1) Infantile esotropia is a type of crossed eyes that develops within the first 6 months of life in an otherwise normal infant, with no significant refractive error or eye movement limitations. 2) The cause is unknown but theories involve a congenital deficit in the brain's "fusion center" or a primary motor misalignment disrupting binocular vision. 3) Treatment involves early surgical alignment of the eyes through muscle surgery like bilateral medial rectus recession, along with non-surgical measures to enhance binocularity and improve vision, with the goal of aligning the eyes within 10 prism diopters of orthophoria.

1. Presenter : Dr. Mahamud Adnan
DO resident, NIO & H.
Infantile Esotropia &
Management

2. Chairman : Dr. Shovana Alam
Associate Professor
Pediatric ophthalmology, NIO & H
Moderator : Dr.Nusrat Shahrin
Assistant Surgeon
Pediatric ophthalmology, NIO & H.

3. Milestone of Vision :
• At birth-
Eyes move randomly, no central fixation
• At 6 weeks-
Apparent fixation reflex , can follow bright light at
short distance

4. Cont.
Milestone of Vision :
• At 4-6 months -
Convergence established .
Foveal reflex developed at 4
th
month .
Central fixation developed at 6 months.
• At 6 years -
Foveal development is complete &
visual acuity achieved 6/6.

5. Visual axis
Pupillary line
Angle kappa

6. Cont.
Phoria = latent deviations
Tropia = manifest deviations
Orthophoria
It implies perfect ocular alignment in the
absence of any stimulus for fusion.

7. Cont.
Esotropia :
The term ‘esotropia’ is derived from two Greek
words ‘eso’ means ‘inward’ and ‘trepe’ means
‘turn’
In esotropia, the eyes are crossed, that is, while
one eye looks straight ahead and the other eye
is turned in toward the nose.

11. Cont.
Pseudo-esotropia :
is the clinical impression of ocular deviation
when no squint is present.
Wide nasal bridge
Prominent epicanthal folds
Narrow interpupillary distance
Negative angle kappa
Usually with the formation of the bridge of
the nose, it disappears.

12. Classification of Esotropia
Accommodative
1.Refractive:
• Fully accommodative
• Partially
accommodative
2.Non-refractive:
• With convergenc
excess
• With accommodation
weakness
3.Mixed
Non-accommodative
Early onset(Infantile)
Microtropia
Basic
Convergence excess
Convergence spasm
Divergence insufficiency
Divergence Paralysis
Sensory
Cyclic

13. Infantile Esotropia
• Definition:
Infantile or congenital esotropia is an
idiopathic condition developing within first 6
months of life in an otherwise normal infant with
no significant refractive error or no limitation of
ocular movements.
• Prevalence : 27/10,000 live births.

15. Etiology
• The cause of infantile esotropia remains unknown.
 Worth Theory
– “Sensory” concept
– Congenital deficit in a “fusion center” in the brain
 Chavasse Theory
 Primary motor misalignment
 Disruption of binocular vision
 Potentially curable if ocular alignment is
achieved in infancy.

16. Risk Factors
• Family history
• Secondary ocular history
• Prematurity
• Low birth weight.
• Perinatal or gestational complication

17. Characteristics
• Idiopathic
• Within 1st 6 months of life
• No significant refractive error(Normally +1.5 D)
• Family history(+/-) but not well defined genetic
pattern
• Otherwise patient is normal

18. Signs
• Apparent , large angle( >30 PD )
• Alternate fixation in primary position.
• Cross fixation in side gaze.
• Poor potential for BSV
• Amblyopia (+/-)
• Nystagmus - horizontal.
• Emmetropia / Mild Hypermetropia / Myopia

19. Cont.
• Associated conditions :
- Dissociated vertical deviation (DVD, 75% )
- Inferior oblique overaction ( 70% )
- Latent and manifest nystagmus ( 50% )

20. Differential Diagnosis
• Pseudo-esotropia
• Congenital 6th nerve palsy
• Secondary(sensory) esotropia
• Duane syndrome
• Mobius syndrome

21. Evaluation
History:
1.Age of onset
2.Head posture
3.Birth history
4.Family history of strabismus
5.Previous ocular history
- use of spectacles
- occlusion therapy
- previous surgery

22. Examination
• Visual acuity :
In preverbal child
- Fixation and following
- Comparison (occlusion of one eye)
- Fixation behaviour test
- Rotation test
- Preferential looking test
- Visual evoked potential

26. Cont.
Measurement of deviation :
• Hirschberg test

27. Cont.
• Cover-uncover test :
- Cover test
- uncover test
- Alternate cover test
- Prism cover test
• Krimsky and prism reflection tests

29. Cont.
• Ocular motility
examination :
- Versions
- Ductions
• Refraction and
Fundoscopy

30. Treatment
Aim :
- Align visual axis
- Enhance binocularity
- Improve visual acuity
Goal :
- Alignment within 10 of orthophoria

31. Non Surgical Treatment
• Correction of refractive error, if any.
• Treat amblyopia
• Botulinum toxin inejction into MR

32. Without spectacle With spectacle

33. Surgical treatment
Time of surgery:
• Between 6 months to 2 years of age
• Recent studies favour early surgery as soon
as diagnosis is made
• Wait up to 6 months of age in intermittent
esotropia or small to moderate angle
deviations

34. Cont.
Before proceeding to surgery:
• Deviation should be constant and stable
• Accommodative element should be absent
• Sensory esotropia should have been ruled
out
• Amblyopia should be treated optimally
• Counseling of parents.

35. Surgical Approaches
• Bilateral Medial Rectus recession
• Ipsilateral MR recession with LR resection
• Adjustment of vertical muscles - Weakening IO

37. Deviations
PD
B/L MR
recession(m
m)
Recession of
MR
Resection of
LR
15 03 03 04
20 3.5 3.5 05
30 4.5 4.5 06
40 5.5 5.5 07
50 06 06 08
60 6.5 6.5 09
70 07 07 10

38. Before surgery After 01 month

39. Post Surgical Outcomes
1. Under correction .
2. Over correction .
3. DVD :
- SR recession with or without posterior
fixation suture
- IO anterior transposition.

40. Cont.
4. IO overaction :
- Disinsertion
- Recession
- Myectomy
4. Amblyopia-subsequently develops in 50% of
cases

41. Cont.
5. Other surgical complications like –
- Slipped rectus muscle
- Anterior segment ischemia
- Cellulitis
- Endophthalmitis
- Retinal detachment

42. Ciancia syndrome
A severe form of infantile esotropia, referred to
as Ciancia syndrome.
 Features:
 Large angle deviation(>50 PD)
 Abducting nystagmus
 Mild abduction deficit

43. Take home message
• Onset of Infantile esotropia is around 4 months
of age
• This produces profound deficits in binocular
vision if not correct promptly.
• We should operate early (<2 years) to promote
the development of binocular vision and some
stereopsis.