Esotropia is commonest childhood squint. Knowing about diagnosis and management are important for better care.

1. Prepared by
Anis Suzanna Binti Mohamad
Pegawai Optometri HSBAS
DIAGNOSIS & MANAGEMENT OF
ACCOMODATIVE ESOTROPIA
19 November 2020

2. Overview
Background
Case report
Discussion
Conclusions

3. Background
 Accommodative esotropia is the most common
form of childhood strabismus presenting to
optometric practice.
Accommodative
esotropia
Physiological
response to high
hypermetropia
Fully
accommodative
esotropia
Abnormal
response to
moderate
hypermetropia
Partial
accommodative
esotropia/near
esotropia
The excess convergence are
due to:-
•Deviation too large
• Amblyopia is decreasing
fusion ability

4. Background
 Average age of presentation: 2.5 y/o (3months to
7y/o)
 Other complicating factors such as:-
 Vertical deviations (IO o/a,SO u/a)
 Amblyopia (cause effect or association of the esotropia)
 Accurate differential diagnosis of esotropia plays a
key role in successful management of the deviation.
(Mx different from Infantile esotropia, 6th nerve and
Duane’s).
 Functional and cosmetic outcomes are often excellent
but depend on accurate diagnosis, urgent and correct
initial management and careful follow‐up.

5. Case report
 Pt initially presented to our clinic when he was 3 years
old.
 Parents had noticed alternating inward turn of the
eye.
 Referred from private Opthal in KK, Sabah. Already
start patching alternate eye.
 Findings on 1st visit,25/02/2014:-
 TCA x 2/12 for PMT. KIV to prescribe gls. Start
occlusion after 1/12 spect wear.
RE LE
VA (Cardiff@1m) 6/12 6/30
Cycloplegic
refraction
+2.00/-1.50x180 +3.00/-1.75x180
Cover test LE small esotropia
Krimsky 18 pd BO

6. Second follow-up
 Pt continue amblyopia treatment under private
optometrist.
 Pt turn up only after ~ a year, was on 3/9/2015.
 Findings:
 TCA x 3/12
 Pt loss of follow-up
RE LE
Vision unaided
(Projector
number)
6/9 6/30
Cycloplegic
refraction
+2.00/-1.00 x 180 +1.75/-1.25 x 180

7. 3rd follow-up to 7th follow-up
 Partial compliance with gls, not compliance with
patching tx
 Start with atropine penalization tx with close
monitoring.
 Stop atropine penalization at 6th follow-up,
Visual acutiy RE LE
3rd f/up
(12/01/2016)
6/9 6/30
4th f/up
(22/02/2016)
6/6 6/21
5th f/up
(21/04/2016)
6/21 (unattentive) 6/9+2
6th f/up
(26/06/2016)
6/9 6/21
7th f/up
(26/12/2016)
6/9 6/12

8. 8th follow-up to 12th follow-up
 Compliance with gls, not compliance with
patching tx
 Start follow-up 6 months monitoring.
 Glss broken before 9th visit.
 Prescibe new gls Rx on 12th visit as VA improved
Visual acutiy RE LE
8th f/up
(10/07/2017)
6/9 6/12
9th f/up
(01/01/2018)
6/9-2 6/21-2
10th f/up
(30/05/2018)
6/6-1 6/21+2
11th f/up
(21/11/2018)
6/6-1 6/15+2
12th f/up
(13/05/2019)
6/7.5-2 6/12-2

9. 13th follow-up to 15th follow-up
 Compliance with glss. Still not compliance with
patching tx.
 Review VA with new gls Rx during 13th visits.
 Pt stop patching at 13th visits? Just continue
wearing glss.
 Given appt yearly for RA check-up and VA
deteriorated on next visit especially LE.
 Plan on 15th visit, prescribe gutt atropine to drop
Visual acutiy RE LE
13th f/up
(18/07/2019)
6/9 6/18
14th f/up
(18/11/2019)
6/6 6/9-3
15th f/up
(26/08/2020)
6/6 6/18-3

10. 16th follow-up
 Pt came for PMT atropine.
 Prescribe new gls Rx using PMT atropine power
on BE.
 Next TCA x 2/12.
RE LE
PMT +2.50/-1.25x10 +2.50/-1.00x170
BCVA 6/6-2 6/12-1

11. VA change over clinic visits
0
1
2
3
4
5
6
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
VisualacuityinMAR
VISIT
VISUAL ACUITY RE
VISUAL ACUITY LE
Visual acuity notations
MAR (1.0) Snellen
Acuity
1.0 6/6
2.0 6/12
3.2 6/18
4.0 6/24
5.0 6/30

12. Discussion
 1) Aetiology and differential diagnosis
 Aetiology helps optometrist to decide whether they
are dealing with:-
 Primary benign esotropia
 Esotropia secondary to a potentially serious systemic
problem
 It determines the management for most esotropia.
 The clinical characteristics of the common esotropia
are listed in the table 1.

14. Quantification of the strabismus is
important to diagnosis..
Magnitude Constancy Laterality
Concomitancy
Fusion
state/capacity
Presence/depth
of amblyopia
AC/A ratio
Cycloplegic
refraction is
MANDATORY

15.  Differential diagnosis
 Infantile esotropia and early onset accomodative
esotropia can be confused.
 Signs suggestive of infantile esotropia:-
 Latent nystagmus
 Smooth pursuit asmmetry
 Dissociated vertical deviation

18. The clinician must seek any accommodative component:-

19. 2) Management
 Management of accommodative esotropia can be
divided into stages:-
Stage
1
Prevent further
motor adaptations.
Prescribe glasses that get the eyes as
straight as possible.
Stage
2
Treat monocular
sensory
adaptations.
Treat amblyopia to achieve best possible
VA in each eye alone.
Stage
3
Treat motor
adaptations and
binocular sensory
adaptations.
•Restore binocular alignment (may
require increased hypermetropic
correction i.e :bifocals, corrective
prisms,vision theraphy or surgery).
•Achieve best possible binocularity
(requires VT).
Stage Promote Wean patients off plus lenses in the

20. 2) Management
 PEDIG trials suggest for:-
 Full time patching
 Part time patching same average effect
over 6 months period
 Atropine penalization
We elected to modify theraphy between these 3
proven options to maintain compliance.
Treating binocularity in Stage 3 is more difficult.
Depends on age of onset and the duration of
constant esotropia.
Aim will achieved at stage 4 in future by weaning
them off spectacles. According to Lambert’s study,
children with lower baseline hypermetropia
refractive errors (+3.00DS OU) are more likely to

21. Point to ponder
 It is important for parents to realize that their
children will need to wear spectacles for:-
1. Maintain good VA
2. Binocular alignment
3. High-grade stereopsis

23. SOP: Diagnosis and Classification of Concomitant
Squint (Esotropia)
Concomitant
squint
Primary
Constant
esotropia
With an
Accommodat
ive
Without an
Accommodat
ive
Intermittent
esotropia
Accommodat
ive
Fully
Accommodat
ive
With
convergence
Fixation
Near Distance
Cyclic
Secondary Consecutive

30. Conclusions
 Clinical assessment must aim to reach a diagnosis
based on aetiology, as the aetiology of esotropia has
a significant impact on management decisions and
prognosis.
 Accommodative esotropia is the most common form
of childhood strabismus and has a favorable
prognosis, if appropriate treatment is initiated
promptly.
 Spectacles and patching
compliance need report in
percentage. Easily monitor.
 Quantification of the
strabismus is important to
diagnosis.
 Modify therapy between full-
time patching, part-time
patching and atropine
penalization to maintain