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Questions and Answers
What is a characteristic feature of Acute Acquired Comitant Esotropia?
What is a characteristic feature of Acute Acquired Comitant Esotropia?
What is a key characteristic of all types of accommodative esotropia?
What is a key characteristic of all types of accommodative esotropia?
Why is it important to identify the amount of hyperopia in patients with accommodative esotropia?
Why is it important to identify the amount of hyperopia in patients with accommodative esotropia?
Which of the following is NOT typically associated with Acute Acquired Comitant Esotropia?
Which of the following is NOT typically associated with Acute Acquired Comitant Esotropia?
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What is the prognosis for binocular vision in partially accommodative esotropia when detected early?
What is the prognosis for binocular vision in partially accommodative esotropia when detected early?
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What does a low AC/A ratio indicate in a patient with Acquired Divergence Insufficiency Esotropia?
What does a low AC/A ratio indicate in a patient with Acquired Divergence Insufficiency Esotropia?
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Which condition may lead to a sudden onset of Acquired Divergence Insufficiency Esotropia?
Which condition may lead to a sudden onset of Acquired Divergence Insufficiency Esotropia?
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What is a common misconception among parents regarding the use of plus lenses for accommodative esotropia?
What is a common misconception among parents regarding the use of plus lenses for accommodative esotropia?
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Which of the following conditions is classified under small angle esotropia?
Which of the following conditions is classified under small angle esotropia?
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Which of the following statements about Acquired Divergence Insufficiency Esotropia is accurate?
Which of the following statements about Acquired Divergence Insufficiency Esotropia is accurate?
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What characterizes pseudoesotropia?
What characterizes pseudoesotropia?
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Which of the following is a feature of infantile esotropia?
Which of the following is a feature of infantile esotropia?
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In which type of esotropia do individuals experience alternating or cross fixation?
In which type of esotropia do individuals experience alternating or cross fixation?
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What is a potential risk factor for developing infantile esotropia?
What is a potential risk factor for developing infantile esotropia?
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What is true about accommodative esotropia?
What is true about accommodative esotropia?
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What is a common characteristic of infantile esotropia in terms of eye angle?
What is a common characteristic of infantile esotropia in terms of eye angle?
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Which condition is commonly associated with overacting inferior obliques in infantile esotropia?
Which condition is commonly associated with overacting inferior obliques in infantile esotropia?
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Which type of esotropia may develop as a consequence of other ocular conditions?
Which type of esotropia may develop as a consequence of other ocular conditions?
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What is a common cause of consecutive esotropia?
What is a common cause of consecutive esotropia?
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What characterizes sensory esotropia?
What characterizes sensory esotropia?
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What is the typical onset age for accommodative esotropia?
What is the typical onset age for accommodative esotropia?
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How does non-refractive accommodative esotropia typically manifest?
How does non-refractive accommodative esotropia typically manifest?
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What should be monitored in patients who have undergone surgery for exotropia?
What should be monitored in patients who have undergone surgery for exotropia?
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What effect might treating accommodative esotropia have if left untreated?
What effect might treating accommodative esotropia have if left untreated?
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Which type of accommodative esotropia involves uncorrected hyperopia?
Which type of accommodative esotropia involves uncorrected hyperopia?
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What visual adaptation is typically absent initially in children with accommodative esotropia?
What visual adaptation is typically absent initially in children with accommodative esotropia?
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Study Notes
Esotropia Classification and Diagnosis
- Esotropia is a type of strabismus where the eyes turn inward.
- Various classifications exist, focusing on age of onset, relationship to accommodation, and angle size.
Esotropia Types
- Age of onset is a crucial factor for classification.
- Relationship to accommodation differentiates between accommodative and non-accommodative esotropia.
- Angle size helps further delineate the severity of the condition.
Early Onset "Esotropia"
- Pseudoesotropia does not involve true misalignment of the eyes.
- Infantile esotropia (congenital) is a condition where the eyes turn inward within the first six months of life.
Later Onset Esotropia
- Acute acquired comitant esotropia has a sudden onset and is typically a large angle.
- Acquired divergence insufficiency esotropia is often gradual, and related to certain disorders.
- Consecutive esotropia is a condition where the eyes move inward after previously being outward.
- Sensory esotropia is related to visual impairment in one eye.
Accommodation and Esotropia
- Accommodative esotropia is associated with accommodation difficulties.
- Partially accommodative esotropia occurs when conditions are present along with some accommodation problems.
- Non-accommodative esotropia is not associated with accommodation problems.
Small Angle Esotropia
- Microtropia is a small angle of esotropia.
- Microtropia with identity refers to a specific type of microtropia.
- Monofixation syndrome is a condition where a person only uses one eye.
Pseudoesotropia
- Pseudoesotropia is not a true strabismus; appearing inward-turning but with the visual axes correctly aligned.
- Clinical features include less sclera visible nasally, prominent epicanthal folds, flat/wide nasal bridge, and narrow interpupillary distance.
- The condition often improves as the child ages, and the nasal bridge and epicanthic folds become less prominent.
What if it's not truly Pseudo?
