormalities

maternal smoking during pregnancy and family history of strabismus

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 Classification

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 1.Infantile(congenital)esotropia
Infantile esotropia is defined as an esotropia that is present by 6 months of age.

Infantile esotropia occurs more frequently in children born prematurely and in up

to 30% of children with neurologic and developmental problems, including

cerebral palsy and hydrocephalus
Infantile esotropia has been associated with an increased risk of development of

mental illness by early adulthood.

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 Etiopathogenesis
The cause of infantile esotropia is remains unknown but the following factors has

been implicated as a causative factor .

1.Innervational disturbance

2.Role of accommodation

3.General and environmental factors

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conti……..

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 Clinical features
Time of onset: manifests within the first 6 months

Angle of deviation usually larger angle of deviation for both distance and near

fixation and stable

Fixation pattern usually an alternate fixation in primary gaze and cross fixation

in the lateral gaze

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Conti…………..
Apparent limitation of abduction

Visual acuity normal and equal both eyes with alternate fixation but

patient may develop amblyopia if preferred fixation occurs.

Refractive error is not prominent and consistent with the age group

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 Clinical evaluation
 Examination of anterior segment

 Estimation of visual acuity

 Examination of Fundus and media

 Cycloplegic refraction

 Measurement of AC/A ratio

 Measurement of deviation

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 DDX
Pseudoesotropia

Infantile accommodative esotropia

Sensory esotropia

Congenital 6th nerve palsy

Congenital fibrosis syndrome

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 Management
Non- surgical management

refractive error correction

Amblyopia treatment

Surgical management

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 Surgical results and Post surgical treatment

1 Subnormal binocular vision

orthophoria or asymptomatic hetrophoria

normal visual acuity

peripheral vision and NRC

Foveal suppression in one eye in binocular vision.

Post surgical treatment

Such px don’t require treatment but regular follow up is important for

 Correction of refractive error

 Maintenance of amblyopia treatment
 Late development of under or over correction
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 Conti………….
2.microtropia

XX's post operative microtropia is the desirable post surgical result

No further treatment is required

3.Small angle residual esotropia or small angle exotropia due to over correction .

Small angle esotropia or exotropia (<15 prism)

ARC(80% of PX)

Stereopsis low grade or absent

No further treatment is required except amblyopia prevention

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Conti……….
4. Large angle residual esotropia(under correction)
Large angle esotropia

Amblyopia

Stereopsis is absent

Treatment resurgical treatment with in 3 month of original surgery.

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Conti…………..
5.Large angle consecutive exotropia
I. Children below age of 2 years having fusion potential with consecutive

exotropia of more than 15 PD.

Early surgical treatment is required.

 II. In patients above 8 years of age :visually matured group with bifoveal fixation

wait for 6 to 8 weeks then do surgery if deviation >20PD

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 2.Accommodative Esotropia
It is a convergent deviation of the eyes associated with activation of the
accommodative reflex.
All accommodative esodeviations are acquired and can be characterized as
follows:
onset typically between 6 months and 7 years of age, averaging 2½ years of age
(can be as early as age 4 months)
 Usually intermittent at onset, becoming constant
 Comitant
 Often hereditary
 Sometimes precipitated by trauma or illness
 Frequently associated with amblyopia
 Possibly occurring with diplopia

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 Classification of accommodative esotropia
 Accommodative esotropia

Refractive

Non refractive

 Hyper accommodative(high AC/A ratio)

 Hypo accommodative(remote NPA)
Partially accommodative

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 Refractive accommodative esotropia
ET occurs because of convergence associated with persistent accommodative

effort to overcome uncorrected hypermetropia.

AC/A ratio is normal, and it is fully corrected in all gazes and at all fixation

distance.

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 Etiopathogenesis
All children with uncorrected hyperopia doesn't develop accommodative esotropia

because in addition to hyperopia there are other factors responsible for development
of accommodative esotropia
Uncorrected hyperopia

Fusional divergence amplitude

AC/A ratio and

Childs personality

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Conti…………..

