The document discusses accommodative esotropia, its classifications, prevalence, clinical features, and management strategies. It emphasizes the conditions under which esotropia occurs, its hereditary nature, and characteristics linked to refractive errors. Management options include optical corrections, amblyopia therapy, orthoptic exercises, and potential surgical intervention for associated deviations.

1. ACCOMMODATIVE
ESOTROPIA
TRISHNA THAPA
PHASE-III
BOVS, NEH, NAMS

2. CONTENTS
Introduction
Classification
Etiopathogenesis
Clinical features
Investigation
Management

3. HISTORY
Was reported early as 1864 by Donders
Donders reasoned that these individual must accommodative more to
overcome hyperopia to clear retinal image

4. PREVALENCE
 The global prevalence of esotropia is 0.77%.
 The incidence is estimated at 1-2% of the population
 In Oman, a total of 51 patients that were identified, twenty-four patients were diagnosed
with fully accommodative ET (FAET) and 27 with partially accommodative ET (PAET)
 In a population based study of AE prevalence in amblyopia in Macedonia, the prevalence of
pure accommodative esotropia in Macedonian strabismic cohort was 11.6% (25/215), partial
accommodative esotropia 7.9% (17/215), and non-accommodative esotropia 59.5%
(128/215)
1. Hassan Hashemi , Reza Pakzad, Samira Heydarian, Abbasali Yekta, Global and regional prevalence of strabismus: a comprehensive systematic review and meta-
analysis ; strabismus 2019 Jun;27(2):54-65. doi: 10.1080/09273972.2019.1604773.
2. Lembo A, Serafino M, Strologo MD, Saunders RA, Trivedi RH, Villani E, Nucci P. Accommodative esotropia: the state of the art. Int Ophthalmol. 2019 Feb;39(2):497-
505. doi: 10.1007/s10792-018-0821-6. Epub 2018 Jan 13. PMID: 29332227.
3.. OK Sreelatha, Hajar Ali Al-Marshoudi, Maha Mameesh, Sana Al Zuhaibi, Anuradha Ganesh Accommodative esotropia: An outcome analysis from a tertiary center in
Oman , . 2022 Nov 2;15(3):274–278. doi: 10.4103/ojo.ojo_80_22
.

5. INTRODUCTION TO ACCOMMODATIVE
ESOTROPIA
Esotropia caused by over convergence in response to accommodation
Characteristics :
Onset age : Between 2 and 3 years (most cases occur between 6 months and 7
years of age )
Usually of intermittent nature at onset, becomes constant with passage of time
Often hereditary
Sometimes precipitated by trauma or illness
Amblyopia frequently associated

6. CLASSIFICATION
1.
• REFRACTIVE ESOTROPIA
2.
• NON-REFRACTIVE ESOTROPIA
3.
• PARTIALLY ACCOMODATIVE ESOTROPIA

7. REFRACTIVE ACCOMMODATIVE ESOTROPIA
Characterized by :
Full hyperopic correction completely eliminates esotropia at near and
distance fixation
Varies in degree depending on the amount of accommodation exerted
Caused by Hypermetropia
Develops around the age of 18 -24 months to clear the retinal blur

8. ETIOPATHOGENESIS
Tendency to develop esotropia depends on :
Degree of Hyperopia
Amount of fusional amplitude in reserve
AC/A ratio
Child’s personality

10. CLINICAL FEATURES
1. Time of onset
 Manifests between the age of 2 and 3 years
2. Hypermetropia
 Hypemetropia ranging between 2 and 6 dioptres with
a mean of 4.75 dioptres

11. CLINICAL FEATURES
3. Ocular Deviation :
- Passes through following stages :
Stage of
Esophoria
Stage of
Intermittent
esotropia
Stage of constant
esotropia

12. CLINICAL FEATURES
4. AC/A ratio
Normal
5. Development of Sensory Adaptation :
Suppression
Abnormal retinal correspondence
Amblyopia - In unilateral constant esotropia with strong fixation
preference
Alternate fixation with no binocular single vision - In alternate
convergent squint

13. CLINICAL FEATURES
6. Associations :
 Vertical deviations
 A-V patterns

14. NON-REFRACTIVE ACCOMODATIVE
ESOTROPIA
Characterized by :
Significantly larger esotropia at near(10 PD or more) ,little or no esotropia
at distance fixation
Unrelated to refractive error
High AC/A ratio
About 5% of esotropia show non-refractive accommodative esotropia

15. ETIOPATHOGENESIS
 Causative factor attributed to :
Innervational and excessive amount of accommodative convergence
associated with abnormal amount of accommodation (i.e. high AC/A
ratio)

16. CLINICAL FEATURES
1. Time of onset :
 Between 2-3 years
2. Ocular deviation :
 Deviation initially small and intermittent(Rarely does it exceed 30
PD)
 The near esotropia is typically much greater than the distance
esodeviation

17. CLINICAL FEATURES
Near-distance disparity
Grade I : 10–19 PD more deviation for near
Grade II : 20–29 PD more deviation for near
Grade III : 30 PD more deviation for near
3. AC/A ratio :
 Characteristically high

