This document provides information on various types of esotropia (convergent strabismus), including: - Accommodative esotropia caused by uncorrected hyperopia or a high AC/A ratio - Partially accommodative esotropia with both accommodative and non-accommodative components - Non-accommodative esotropia including convergence excess, cyclical esotropia, and acquired forms - Esotropia associated with high myopia or nystagmus is also discussed Treatment options including refractive correction, orthoptic exercises, prisms, botulinum toxin, and surgery are mentioned for different types of esotropia.

1. Esotropia
Dr Azmat Khan

2. Esotropia occurs when there is excess
convergence than can’t be controlled with
fusional divergence.
The fault can be either in the
 Demand on the fusion
 Quality of fusion

3. Primary
Secondary
Consecutive
Residual
Accommodative
&
Non accommodative

4. Accommodative
Esotropia
Intermittent
Convergence Excess
Hypo Accomodative
Convergence Excess
Constant
Partially
accommodative
esotropia
Early Onset
Accomodative
Fully
Accommodative

5. • Near
• Distance
• Cyclical

6. • Nystagmus
blockage
syndrome
•Esotropia
associated with
Myopia
• Swan’s blind-
spot mechanism
• Infantile
•Acquired
non
accommodative
•Microtropia

7. Definition:
A convergent deviation of the eyes associated
with activation of the accommodation reflex.

8. Uncorrected Hyperopia
 Clearing the blurred
vision by accommodation
leads to overstimulation
of accommodative
convergence
 Usually moderate size
esotropia
 Hyperopia of + 3.0 to +
10.0 D) (average + 4.0 D)
High AC/A Ratio
 Abnormal relationship
between accommodation
and accommodative
convergence
 Refractive error normal,
averaging about + 2.25
D
 Significant increase of
deviation for near

9. Fully accommodative esotropia with normal
AC/A ratio
After prescribing the full hyperopic correction the
eyes are straight for near and distance
Or
This is an esotropia which occurs when
accommodation is exerted to overcome
uncorrected hypermetropia accommodation is
accompanied by equivalent accommodative
convergence,which is excessive for the distance
of the fixation distance.

11. Features
 Age 2-5 years
 Hypermetropia commonly
 2-7D in both eyes
 Associated Signs(may rub or close an eye,
upset
 Bsv present with hypermetrpoia corrected
 Microtropia in small cases

12.  Correction of refractive error
 Use of contact lens
 Restoration of visual acuity
 Orthoptic treatment
Diplopia recognition
Control without spectacle
Increase near binocular visual acuity
 Surgical treatment

13. Convergence excess accommodative
esotropia with high AC/A ratio
Through full hyperopic correction eyes are straight
for distance, but still residual esotropia for near
Or
This is an Esotriopia which occurs on near fixation
with the refractive error corrected,due to
excessive accommodative convergence excerted
for each diopter of accommodation .

14. High Ac/A Ratio may have two reasons
1. Hyperkinetic form – due to abnormal convergence
response to normal accommodative effort (most
common form)
2. Hypoaccommodative form – a weakenend
accommodation mechanism results in an
abnormal increase in neural effort to achieve
necessary accommodative response

15.  Age 2-5years
 AC/A ratio often exceeding 8:1
 Uncorrected hypermetropia is 1.5 to
5ds,esotropia is often present for all distance
as well for near after correction
 Emmotropia and myopia occasionally seen
 Equal visual acuity, any amblyopia present is
likely to be associated with uncorrected
anisometropia.

16.  Microtropia is more common in this group
mainly association with anisometropia.
 Suppression is present when deviation is
manifest.
 Normal near point of accommodation.

17.  Correction of refractive error
 Restoration of visual Acuity
 Conservative treatment
optical
miotics
orthoptic excercises
botulinum toxcin
Surgical

19. How to advice bifocals

20.  Esotropia on near fixation in patient with
remote near point of accommodation.
 Increased accommodation effort required for
clear vision accompanied by commensurate
accommodative convergence.
 Orthophoria or a small esophoria is present on
distance fixation.
 AC/A ratio is low or normal

21.  Correction of refractive error
 Restoration of visual acuity

22. Fully accommodative esotropia with a
moderate degree of hypermetropia and onset
before 6 months of age is seen only very
occasionally
Hypermetropia and high AC/A ratio is the
causes.

23.  Binocular vision will be reduce
 Strabismic Amblyopia will be present with high
incidence
Management
 The weak binocular vision found in these patients
makes them particularly prone to consecutive
exotropia.
 Hypermetropia will be corrected fully
 Surgery to improve alignment.

