Based on presentation by Vivek Chaudhary on the topic NON ACCOMMODATIVE CONVERGENT SQUINT ON 10-11th April 2017. Thanks To Deepak Rai (Optometrist)

1. Presenter

2. Definition
 Non-Accommodative Esotropia or Non-Accommodative convergent Squint
refers to the ESO-DEVIATIONS which are not primarily elicited by the direct
influence of ACCOMMODATION.
 Characterized by
-Comitant Esotropia
-Acquired
-Onset after 6 months to 5 years
-Small to large angle deviation
-little or no hyperopia
-Normal AC/A ratio
-No neurologic or systemic sign or symptoms

3. SQUINT
Pseudo Squint
Manifest
Squint
(Tropia)
Latent Squint
(Phoria)
Horizontal
Vertical
Cyclo
-Eso
-Exo
Comitant
Incomitant
Secondary
Accommodative
Non-Accommodative
Microtropia
Nystagmus Blockage Syndrome

4. Non-Accommodative Esotropia
Essential
Infantile Acquired
Basic
type
Convergence
Excess
Divergence
Insufficiency
Acute acquired
Comitant eso
Acute strabismus after
Artificial interruption
of fusion
Acute strabismus
Without Preceding
disruption
Of fusion
Acute esotropia
of neurologic origin
Cyclic
Recurrent

5. A. Essential
B. Acute Acquired Comitant
A. 1.ESSENTIAL INFANTILE ESOTROPIA
-Esotropia unilateral or bilateral
-occurs after birth within 6 months
Etiology
-Primary cause idiopathic
-Secondary causes are :
>Primary motor dysfunction associated with poor fusion
>family history of strabismus
>born prematurely
>a seizure disorder of hydrocephalus

6. FIXATION PATTERN INVESTIGATION
. Doll’s eye movement
. Alternate Patching
ASSOCIATED FACTOTS
 Nystagmus; both manifest (rare) and latent (common)
 Amblyopia ; not common
 Inferior oblique Over Action
 Abnormal Head Posture
 DVD OR DHD
 Asymmetric Optokinetic Nystagmus
Placing object on lateral side

7. Clinical Features
 Amount of Deviation =30- 40
 Onset = after birth – 6 months (75% 2-3 months)
 Fixation Pattern = cross fixation
 Visual Acuity = Normal or Equal in Both Eyes
 Refractive Error = may or may not present
TREATMENT
 Muscle Surgery – first check for associated factors and then wait for 6- 7 months for
surgery
 Bilateral MR Recession or LR Resection

8.  A. 2. ESSENTIAL Acquired Esotropia
a. Basic
b. Convergence
c. Divergence Insufficiency
a. Basic Esotropia
- Comitant Esotropia
- Amount of deviation is almost equal for distance and near in optically corrected eye
- Normal AC/A ratio
Etiology
-Innervational imbalance in muscle Excessive Tonic convergence
Muscle Imbalance
Improper Muscle Tone

9. CLINICAL FEATURES
Onset = after 6 months – 5 years
Amount of Deviation = almost equal for distance and near
Normal AC/A ratio
NPA within normal limit
Refractive Error = Hyperopia or Emmetropia
TREATMENT
(No glasses or miotics are helpful)
-First treat amblyopia
-Muscle Surgery (BL MR recession but depends on surgeon)

10.  b. Convergence Excess Esotropia
- Comitant Esotropia
- More deviation at near than distance
-Divergence is normal ( Deviation at distance is neutralized)
-Not associated with any refractive error or High AC/A ratio
Etiology
Increased Innervational Tone of Converging Muscle
Clinical Features
 onset – 1 to 5 years of age
 AC/A ratio is normal
 NPA is normal
 Amount of Deviation is more at near than distance
 Refractive Error may be Hyperopic or else EMMETROPIC

11.  TREATMENT
Muscle Surgery ( BL MR Recession but depends on surgeon)

12.  C. DIVERGENCE INSUFFICIENCY ESOTROPIA
Comitant esotropia in which deviation is more in distance than near and is associated
with the weakening of the diverging muscle.
- Convergence for near is normal
- Chances of amblyopia is high
Etiology
Innervational imbalance in muscle action
Clinical Features
- After 6 months to any age
- AC/A ratio is normal
- NPA is normal
- Amount of deviation is more at distance than near
- Refractive Error is not associated

