Concomitant Esotropia

Presentor: Priyanka Rajbhandari

Optometrist, LEIRC
 Concomitant Esotropia
• Manifest convergent deviation of the visual
axes in which the amount of deviation in the
squinting eye remains constant in all
directions of gaze and there is no associated
limitation of ocular movements.
 Classification
1. Infantile(congenital) esotropia

2. Accommodative esotropia
i. Refractive accommodative esotropia
ii. Non-refractive accommodative esotropia(high AC/A
ratio)
iii. Hypoaccommodative esotropia
iv. Partially accommodative esotropia

3. Non-accommodative esotropia
4. Sensory esotropia
 Infantile Esotropia
• old name- congenital esotropia.
• usually presents at 1-2 months of age.
• may be detected shortly after birth or any
time within first 6 months of life.
 Etiology
1. Innervational disturbance
2. Role of accommodation
3. General and environmental factors
 Clinical features
1. Time of onset
- In most cases, squint manifests within first 6 months of
life.

2. Angle of deviation
- Most patients with infantile esotropia have a large
angle of deviation for both distance and near
fixation( 30 degrees or more).
- Angle of deviation is usually stable except for few cases
having an accommodative element in the etiology.
3. Fixation pattern
- Usually an alternate fixation occurs in primary
gaze and crossed fixation in lateral gaze; i.e.
the infant fixates the objects in the left field
with right eye and the object in the right field
with the left eye.
4. Apparent limitation of abduction
- The cross-fixation makes the abduction of
either eye unnecessary and thus on initial
examination, the impression of B/L 6th nerve
palsy may be given.
Examination techniques that help in
demonstrating the presence of abduction are:
1. Doll’s head phenomenon test
2. Alternate patching
• In the doll’s head maneuver, the child is given
an interesting fixation target to look at and the
head it gently rotated away from the target.
5. Visual acuity
- Normal and equal in both eyes of patients
who freely alternate fixation.
- If one eye is preferred for fixation, amblyopia
will develop in the other eye.
6. Refractive errors
- Consistent with the patient’s age group.
 Associations:
1. Inferior oblique overaction(around 70%)
2. Dissociated vertical deviation(DVD)(50-90%)
3. Latent nystagmus(40%)
 Management
A. Non-surgical treatment:
1. Correction of refractive error
2. Treatment of amblyopia
3. Botulinum toxin:
• Botulinum toxin can be injected into the
medial recti to weaken them and bring eyes
back into alignment.
B. Surgical Treatment:
1. Bimedial recessions
2. Unilateral recess-resect procedure on the
non-dominant eye
 Time of Surgery
 Before the surgery is performed for infantile esotropia,
following pre-requisites should be ascertained:
• Deviation should be constant and stable.
• Fixation should be alternating or only a mild fixation
preference should be present.
• Accommodative element should be absent.
• Sensory esotropia should have been ruled out.
• Amblyopia should have been treated.
• Associated vertical deviations or A/V patterns should be
revealed.
 Refractive Accommodative Esotropia
• The mechanism involves 3 factors:
(1) uncorrected hyperopia,
(2) accommodative convergence, and
(3) poor fusional divergence.
• Due to uncorrected high hyperopia, the
accommodative drive to produce a clear retinal
image leads to increased convergence.
• Further, if the patient’s fusional divergence is
poor, esotropia occurs.
 Clinical features

• usually occurs in a child between 2-3 years of age or may occur

anytime between birth to 7 years.
• The parents report that the child’s eyes are straight some of
the time, but that when the child is focusing at near or is tired,
one or both eyes cross inward.
• At onset, younger children may demonstrate increased eye
rubbing or squinting.
• Older children may complain of asthenopic symptoms such as
headaches or diplopia.
• However, once the esotropia is more manifest and abnormal
retinal correspondence develops, these symptoms are relieved.
• The cycloplegic refractive error in refractive
accommodative esotropia ranges between +
1.5 and +7.0 D.
• The angle of deviation is typically the same
for distance and near, averaging between 20
and 40 prism diopters.
• When the esodeviation becomes constant,
amblyopia develops.
• AC/A ratio is usually normal.
 Associations:
• Vertical deviations
• A-V pattern
 Treatment
• A full hyperopic correction based on
cycloplegic refraction is the mainstay of
treatment of refractive accommodative
esotropia.
• Glasses must be worn on a full-time basis.
With part-time use of glasses, the child’s
accommodation is never fully relaxed.
Non-refractive accommodative esotropia

