Esotropia
Chairman – Dr Abdullahel azam
Senior Consultant, GEHTI
Moderator – Dr Tanzin Huda
Junior Consultant, GEHTI
Presenter – Dr Kazi Fabiha Tasnim
DO Resident, GEHTI
• Esotropia :
It is a type of strabismus where one or both
eyes turn inward.
Pseudoesotropia:
•Apparent convergent squint .
Causes are – 1.Prominent epicanthal fold
2.Negative angle kappa
• Concomitant Esotropia:
In a concomitant esotropia the variability if the
angle of deviation is within 5 ∆ in different gaze positions.
• Incomitant deviation:
In Incomitant deviation the angle differs in
various positions or gaze as a result of abnormal
innervation or restriction.
• Classification of Esotropia:
Accommodative Non-
• Refractive accommodative
• Fully accommodative • Early onset (essential
• Partially accommodative infantile)
• Non-refractive • Microtropia
• With convergence excess • Basic
• With accommodation • Convergence excess
weakness • Convergence spasm
• Mixed • Divergence
insufficiency
• Divergence paralysis
• Sensory
• Consecutive
Early onset Esotropia / Essential Infantile:
• Age of onset – upto the age of 4 months but may occur
anytime in first 6 months of life
• No significant refractive error
• No limitations of ocular movement
• Angle – fairly large(>30∆) and stable
• Usually alternateing, and cross fixating in side gaze
• Inferior oblique overaction
• Dissociated vertical deviation in 80% cases by the age
of 3 years.
• Horizontal nystagmus
Treatment:
• Initial treatment –
Eyes should be surgically aligned within 4 months of
the date of onset of constant esotropia.
Type of Surgery : Recession of both medial rectus
muscles or unilateral medial rectus recession with lateral
rectus muscle resection.
If Angles > 65 ∆ : recession of both medial rectus
muscles as well as resection of both lateral rectus
muscles.
•Subsequent treatment –
Under correction- further recession of the medial recti,
resection of one or both lateral recti
• Inferior oblique overaction – weakening
of inferior oblique include disinsertion,
recession and myectomy .
• DVD – surgery includes superior rectus
recession with or without posterior
fixation sutures, resection or tuck of
inferior rectus and inferior oblique
anterior transposition.
Refractive Accommodative Esotropia:
• AC/ A ratio is normal
• Physiological response to excessive hypermetropia usually
between +2.00 and +7.00 D.
• Angle usually <10∆
• Age of onset – 18 months to 3 years
• Fully accomodative esotropia – hypermetropia with
esotropia when refractive error is uncorrected.
Treatment – Optical correction.
• Partially accommodative esotropia – Esotropia occurs
partially due to hypermetropia and there is non
accommodative element.
Amblyopia is frequent, bilateral congenital superior oblique
weakness may present.
Non Refractive accommodative :
•Convergence excess - AC/A ratio is high(accomodation is
normal, convergence is high).
Normal near point of
accomodation .
Straight eyes with BSV for
distance .
Esotropia for near with
suppression.
• Hypoaccomodative convergence excess – AC/ A ratio
high.
Remote near point if accommodation.
Treatment : correction of refractive error
Other esotropias
• Near esotropia (non-accommodative
convergence excess) :
Presentation is usually in older children and young
adults.
Signs –
No significant refractive error.
Orthophoria or small esophoria with BSV for
distance.
Esotropia for near but normal or low AC/A ratio.
Normal near point of accommodation.
Treatment - involves bilateral medial rectus
Distance esotropia :
•Presentation - healthy young adults, who are often
myopic.
•Signs -
Intermittent or constant esotropia for distance.
Minimal or no deviation for near.
Normal bilateral abduction.
Fusional divergence amplitudes may be reduced.
Absence of neurological disease.
•Treatment - is with prisms until spontaneous
resolution or surgery .
Acute (late-onset) esotropia:
•Presentation – 5 to 6 years of age.
• Signs -
Sudden onset of diplopia and esotropia.
Normal ocular motility without significant refractive
error.
Underlying sixth nerve palsy must be excluded.
• Management
Because the onset of comitant esotropia in an older
child may indicate an underlying neurological disorder,
it is important to check the pupil reflexes and exclude
optic disc changes, nystagmus and a sixth nerve palsy.
Neuro-radiological examination may be needed.
• Treatment is aimed at re-establishing BSV to prevent
Secondary (sensory)
esotropia:
•Secondary esotropia is
caused by a unilateral
reduction in VA that
interferes with or abolishes
fusion.
• Causes are cataract, optic
atrophy or hypoplasia,
macular scarring or
retinoblastoma
High myopia esotropia (‘heavy eye syndrome’)
is a cause of acquired esotropia in adults secondary to high
myopia (average: −18 D; range −12 D to −21 D and axial
length 27-35 mm)
Cause - Shifting of the lateral rectus and superior rectus
muscles secondary to an elongated posterior portion of a
highly myopic eyeball.
Imaging consistently demonstrates inferior shift of the
lateral rectus and nasal shift of the inferior and superior
recti causing the eye to shi supero-temporally from the
pulley array, converting the lateral rectus from abductor to
infraductor.
Consecutive esotropia:
Consecutive esotropia follows surgical over-correction of
an exodeviation.
Cyclic esotropia:
•Cyclic esotropia is a very rare condition characterized
by alternating manifest esotropia with suppression and
BSV, each typically lasting 24 hours.
•This condition may persist for months or years and the
patient may eventually develop a constant esotropia.
•Treatment – surgery.
Take home massage:
• Irrespective of age all children with Esotropia should
undergo cycloplegic refraction.
• Early diagnosis and evaluation is necessary for proper
treatment of Esotropia .
Thank you
