This document discusses the management of esotropia, a type of strabismus where the eyes turn inward. It describes the different types of esotropia including concomitant, accommodative, and inconcomitant esotropia. For treatment, it emphasizes correcting refractive errors and amblyopia first before considering surgery. For concomitant esotropia in young children, the initial surgery is typically recession of both medial rectus muscles. For accommodative esotropia, treatment involves correcting refractive errors or surgery depending on the severity. Management is tailored based on the specific type and cause of esotropia.

2. MANAGEMENT OF
ESOTROPIA
Dr Amna Ali
Resident -4TH YEAR
EYE UNIT 1

3. Esotropia

4. Concomitant esotropia
 A manifest convergent misalignment of the
eye(s) in which the measured angle of
esodeviation is nearly constant in all fields of
gaze at distance fixation

5. Concomitant esotropia
Accommodative
a Refractive
• Fully accommodative
• Partially accommodative
b Non-refractive
• With convergence excess
• With accommodation weakness
c Mixed

6. 2. Non-accommodative
• Essential infantile
• Microtropia
• Basic
• Convergence excess
• Convergence spasm
• Divergence insufficiency
• Divergence paralysis
• Sensory
• Consecutive
• Acute onset
• Cyclic

7. Inconcomitant esotropia
 Sixth nerve palsy
 Medial rectus muscle restricition following
excessive resection
 Thyroid eye disease
 Medial orbital wall fracture
 Congenital fibrosis of extraocular muscles
 Esotropia associated with high myopia
 Duane retraction syndrome
 Mobius syndrome

8. MANAGEMENT
 HISTORY
Age of onset,
Frequency of crossing,
Prior therapy (e.g., glasses, patching),
History of trauma,
previous photographs,
Birth history ,
General health,
Family history of squint.

9. SYMPTOMS
Blurring of vision and discomfort (sudden onset)
Diplopia in any position
Cosmesis embarasment
Intermediate duration at the time of stress and
inattention

10. Examinations
 Visual acuity of each eye, with best correction
and pinhole.
 Manifest and cycloplegic refractions especially
if <7 years of age.
 Ocular motility examination; observe for
restricted movements or oblique overactions.
Look specifically for an esotropia increasing in
either side gaze.
 Mahindra’s technique

11.  Hirshberg’s and krimsky test
 Measure the distance deviation in all fields of gaze
and the near deviation in the primary position (straight
ahead) and using prisms.
 Cover test with and without glasses in near and far
 Uncover test with and without glasses in near and far
 Alternate cover test with and without glasses in near
and far
 Prism cover test with and without glasses in near
and far
 Complete anterior sement eye examination with slit
lamp and fundoscopy.

12.  Look for any cranial nerve abnormalities.
 If acute-onset divergence insufficiency,
paralysis, or incomitant esotropia is present, a
head CT SCAN (axial and coronal views) or
an MRI is necessary to rule out an intracranial
mass lesion.

13.  With incomitant esodeviation
Forced-duction testing
 Consider thyroid function tests or a work-up for
myasthenia gravis, or look for characteristics
of strabismus syndromes

14. TREATMENT
 In all cases, correct refractive errors of +2.00
diopters or more,
 in children treat any amblyopia

17. Early-onset esotropia
 Early ocular alignment ideally in 12 months after correction of
refractive error and amlyopia
The initial procedure can be either recession of both medial
recti or unilateral medial rectus recession with lateral rectus
resection.
Associated significant inferior oblique overaction should
also be addressed.
• An acceptable goal is alignment of the eyes to within 10
Δ.
• Associated with peripheral fusion and central
suppression
Amblyopia can be treated after surgical correction(American
Academy)

19. Post op

20. Subsequent treatment
1 Undercorrection.
2 Inferior oblique overaction
3 DVD
4 Amblyopia.
5 An accommodative element

21. Inferior oblique overaction

22. Post op:

23.  Congenital esotropia observational study
 European multicenter prospective study?
American academy 2014-2015

24. Accommodative esotropia
 Refractive accommodative esotropia
Fully accomodative partial accomodative
 Non-refractive accommodative esotropia
covergence excess hypoaccomodative

25. Correction of refractive error
For convergence excess esotropia
For hypoaccommodative esotropia
At higher levels surgery is the better long-term
option.
BIFOCALS

26. Correction of refractive esotropia

28. Surgery
 • Surgery should only be considered if spectacles do not fully
correct the deviation and after every attempt has been made to treat
amblyopia.
PRISM ADAPTATION STUDY
• The usual first procedure for convergence excess esotropia is
recession of both medial rectus muscles. This relies on fusion to
prevent a distance exotropia; a few patients become divergent after
surgery and need a further procedure.
• Medial rectus posterior fixation sutures (Faden operation) can
also be used either as a first procedure, or in the case of under-
correction following bi medial recessions.

29. Microtropia (Monofixation
syndrome)
Treatment
involves correction of refractive errors and
occlusion for amblyopia as indicated. Most
patients remain stable and symptom-free.

30.  NEAR ESOTROPIA (NON-
ACCOMMODATIVE CONVERGENCE
EXCESS)
 Treatment involves bilateral medial rectus
recessions

31. DISTANCE ESOTROPIA
 Treatment is with prisms until spontaneous
resolution or surgery in persistent cases.

32.  ACUTE (LATE-ONSET) ESOTROPIA
 Treatment is aimed at re-establishing BSV to
prevent suppression, using prisms, botulinum
toxin or surgery.

33.  SECONDARY (SENSORY) ESOTROPIA
 causes include cataract, optic atrophy or
hypoplasia, macular scarring or
retinoblastoma.
 Fundus examination under mydriasis is
therefore essential in all children with
strabismus

34.  CONSECUTIVE ESOTROPIA
 follows surgical overcorrection of an exodeviation.
If it occurs following surgery for an intermittent
exotropia in a child it should not be allowed to
persist for more than 6 weeks without further
intervention.


35.  CYCLIC ESOTROPIA
 Earlier correction of the full manifest angle can
be successfully performed during the
intermittent phase.


36.  HIGH MYOPIA ESOTROPIA
 Patients with high myopia may have instability of
the muscle pulleys that stabilize the superior
rectus and lateral rectus muscles. This results in
nasal displacement of the superior rectus and
inferior displacement of the lateral rectus. The
possibility of this condition should be considered
in high myopes with acquired esotropia;
 MR scan
 Treatment involves plication of the superior and
lateral recti with a non-absorbable suture.

37.  SPASM OF NEAR REFLEX
 Advising the patient to reassure and avoid
those activities that trigger the response

38. INCOMITANT STRABISMUS
 PATCHING
 PRESS ON PRISMS
 CORRECTION OF SIGNIFICANT
REFRACTIVE ERROR
 BOTULINUM TOXIN INJECTION
 SURGERY
 HORIZONTAL MUSCLE PROCEDURE IF
ABDUCTION IS PARTIALY PRESERVED
 VERTICAL MUSCLE PROCEDURE IF
ABDUCTION IS ABSENT

39.  FOLLOW-UP
 At each visit, evaluate for amblyopia and
measure the degree of deviation with prisms
(with glasses worn)..
 In the absence of amblyopia, the child is
reevaluated in 3 to 6 weeks after a new
prescription is given. If no changes are made
and the eyes are straight, the patient should
be followed several times a year when young,
decreasing to annually at age 5.

40. TREATMENT
 DEPEND ON CAUSE
 CORRECT REFRACTIVE ERROR and amblyopia
 THEN PROCEED TO
SURGICAL CORRECTION
STRENGHTENING PROCEDURE
WEAKENING PROCEDURE