• It is a type of accommodative esotropia which

is caused by a high AC/A ratio and thus
esotropia is significantly greater at near than
distance fixation.
 Etiopathogenesis
• occurrence of an excessive amount of
accommodative convergence associated with
the normal amount of accommodation (i.e.
high AC/A ratio).
 Clinical features
• usually present between 2 and 3 years of age.
• The refractive error in this condition may be
hyperopic, emmetropic, or myopic. The
average refractive error is +2.25 D.
• A normal AC:A ratio is 3 to 5 prism diopters: 1
diopter.
 Treatment
Bifocals(+2.50 D to +3.00 D) are the most
commonly used treatment strategy for non-
refractive accommodative esotropia.
• They are prescribed to relax the near
accommodation and correct the near deviation,
thus promoting near fusion.
• Distance refractive correction should be
prescribed as appropriate.
 Miotic agents:
• In children less than 1 year old, spectacle
compliance may not be ideal (due to lack of
cooperation, flat nasal bridge, and the difficulty
of fitting them appropriately).
• Miotics are advantageous over bifocals because
they allow the child to remain spectacle-free, yet
do not require strict cooperation from the child.
• Miotics facilitate accommodation and thus reduce
the accommodative convergence.
• Treatment of accommodative esotropia includes
echothiopate iodide 0.125%.
• It has a parasympathomimetic effect on the iris
sphincter and ciliary muscle, thus reducing the
accommodative effort required to obtain a clear
retinal image. Consequently, the reflex convergence
also reduces.
 Surgery:
• surgery is indicated in patients with large
angle of squint in which deviation cannot be
corrected by above measures.
 Orthoptic exercises:
• orthoptic exercises along with the use of
bifocals glasses/ miotics can be given to
overcome suppression and to improve
fusional divergence.
Partially Accommodative Esotropia

• similar to accommodative esotropia.

• In partially accommodative esotropia, patients
show a reduction in the angle of esotropia
when wearing glasses but have a residual
esotropia despite the full hyperopic correction.
• Partially accommodative esotropia may also
refer to an esotropia that was initially fully
accommodative, but that subsequently
decompensated over time.
• Undercorrection of hyperopia, larger distance
deviation should be ruled out as the cause of
residual esotropia.
 Treatment
• The initial treatment of partially
accommodative esotropia is correction of the
full hyperopic error.
• Strabismus surgery for the squint that
exists(residual esotropia >10 Pd for distance
and near) even after the patient wears the full
hyperopic correction.
• B/L MR recession is the procedure of choice
for partially accommodative esotropia.
Prism adaptation
• Another method involves the use of prism adaptation,
which involves prescribing base-out prisms for residual
esotropia after full hyperopic correction.
• The patient then returns in 2 weeks and if the
esotropia has increased, a larger prism is given.
• This process continues at 1- to 2-weekly intervals until
the deviation has stabilized.
• The surgeon then operates on the full “prism-adapted”
angle.
 Sensory Esotropia
• It refers to the esotropia which develops due to
poor visual function in one eye since childhood.
• Unilateral reduced visual acuity occurs due to
various organic causes.
• In children under 4 years of age, the blind or
poorer-seeing eye will generally become esotropic.
• Older children or adults with sensory visual
deprivation will generally develop a sensory
exotropia.
 Clinical features
• monocular visual loss due to organic causes.
• Deviation- sensory esotropia is always
comitant.
• Amblyopia
 Treatment
• Surgical treatment – to improve cosmetic appearance
since the visual loss is due to organic lesion.
• In children with sensory esotropia due to uncorrected
aphakia or traumatic cataract, cataract surgery,
treatment of aphakia and occlusion therapy for
amblyopia should be tried first followed by squint
surgery.
• MR recession with or without LR resection depending
upon the size of deviation should be performed on the
eye with poor vision.
 Consecutive Esotropia
• occurs when a person who was formerly
exotropic becomes esotropic as a result of
surgical overcorrection for exotropia.
 Acquired non-accommodative esotropia
 Basic Esotropia:
• Develops after 6 months of age and is not accommodative.
• deviation is usually equal at distance and near.
• refractive error is insignificant.
• Children may initially have diplopia if onset is acute.
• Acute onset of esotropia may indicate and underlying
neurologic disorder(headache, nausea or vomiting, small V
pattern incomitance, abnormal head position).
• Amblyopia, when present, should be treated first.
• The prognosis for recovery of binocular vision with prism or
surgery is good as patients previously had the ability to fuse.
 Cyclic esotropia:
• A comitant, intermittent esotropia occurs at
regular intervals, classically every other day.( a
strabismic and a non-strabismic phase of 24
hours each).
• This form of strabismus is rare and the cause
unknown.
• most frequently occurs between 2-6 yrs of age.
• Surgical treatment is typically effective.
 Clinical features
1. During strabismic phase(24 hrs):
• deviation is usually large (40 to 70 pd), consistent
deviation on subsequent examinations.
• suppression in deviated eye.
• fusional amplitudes are defective.
2. During non-strabismic phase(next 24 hrs):
• no manifest deviation, esophoria may be
present.
• fusion, stereopsis are both normal.
 Treatment
• Surgery in the form of either B/L MR
recessions or recession of the MR and
resection of the LR is indicated.
 Divergence insufficiency type esotropia:
• most often associated with adult patients 50
years and older.
• characterized by an esodeviation greater at
distance than near.
• Fusional divergence amplitudes are reduced at
both distance and near fixation, and this
esotropia is comitant in primary and lateral
gazes.