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 Clinical features
1.Time of onset 2-3 years
2.hypermetropia (2-6D)
3.Ocular deviation (esophoria,intermitent esotropia, constant
esotropia)
4.AC/A ratio is usually normal
5.Development of sensory adaptation
Suppression
ARC
Amblyopia
Alternate fixation with no BSV
6.association
Vertical devation
A-V pattern deviation

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 Clinical evaluation
Measurement of devaition

Cycloplegic refraction

Measurement of fusional divergence amplitude

Examination of fundus and ocular media

DDX
Sensory esotropia
Essential infantile esotropia

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 Treatment
1. optical correction
 full Rx of cycloplegic refraction
 Atropine

2.Amblyopia treatment constant unilateral accommodative esotropia with amblyopia

3. orthoptic treatment to overcome suppression and improve negative fusional vergence

4. surgical treatment if accommodative esotropia is associated with vertical or A-V

pattern devaition

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 Non- refractive hyperaccommodative esotropia
It refers to a type of accommodative esotropia caused by high AC/A ratio

Esotropia is significantly greater at near than at distance

It is unrelated to refractive error and NPA is normal for the age of the patient .

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 Ethiopathogenesis
High AC/A ratio the principal factor in the Ethiopathogenesis of non-refractive accommodative

esotropia is occurrence of excessive accommodation convergence associated with normal amount of

accommodation.
Amplitude of fusional divergence modifies the deviation as follows

 Esophoria for near will occurs when fusional divergence is enough to cope up with increase

convergence at near fixation

Esophoria for distance and esotropia for near fixation occurs when fusional divergence is enough to

cope up with convergence exerted for distance fixation but is insufficient to cope up with excessive
convergence at near fixation.
Esotropia greater at near fixation than at distance fixation occurs when fusional divergence in

insufficient to counter the convergence exerted for distance fixation

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 clinical features
Time of onset 2-3 years
Ocular deviation near esotropia is much greater than distance deviation
AC/A ratio high
Development of sensory adaptation
Suppression
ARC
Amblyopia
Associations
Vertical deviation
A-V pattern deviation

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 clinical
• Measurement of deviation evaluation
Cycloplegic refraction

Measurement of AC/A ratio

Measurement of fusional divergence amplitude

Examination of fundus and ocular media

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 Treatment
1.Amblyopia therapy

2. Full cycloplegic refraction RX

3.Bifocal Glass

4.Miotics

5.orthoptic exercise

6. Surgical

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 Hypo-accommodative esotropia
Accommodative esotropia which is associated with weakness of accommodation.

 To overcome accommodation there is an increase accommodative effort which

intern result in increase convergence resulting near esotropia.

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 clinical features
Esotropia is large for near fixation than distance fixation

Esotropia is not related to uncorrected hypermetropia

AC/A ratio is not high

Remote NPA

Treatment

Bifocal glass
Orthoptic exercise

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Partially accommodative esotropia
Partially accommodative ET is diagnosed when only a part of the deviation

is due to accommodative factors.

The non-accommodative component may be congenital or may develop

after correction of refractive error.

May occur if there is a long delay in refractive correction.

In some cases, partially accommodative esotropia results from

decompensation of a pure refractive accommodative esotropia.

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 clinical feature
Partially accommodative esotropia is usually constant
It is typically associated with suppression, ARC and amblyopia.
Treatment
1. Correction of accommodative part of esotropia
2. Amblyopia treatment
3. Surgical treatment

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Diagnosis and management of accommodative esotropia

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 3.Non-accommodative esotropia
The distinctive feature between accommodative and non-accommodative esotropia is the

absence of disparity in deviation while fixating upon a near or distant target.

common subtypes of non-accommodative esotropia include:

Essential infantile esotropia

Late onset acquired esotropia

 Basic type
 Acute onset
 Convergence excess
Sensory esotropia

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 Basic esotropia
Clinical features
Childhood onset after 6 month

Deviation equal at distance and near

Accommodative factor characteristically absent

Refractive error is insignificant

AC/A ratio is normal

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 Clinical evaluation
1.measurement of deviation

2.cycloplegic refraction

3.measurement of AC/A ratio

4.examination of fundus and ocular media

Special work to rule out possible lesions of malformation in the central nervous system.

Treatment
1.Amblyopia treatment when present

2.Surgery is the ultimate treatment of basic esotropia

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 Non accommodative convergence excess esotropia
Clinical feature
Age of onset usually between 2-5 years

Deviation large angle

Esotropia for near with small angle esotropia or esophoria or orthophoria at distance.

