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HAWASSA UNIVERSITY
COLLEGE OF MEDICINE AND H EALTH S CIENCE
DEPARTMENT OF OP TOMETRY
R E F R A C T I O N C A S E P R E S E N TAT I O N
TITLE:- A CCOMODATIV E ES OTROP IA
P R E PA R E D B Y. W A D O L E S A H I LU
2 2 / 0 7 / 1 7 E . C
DEMOGRAPHY
Name: Bamlak Tamene
Age: 3
Sex: Female
Adress: Shashemene
Occupation: student
Card Number: 38456/17
Examiner: Wadole Sahilu
Date: 07/07/2017
VA: OD: 6/9 OS:6/24
CASE HISTORY;
C/C: deviation of left eye since 6 months.
HPI: This 3 year old patient came to our clinic with
above c/c which was gradual, painless and
constant deviation of the left eye associated with
photophobia outdoor and intermittent squinting of
the left eye, but no other symptoms of headache,
double vision, floater, flash of light, itching, foreign
body sensation, tearing and discharge.
POH: has hx of medication(eye drop) TID for allergy and
another unknown medication. The medications has shown
improvement on the allergy sign and symptoms.
no +ve history of spectacle, surgery and trauma
GHM: no +ve history of DM, HTN or Asthma
: fifth child for the family.
: born with a full term with SVD and fully vaccinated.
FOH: the father had a cataract surgery 3 years ago.
:The father has history of spectacle and medication use
after the surgery for 2 years and half.
: Her mother also has deviation of the left eye since
childhood but had never been treated.
FGHM: no +ve history of DM, HTN, asthma
Hobbies: playing
Physical Examination
G/A : well-looking
Globe: Symmetrical
Orbit: NPM (OU)
O/A : CCR (OD) and temporal half of the iris (OS)(15)
+1 0 -1
O/M: SAFE with star pattern (OD) +1 -1
+1 -1
0
OD OS
CT: Distance Near Distance Near
: cover NMD NMD outward mov’t NMD
: cover/uncover NMD NMD NMD NMD
: Alternate cover test NMD NMD NMD NMD
:Prism cover test NMD NMD NMD NMD
Convergence Test:
:NPC - no instrument
: Jump – SSS
Pupil : OD OS
: Direct - -
: Indirect - -
: consensual no RAPD no RAPD
SLE :
Eye lid:- well opposed (ou)
Eye lash: well directed (ou)
Punctum : open (ou)
MG orifice:- open(ou)
cornea:-clear and transparent(ou)
Conjunctiva : pink and translucent ( both tarsal and bulbar on both eyes)
Sclera :white (ou)
A/C : deep and clear (ou)
Iris : well pigmented (ou)
Pupil: PERRL (ou)
Lens : clear and transparent (ou)
Funduscopy
disc- pink
VCD ratio – 0.3 (OU)
Flat and shiny macula(OU)
Assesment : Anisometropic Hyperopia
: Refractive Esotropia
Plan :Cycloplegic Refraction
Refraction:
Dry refraction: OD +0.75 VA: 6/6
OS +3.00 VA: 6/9
Wet Refraction: OD +1.50 V/A :6/6
OS +4.50 V/A:6/9 (no deviation)
Final Prescription:- OD: +1.50 V/A: 6/6 OS: +4.50 V/A:
6/9
Advice: Full time spectacle wear
Follow up: after 6 month
Accommodative Esotropia
is a convergent inward deviation of the eyes
associated with activation of the accommodative
reflex. The accommodative
convergence/accommodation (AC/A) ratio can be
normal or high.
The normal accomodative covergence to
accomodation is 3-5 per accomodation.
All accommodative Esodeviations are acquired and can be
characterized as follows:
• onset from 4 months to 7 years of age; typically 2–3 years of age
• usually intermittent at onset, later becoming constant
• commitant
• often familial
• sometimes precipitated by trauma or illness
• frequently associated with amblyopia
• diplopia may be present (especially with onset at an older age); it
usually disappears with the development of a facultative
suppression scotoma in the deviating eye
• deviation angle decreases to less than 10 prism diopters (Δ) with
proper refractive correction (if the residual angle is larger, the patient
has partially accommodative esotropia.