24. Partial accommodative esotropia with normal AC/A
ratio
Through full hyperopic correction angle is significantly reduced
residual angle which is the same for near and distance
Often combined with ARC and Amblyopia!
These patients have a non accommodative elements to the
esotropia that result is menifest deviation for near and
distance.
Accommodative elements may be
Uncorrected hypermetropia
High AC/A ratio

26.  Esotropia decrease by at least 10pd with
correction of hypermetropia but remain
manifest for near and distance fixation

27.  The esotropia at 33cm is at least 10pd
greater then the distance at 6m.
 The addition of of +3 lenses equalizes the
near and distance measurement.
 Higher AC/A ratio the greater the difference
between near and distance deviation.

28.  Larger deviation for near persist after
correction but should be eliminated by bifocal
spectacles with correct near addition.
 If larger near esotropia persist the difference
in angle may be due to proximal or tonic
convergence rather accommodative
convergence.

29.  Decompensation of an intermittent
accommodative esotropia
 A constant esotropia developing an
accommodative element.

30.  Partially accommodative esotropia can
occasionally arise from a fully accommodative
or from convergence excess esotropia in
which nonaccommodative component has
developed
 Most cases arise from small angle early onset
esotropia which later develops an
accommodative elements.

31.  Age 1- 3years
 Anisometropia and astigmatism are common
 Amblyopia is commonly found may be either
strabismic or anisometropia(with or without a
meridional component)or combination of
both types.
 Fusional potiental is found in minority

32.  Associated vertical deviations are common
and are often due to unilateral or bilateral
over action of inferior oblique muscles with
or without Vpattern less often A pattern are
seen with associated overaction of the
superior oblique and primary underaction of
inferior rectus.
 DVD and latent nystagmus are associated
with poor potential for BSV.

33.  Correction of Refractive error
 Restoration of visual acuity
 Botulinum toxin
 Surgery

34. Non
accommodative
Esotropia

35. Intermittent esotropia
Near esotropia(non accommodative convergence
excess)
Description:
BSV for distance fixation and an esotropia for near
fixation which could not explained by a AC/A
ratio or by defective accommodation.

36.  It was thought that high proximal convergence
accounted for the near esotropia, mean value
of convergence to be 2.5pd and therefore
insufficient to explain the degree of esotropia.
 High tonic convergence is more common
cause.
 There is no means of measuring tonic
convergence
 Diagnose is arrived at exclusion of high AC/A
ratio and hypoaccommodation

37.  Orthophoria or small esophoria for distance
fixation
 Moderate or large degree for near fixation
 Often no refractive error
 Eqaul visual acuity
 Normal or even low AC/A ratio
 Normal near point of accommodation
 Minimal reduction in degree of esotropia with
convex lenses.
 Normal sensory and motor fusion for distance
 No amblyopia

38.  Conservative treatment
 Bifocal spectacles,Miotic drugs,and orthoptic
treatment have no affect on this type of
esotropia
 Any significant R/E should be corrected

40.  Intially there is an esotropia for distance
fixation becoming more constant with
time,BSV present for near with refractive error
fully corrected.

41.  No deviation or esophoria for near fixation .
 Small to moderate esotropia on distance
fixation
 Suppression at distance
 No significant refractive error in most cases
 Equal visual acuity
 Full extra ocular movement

42. Conservative
 Base out prisms are effective in controlling
deviation in the distance.
Surgical treatment

43.  An alternate day cycle (48h)
 Menifest phase lasts 24hr and is followed by
a straight phase of similar duration.
 Onset around 4-6yrs of age
 Most patients are emmetropic with equal
vision
 Bsv present on straight days
 Suppression prevents diplopia when
strabismus is manifest

44.  It can be associated with central nervous
system diseases
 Bsv demonstrable in rare cases eyes appear
straight but fusion will absent
 Manifest phase usually increase with time
until constant strabismus develops.

45.  Optical (prisms)
 prisms have been used and surgery thereby
avoided
 botulinum toxin has been used with a
successful outcome
 If plaining surgery full menifest angle of
deviation should be corrected

46.  Constant nonaccommodative primary
esotropia contains
 the following categories
 infantile esotropia
 acquired nonaccommodative esotropia
 esotropia associated with myopia
 nystagmus blockage syndrome
 microesotropia.