13.  TREATMENT
Muscle Surgery is not reliable
Spectacles with BO prisms are helpful
Spectacle to be worn when distance vision is needed

14.  B. ACUTE ACQUIRED COMITANT ESOTROPIA
 Comitant esotropia which is always associated with diplopia.
 It has acute onset and so can occur at any age.
 It is not associated with paralysis of muscle
B.1. ACUTE STRABISMUS AFTER ARTIFICIAL INTERRUPTION OF FUSION
Patients may have no history of Squint.
Esotropia occurs after interruption of FUSION.
Fusion breakdown conditions are :-
i. Prolonged bandaging or Patching
ii. Occlusion in refractive amblyopia
iii. Swelling of eyelid followed by trauma
Postulate ; initially patients have ESOPHORIA which was being controlled
by well self functioning fusion.

15.  CLINICAL FEATURES
 Onset is acute , can occur at any age group
 Diplopia is always present
 Amount of Deviation is slightly more in near than distance
 Associated with precipitating factors
TREATMENT
 Refractive Error management
 Systemic Illness management
 Muscle Surgery
 STRATEGY
Patient may close one or both eye to avoid diplopia
Refractive Error or Systemic Illness
BL MR Recession or BL LR Resection
Removal of Precipitating factors may dissolve deviation in some cases.
Unless, Surgery is done

16.  B.2. ACUTE STRABISMUS WITHOUT PRECEEDING DISRUPTION OF FUSION
Characteristics:
 Acute onset
 Diplopia
 Relatively large angle of Esotropia
 No sign of paralysis of muscle
 No interruption in fusion is associated
 Precipitating Factors
CLINICAL FEATURES
 Onset is acute for all age group
 Refractive error has minimal effect
 Accommodative Element is minimal
 Amount of deviation ranges from 20 - 60
Prolonged illness

17. ETIOLOGY
Idiopathic
TREATMENT
 Refractive Error management
 Systemic Illness management
 Muscle Surgery BL MR Recession or BL LR Resection
 STRATEGY
 Removal of Precipitating factors may dissolve deviation in some cases.
 Unless, Surgery is done

18.  B.3. ACUTE ESOTROPIA OF NEUROLOGIC ORIGIN
Characterized by
It is always associated with neurological problems like
CLINICAL FEATURES
 Etiology neurologic origin
 Onset is acute
 Refractive error Influence is minimal
 No certain associations, sign or symptoms
Hydrocephalus
Brain Tumor
Craniocervical junction anomaly

19.  TREATMENT
STRATEGY
Being a life threatening entity
Refer
To Neurologist
Treatment may dissolve Esotropia
If Not
Go for Surgery

20. C. CYCLIC ESOTROPIA
Characterized by
o A strabismic and no- strabismic phase of 24 hours each.
o This 48 hours of cycle is most common.
o However 72 and 96 hours cycle is also reported.
o Cycle may last from 4 months to several years.
o Unless treated , esotropia becomes constant.
CLINIAL FEATURES
 Onset – early infancy
 Amount of Deviation for both Near and Distance ranges from 40-70
 Suppression in one eye
 History of Amblyopia after being constant deviation
 Fusional Amplitude is defective or absent
 Fusion and stereopsis are normal
 No manifest deviation, esophoria may be present.
Usually during early childhood
Non strabismic phase

21.  Not related to
 Visual Acuity
 General or Ocular fatigue
 Accommodation
 Disruption of sensory fusion
 Esotropia may be UL or B L

22. ETIOLOGY
Idiopathic
TREATMENT
Muscle Surgery

23. D. RECURRENT ESOTROPIA ( AKA Malignant Esotropia)
An unusual form of esotropia which reoccurs of the same angle even after multiple
operations.
No associations with conditions like :-
Increased uncorrected hyperopia
A deep seated ARC
Nystagmus blockage syndrome
An unstable AC/A ratio
Blind Spot Syndrome
CLINICAL FEATURES
 Recurrent occurrence
 AC/A Normal
 Refractive Error influence is minimal

24. ETIOLOGY
Idiopathic
TREATMENT
Initially Muscle Surgery
BI Prisms mounted on spectacle