Near distance disparity around 15 PD

AC/A ratio determined by gradient method is normal or low

NPA within normal limit

Refractive error patients are usually hypermetropic or emmetropic

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Treatment
Surgical correction by bilateral medial rectus recession with Faden operation

is the treatment of choice.

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 Acute comitant esotropia
Sudden onset of large angle comitant esotropia without any paralytic element.

It is typically associated with diplopia

Voluntary closure of one eye may be only sign for pre verbal infants

Two forms of acute comitant esotropia has been reported

Acute strabismus after artificial interruption of fusion

 Acute comitant esotropia without preceding disruption of fusion

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Acute strabismus after artificial interruption of fusion
It has been reported to occure in pxs with no previous hx of squint ,after an interruption

of fusion under the following conditions

Prolonged bandage of one eye for any surgery or perforating injury

Occlusion of one eye for treatment of amblyopia without squint e.g anisometropic amblyopia

Swelling of lids following blunt trauma

Treatment
Spontaneous improvement

Correction of underlying hypermetropia

Surgery

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Acute comitant esotropia without preceding disruption of fusion
Etiology:
It has been postulated that such pxs has asymptomatic esophoria with only slim
reserve of fusional amplitude that maintain alignment .
Clinical feature
Onset is acute with diplopia
Duration is relatively large
Refractive error is insignificant
Disruption of fusion is not a risk factor
No signs of paralysis of lateral rectus muscle
Good potential for binocular co operation
Treatment
surgery
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 Microtropia
Microtropia is a small-angle (lesser than 5°) ET associated with abnormal retinal correspondence,

amblyopia, normal peripheral fusion.

Depending upon the degree of deviation lange classified heterotropia as follows

Microtropia

Small angle esotropia

Large angle esotropia

Clinical features

Features of microtropia as described by lange and also adopted by von Noorded et al can be

grouped as
Consistant findings and
Variable findings
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 Clinical features
Consistant findings
Amblyopia
ARC
Relative scotoma on the fovea or parafoveal fixation of deviated eye
Normal or near normal peripheral fusion
Defective stereoacuty
Variable findings
Fixation pattern
Size of deviation
Anisometropia
Cover test may be negative or positive

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 Treatment

1. In young patients(age 6 or under)

Full time occlusion therapy should be done to treat amblyopia after full

refractive correction
Recurrent cases part time occlusion should be continued for a long time

2.Older children or adults

No treatment is required since they have comfortable and nearly normal

binocular single vision with good peripheral fusional amplitude

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 sensory esotropia
It refers to the esotropia which develop due to poor visual function in one eye
during childhood.
Ethiopathogenesis
Sensory esotropia results from monocular lesions which either prevent the
development of normal binocular single vision or interfere with its maintenance.e.g
congenital or acquired cataract,
Sever congenital ptosis,
Pediatric aphakia
Corneal opacities
Anisometropia
Optic atrophy
Retinoblastoma
Macular lesions
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 Conti………..

Clinical feature

Monocular visual loss

Sensory esotropia is always comitant

Vertical deviation due to over action of IO is a frequent association

Amblyopia may be superimposed over the originally caused organic visual loss.

Management
Surgical treatment

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Consecutive esotropia
It is the occurrence of esotropia in an eye which was previously exotropic.
It has been reported to occur under the following two clinical conditions
1. surgical over correction of exotropia
2.spontaneous consecutive esotropia :Change of exotropia into esotropia
with out exogenous mechanical factor or acquired paralysis of lateral rectus
muscle .
It is extremely rare condition

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 Treatment
Very large correction with gross limitation of ocular motility may occurs
due to lost lateral rectus muscle .In this case px should under go re surgery
Within 24 hours .
 Small to moderate over correction needs to be managed depends on age of
the patient
A. Adults(visually matured)
over correction of 10 Pd to 20 PD is desirable result .
If over correction is more than 20 Pd after at least 6 weeks of surgery non
surgical measures should be tried and follow the px for about 6 months.
Refraction
Bifocal or miotics
Fersenel prism
Re surgery
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B. Small children(visually immature px)
Consecutive esotropia is associated with greater danger of developing monofixation

sundrome and suppression amblyopia.

Following measure should be taken with in 2 weeks of the surgery.
Refraction

Bifocal or miotics

Occlusion therapy

 Alternate occlusion

 Conventional occlusion
Prism therapy

Re surgery
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 Reference

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THANK YOU, if you have
any ??? Just well come

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