47.  essential infantile esotropia;
 accommodative esotropia;
 nystagmus blockage syndrome;
 sixth nerve palsy

48. This is an infantile esotropia in which the
aetiology is largely unknown but is probably
multifactorial

49.  Angle exceed 30pd
 Onset before the age of 6months
 Usually alternating
 Cross fixation
 Latent nystagmus
 Associated vertical deviations
 Bilateral or unilateral Inferior oblique O/A
may be coexist with DVD
 Asymmetry of optokinetic nystagmus
(OKN)

50.  Abnormal head position
1. to compensate for nystagmus
2. to compensate for limitation of abduction
3. in the presence of DVD

51.  Correction of the refractive error
 Restoration of visual acuity
 Botulinurn toxin
 SURGERY

52. Advantages and disadvantages of early vs late
surgery
Surgery performed before 2 years of age
1. greater potential for binocular single vision
2. improved child-parent interaction
3. reduced mechanical component from muscle
and connective tissue contracture

53. 1.problems with assessment and obtaining reliable
measurements in the young child
2.changing anatomical landmarks in the infant eye
3.difficulty with Amblyopia management after
surgery

54. Advantages
1.reliable measurement and assessment of
alphabet patterns and DVD is usually
possible
2. Amblyopia management facilitated by
improved cooperation
3. anatomical relationships approaching
adult dimensions

55. 1. reduced potential for binocular single
vision
2. increased mechanical component from
muscle and connective tissue contracture
3. potential problems with child-parent
bonding.

56.  Deviations measuring 25-45 A bilateral medial
rectus recession of 3-6 mm.
 Deviations measuring 50-65 A bilateral medial
rectus recession of 5 mm and a single lateral rectus
resection of 5-7 mm.
 Esotropia measuring 70 A or more this is initially
treated with botulinum toxin injection of both
medial recti

57. Description
This is a non accommodative esotropia with an
onset after 6 months of age.
Two main subtypes are recognized,depending
on the age at onset
 Esotropia occurring between 6 and 24 months
of age
 Esotropia with onset from 2 to 8 years of age
(normo-sensorial late-onset esotropia).

58.  Previous binocular experience implies that
the potential for binocular single vision
should be good,however this is rarely the
case.
 Associated strabismic amblyopia is usually
present, requiring early effective
management prior to surgical treatment.

59. Assessment of binocular potential
 Botulinum toxin used diagnostically offers the
only real option of aligning the visual axes to
allow assessment of binocular potential in this
age group.
 Prism adaptation can be used on patients
presenting after the age of 3yrs.

60.  Good potential for binocular single vision
 Poor potential for binocular single vision.

61. The term ‘normo-sensorial late-onset
esotropia’ was introduced by Lang to
describe constant esotropia with onset from 2
to 8 years of age, or sometimes slightly later.

62.  The esotropia may be intermittent for a short
period but rapidly becomes constant and of
large angle.
 Diplopia is usually present in the early stages,
either the child complains of it or is seen to
close one eye.
 There is no significant accommodative
component.

63.  Normal retinal correspondence and sensory
and motor fusion are present.
 A full range of eye movements and clinically
normal lateral rectus muscle saccadic velocities
are always found.
 A minor injury or a short period of uniocular
occlusion may be precipitate

64.  prisms to restore binocular single vision. In
some patients spontaneous improvement
occurs, which eventually allows the prisms to
be discarded.
 Those patients who fail to improve after using
prisms may respond successfully either to
botulinum toxin or to early surgery aimed at
aligning the visual axes, with an excellent
prognosis for the restoration of binocular
single vision

65. Myopia is seen in association with most types
of strabismus. In general, the prevalence of
myopia in these conditions does not differ
from that of the normal population. There are
however, two types of esotropia which are
characteristically seen in association
 moderate level of myopia
 high levels of myopia:

66.  myopia can be associated with a gradual
onset of esotropia with diplopia
 Develops first for distance fixation.
 Full eye movement
 Prism is useful in initial management of
diplopia.
 Surgery usually bilateral medial rectus
recession.

67.  This degree of myopia can result in an
esotropia associated with mechanical
restriction of movement
 Diplopia is rarely present
 The myopia is greater than 15DS.
 Range of abduction is Limited.
 Myositis may be cause
 Fibrosis and atrophy with no evidence of
inflammation

68.  In this condition is a direct result of the
enlarging globe compressing the lateral
rectus, resulting in atrophy of that muscle.
 Long-standing esotropia may lead to medial
rectus fibrosis that both increases the
deviation and causes mechanical restriction
of abduction

69.  Botulinum toxin to both medial rectus
muscles was effective in producing short-
term alignment it is also useful
for exploring binocular potential in this
condition.
 Surgery

70.  Swan (1948) first described the condition in
which the image of the fixation object falls on
the optic disc of the deviating eye in an
esotropia measuring 30-35 .
 Suppression of the diplopic image is not
needed and normal retinal correspondence
should be retained.
 It is difficult to be certain that this mechanism
is maintained for all distances of fixation and
therefore we doubt if it is an entity.