Pathogenesis and Types of
Accommodative Esotropia
1. Normal AC/A ratio accommodative esotropia
The mechanism of accommodative esotropia with normal
AC/A ratio (also referred to as refractive a accommodative
esotropia) involves 3 factors:
uncorrected hyperopia
accommodative convergence
insufficient fusional divergence
Because of uncorrected hyperopia, the patient must
accommodate to focus the retinal image. Accommodation is
accompanied by the other components of the near reflex,
namely convergence and miosis.
If the patient’s fusional divergence mechanism is
insufficient to compensate for the increased convergence
tonus, esotropia results. The angle of esotropia is
approximately the same at distance and near fixation and is
generally between 20Δ and 30Δ. Patients with refractive
accommodative esotropia have an average of +4.00 diopters
(D) of hyperopia.
2. High AC/A ratio accommodative
esotropia
Patients with high AC/A ratio accommodative esotropia (also referred to as
non-refractive accommodative esotropia) have an excessive convergence
response for the amount of accommodation required to focus while wearing
their full cycloplegic correction. In this form of esotropia, the deviation is
present only at near fixation or is much larger at near (by 10Δ or more). The
refractive error in high AC/A ratio accommodative esotropia averages +2.25
D.
However, this esotropia can occur in patients with a normal level of
hyperopia or high hyperopia, with emmetropia, or even with myopia.
3. Partially Accommodative Esotropia
is similar to accommodative esotropia in that a significant component of
the esotropia results from accommodative convergence. However,
unlike pure accommodative esotropia, patients with partially
accommodative esotropia show a reduction in the angle of esotropia
when wearing glasses but have a residual esotropia despite provision of
the full hyperopic correction.
Under correction of hyperopia due to insufficient cycloplegia should be
ruled out as the cause of residual esotropia, especially in eyes with dark
iris.
MANAGEMENT
1. Normal AC/A ratio accommodative esotropia
Treatment of refractive accommodative esotropia consists of
correction of the full amount of hyperopia, as determined under
cycloplegia. If binocular fusion is maintained, the refractive correction
can later be decreased to 1.00–2.00 D less than the full cycloplegic
refraction. Amblyopia, if present, may respond to spectacle correction
alone, but treatment with occlusion or atropine may be necessary if the
amblyopia persists after a period of spectacle wear
Full time wearing of the spectacle is very necessary because, refractive
correction is necessary to help the strabismus; not to correct it.
2. High AC/A ratio accommodative esotropia
A high AC/A ratio can be managed optically or surgically; it can also be observed.
Bifocals Plus lenses for uncorrected hyperopia reduce accommodation and therefore
accommodative convergence. Bifocal glasses further reduce or eliminate the need to
accommodate for near fixation. Considerations for bifocals include the following:
• Flat- top style bifocals are prescribed initially. The clinician should use lowest plus
power needed (up to +3.00 D) to achieve ocular alignment at near fixation.
• The bifocal segment should be set high enough that the top of the bifocal segment
bisects the pupil.
• Progressive bifocal lenses have been used successfully in older children after they
have learned how to use bifocal glasses.
The process of reducing the bifocal power in 0.50–1.00 D steps can be started at
about age 7 or 8 years and can allow weaning by age 10–12 years. If a child cannot be
weaned from bifocals, surgery may be considered.
Surgery Surgical management of high AC/A ratio
accommodative esotropia is controversial. Some
ophthalmologists advocate surgery (medial rectus muscle
recessions with or without posterior or pulley fixation) to
normalize the AC/A ratio, which may allow the
discontinuation of bifocal use.
3. PARTIALLY ACCOMODATIVE ESOTROPIA
It consists of strabismus surgery for the deviation that persists
while the patient wears the full hyperopic correction. It is important
that the patient and parents understand before surgery that its
purpose is to produce straight eyes with spectacle wear— not to
enable the child to discontinue wearing glasses altogether.
In older patients, refractive surgery may be considered to both
reduce the hyperopic refractive error and improve the ocular
alignment.
TH
AN
YO K
U!