18. 4. Development of sensory adaptations :
 Suppression
 Abnormal retinal correspondence
 Amblyopia
5. Associations
 Vertical deviations
 A–V pattern

19. HYPOACCOMODATIVE ESOTROPIA
Term coined by Costenbader
Clear and single
near objects
Convergence
Accommodation

20. HYPOACCOMODATIVE ESOTROPIA
Weak accommodation , over convergence
Esotropia large for near fixation and small for distance fixation

21. Esotropia is not related to uncorrected hypermetropia
CA/C is low ?
Near point of accommodation (NPA) definitely remote, i.e. there
is weakness of accommodation

22. PARTIALLY ACCOMMODATIVE ESOTROPIA
Esotropia caused by combination of hypermetropia and high AC/A
ratio

23. PARTIALLY ACCOMMODATIVE
ESOTROPIA
1. Infantile esotropia with superadded
accommodative esotropia :
• Infantile esotropia with RAE
2. Decompensated accommodative esotropia
with superadded non-accommodative esotropia
• RAE with NRAE

24. CLINICAL TYPES
1. Infantile esotropia with superadded accommodative esotropia :
 Child first develops typical infantile esotropia before 6 months of age
which is non-accommodative
 Superadded by accommodative esotropia, usually, by the age of 2–3
years

25. 2. Decompensated accommodative esotropia with superadded non-
accommodative esotropia
Increased
convergence tone
or mechanical
factors such as
hypertrophy or
contracture of the
medial rectus
muscles,
conjunctiva or
Tenon's capsule
Accommodative
esotropia is well
corrected with
glasses or
bifocal lenses.
Esotropia again
develops due to
some
superadded non-
accommodative
factors

26. CLINICAL EVALUATION AND DIAGNOSIS
History
Symptoms
Measurement of visual Acuity(With and without glasses for near and
distance)
General Inspection:
 IPD, nasal bridge, epicanthus,
 Pupillary reaction
 Facial asymmetries
 Abnormal head posture

27. CLINICAL EVALUATION AND DIAGNOSIS
Bruckner test
Hirschberg test
Prism Cover tests
Synaptophore test
Ocular motility test

28. CLINICAL EVALUATION AND DIAGNOSIS
 Measurement of deviation(direction, frequency, laterality, magnitude of
deviation)
 Cycloplegic refraction
 Measurement of accommodation, AC/A ratio
 Measurement of fusional divergence amplitude
 Examination of fundus and ocular media

29. MANAGEMENT
1. Optical correction
2. Amblyopia therapy
3. Miotics
4. Orthoptics exercises
5. Surgery

30. 1. Optical correction
A. For accommodative esotropia
 Full optical correction
Atropinization for a few weeks to relax accommodation for
those who has never worn glass before

31. Method of prescribing optical correction and
follow-up
i. From birth to 6 months
 Full retinoscopic findings plus an additional +1.5D(for
hypermetropia of +2.0 diopters or more)
 These infants should be seen every 2–3 weeks
ii. From 6 months to 6 years
 Hypermetropia of more than +1.5 D should be prescribed full
retinoscopic finding without any additional plus lens
 Should be followed every month till their deviation is stabilized

32. iii. Above 6 years of age
 The optical prescription should include the minimum power lens
that should provide both binocular single vision with esophoria and
maximum visual acuity
 These patients should be followed up every 6 months for 2 years

33. B. For non-refractive accommodative esotropia
 Full cycloplegic refraction with bifocal add of +3.00
with simultaneous orthoptic exercises proven to be
extremely useful
 Below 6 months: Bifocals not required
 For children above 6 months: A focal add of +3.00
D should be given with full retinoscopic correction

34. PRESCRIPTION OF BIFOCALS
Usually, +3.00 D add required in bifocal glasses
However, add determined by hit and trial method
Starting with +1D in increasing steps to +3 D till all near
esotropia corrected
Executive bifocal preferred
Follow up examination every 3 months up to 1 year, every
6 months up to 2 years ,thereafter every year

35. C. For hypo accommodative esotropia:
 NPA is definitely remote so, near add of plus lens are required to
compensate for weak accommodation
 Full cycloplegic correction is required for distance segment
D. For partially accommodative esotropia:
 Full hyperopic correction prescribed
 High AC/A ration can be treated with the help of bifocals

36. 2. Role of Miotics
In extremely uncooperative and hyperexcited children,
miotics as short-term alternative to spectacles
Most commonly used miotics:
 Phosphopline iodide(0.006%,0.125%)
 Diisopropyl fluorophosphate ointment(DFP 0.025%)
3. Amblyopia therapy
Indicated when child s brought late with constant
unilateral accommodative esotropia

37. 4. Orthoptic treatment
Aims at overcoming suppression and
negative fusional convergence
5.Role of surgery
Only indicated in patients who have
associated vertical deviations of A – V
patterns

38. REFERENCES
Theory and Practice of Squint and Orthoptics, AK khurana, 3rd
edition
Lyle and Jackson’s practical orthoptics in the treatment of
squint ,5th
edition
Pediatric Ophthalmology and strabismus : AAO
Binocular Vision and Ocular Motility, Gunter K. Von
Noorden, MD
Internet resources

39. THANK YOU !