71. An esotropia that results from the use of the
convergence mechanism to block or abolish
manifest nystagmus and improve visual acuity

72.  A congenital horizontal nystagmus is present
which remains the same whether both eyes
open or if one eye is covered
 The esotropia is nonaccommodative and
variable.
 The patient adopts a face turn to the side of
the fixing eye
 The esotropia is usually unilateral, and
strabismic amblyopia is common

73.  Pupil miosis may occur during the esotropic
phase.
 The squinting eye remains adducted when a
baseout
 prism is introduced in front of the fixing eye
 High incidence of neurological disorders or
ocular or oculocutaneous albinism.
 DVDisrare.
 The results of strabismus surgery are
unpredictable.

74.  Significant refractive errors should be corrected
with
spectacles, although these may prove unsatisfactory
when the compensatory head posture results in
eccentric
viewing through the spectacle lens.
 Occlusion for amblyopia
Surgery is indicated if the esotropia is constant
and cosmetically poor
 Surgical procedures routinely used to treat
essential infantile esotropia are usually ineffective
in the nystagmus blockage syndrome

75.  Is an esotropia occurring in a patient history
of exotropia or exophoria.
 Most commonly result from surgical
overcorrection of primary exotropia.

76.  This is rare condition
 Mostly in constant infantile exotropia without
evidence of ocular pathology
 Gradual onset of esotropia.
 DVD was present in all cases.

77.  Planned overcorrection
In patient with intermittent distance
exotropia,
The esotropia is expected to resolve
spontaneously and rarly require treatment.
Diplopia is variably present and patient is
encouraged to fuse.
In pt with poor BSV undergo surgery for
cosmetic purpose

78. Early marked postoperative esotropia
 Large eso with -3 or more limitation of
abduction,slippage of lateral rectus should be
suspected.
Late postoperative esotropia
Distance esotropia develops some weeks after
surgery to correct intermittent exotropia.
Intervention with botulinum toxin or further
surgery.

79.  Secondary esotropia results from visual loss
which is so severe that it completely disrupts
the fusion mechanism:
 usually there is loss of foveal function
 Unilateral or bilateral
 Visual loss at or shortly after birth can result
in either an esotropia or an exotropia

80.  Visual loss in childhood more often results in
an esotropia, probably due to the very active
accommodation and convergence mechanism
at this age.
 Visual loss in later childhood and adulthood
results in an exotropia in most instances

81. Surgical treatment
 Surgery is indicated to restore a normal
appearance in most cases, the timing of
surgery is influenced by the stability of the
alignment
 Surgery is best carried out on the affected
eye,acombined medial rectus recession and
lateral rectus resection is the operation of
choice

82. Botulinum toxin
 We have used repeated botulinum toxin
injections to treat patients with small but
cosmetically unacceptable deviations when
we were uncertain whether or not the angle
would increase in size.

83. Description
Residual esotropia is an esotropia remaining
after surgery for a larger primary esotropia.
Planned residual esotropia
 Patient at risk developing of consecutive
exotropia,those with high hypermetropia and
dense amblyopia
 Patient to left insuperable diplopia

84.  Patients for whom the surgeon elects to carry
out surgery for a large-angle esotropia in two
stages,

85. Early postoperative management aims to reduce
the
size of the deviation if possible by
Ensuring that hypermetropic patients wear their
spectacles all waking hours.
Patients with good binocular potential may
be helped by temporary overcorrection, which can
be achieved using Fresnel lenses, usually no
stronger
than 1 DS, in an attempt to obtain binocular single
vision.

86. The use of botulinum toxin injected into the
recessed
medial rectus muscle. This can be effective in
the early
postoperative period if the esotropia measures
less
than 20 A.

87. The size of the deviation for near and distance.
 Residual esotropic angles between 15 and 20
A the early postoperative period,some
patients have responded to botulinum toxin
injected into the recessed medial rectus
muscle
 Residual esotropic angles larger than 20 A
with poor cosmesis can generally be
managed by surgery on the previously
unoperated muscles.

88. Further treatment should be expedited in
patients
under 7 years of age to establish and
consolidate
binocular single vision as soon as possible. If
this can
be achieved during the period of visual
maturation, the
risk of developing strabismic amblyopia is
minimized.

89. Correction of hypermetropia is occasionally
sufficient
to re-establish binocularity in children with
deviations
less than 20 . Older children and adults may
tolerate the long-term use of prisms, especially
if spectacles are already worn.