- Thorough assessment (Hirshberg, and Bruckner) and clinical examination are essential to assess for underlying strabismus.
- Follow-up is critical; about 12% of children initially diagnosed with pseudoesotropia may develop a true strabismus or refractive amblyopia within the first three years.
Infantile Esotropia (Formerly "Congenital")
- Usually develops within a child's first six months of life.
- Alignment and motor control of the eyes does not fully form until around 3 months of age.
- Most cases are not noticed until the infant is between 2 and 5 months of age.
- This type accounts for about 8% of all cases of esotropia.
- A prevalence rate of 0.1–1% of the population are affected.
Infantile Esotropia (Risk Factors)
- Associated with premature birth, low birth weight, and a family history of eye disorders.
- Etiology is often multifactorial and related to abnormalities of the sensory fusion or motor fusion systems.
- Accommodation problems are not causative factors.
Infantile Esotropia (Features)
- Characterized by a large angle of constant esotropia (ranging typically from 40–60 prism diopters at diverse distances.)
- These children usually have normal amount of accommodation (AC/A).
- Alternating or "cross fixation" is a common feature.
- Unilateral cases may require amblyopia treatment.
- Often accompany accommodative or dense suppression.
Infantile Esotropia (Continued)
- Typically comitant, it may occasionally demonstrate an alternating or "V" pattern.
- Common to have overacting inferior obliques (OAIO).
- Dissociated Vertical Deviation (DVD) is also a possible associated feature.
- Some individuals may experience latent or manifest nystagmus.
Acute Acquired Comitant Esotropia
- Onset is frequently sudden.
- The angle is normally large (>40 prism diopters).
- It is unrelated to refractive error.
- The accommodation/accommodation ratio (AC/A) measures accommodative function.
- Diplopia (double vision) may be apparent.
Acute Acquired Comitant Esotropia (Etiology)
- Underlying etiology may be unknown, and often serious CNS issues.
- Possible etiologies include cerebellar or brainstem tumors, or in response to physical/emotional stress.
- Another possible etiology involves disruptions caused by extended visual occlusion.
- Near-work activities and digital use could potentially cause the problem to occur.
Acute Acquired Comitant Esotropia (Work-up)
- Thorough ocular motility examination.
- Comitant (no difference in deviation at different distances) is not definitive, possibly requiring investigation for underlying issues.
- Absence of amblyopia or suppression, and normal binocular vision (BV) indicate a favorable prognosis, if not affected by pathology or disease.
- Neuroimaging is essential to rule out any underlying neurological disorders, such as tumors.
Acquired Divergence Insufficiency Esotropia
- Characterized by a slow onset, inward-turning eyes occurring at distance.
- Patients frequently diagnosed after cataract surgery.
- Diplopia (horizontal double vision.) is very common.
Acquired Divergence Insufficiency Esotropia (Additional)
- Often have adult onset (rare in those under 50.)
- May be accompanied by neurological findings.
- Potential VI (abducens) nerve palsy can be a possible cause in some cases.
- Midbrain lesions are a possible condition needing ruling out through MRI.
Consecutive Esotropia
- Formerly inward-turning eyes that were initially outward turning
- The most frequent etiology is post-strabismus surgery.
- Post-optical correction.
- Purposefully over-correcting the eye position, resulting in new inward deviation could be an unusual case.
- Monitoring is needed for potential diplopia, particularly with purposeful over-correction by the surgeon.
Sensory Esotropia
- The eye turns inward due to reduced vision in one eye, resulting in a lack of binocular fusion.
- Examples include cataract, corneal clouding, optic nerve or retinal conditions.
- The greater the degree of vision loss in the eye , may indicate a potential large-angle esotropia.
- A frequent diagnosis when vision loss occurs at a younger age.
Accommodation and Esotropia
- Three types of accommodative esotropia exist: Refractive, Non-refractive, and Combination.
Accommodative Esotropia
- Average onset is between 2 to 3 years old (range between 4 months to 7 years.)
- The onset is typically intermittent, gradually increasing in frequency and duration.
- Angles typically range from 15 to 40 prism diopters, susceptible to variation with accommodation and fatigue factors.
Accommodative Esotropia (Characteristics)
- Initially, there are no sensory adaptations.
- A potential of double vision (though individuals may not articulate that.)
- Signs include head turning or covering one eye, to reduce discomfort.
- Untreated esotropia can result in amblyopia and suppression or accommodative problems.
Accommodative Esotropia (Types)
- Three types of accommodative esotropia are: Refractive (normal accommodation ratio [AC/A]), Non-refractive (high AC/A) and Combination.
Refractive Accommodative Esotropia
- Presence of uncorrected hyperopia (farsightedness).
- The Rx value would be 2 to 6+ Diopters.
- Normal accommodation ratio (AC/A).
- Full plus correction during cycloplegic retinoscopy resolves distance and near esotropia.
Non-Refractive Accommodative Esotropia
- No significant amount of hyperopia.
- The Rx is often around +2 diopters.
- A high AC/A ratio.
- The eyes tend to deviate inwards at near, but improve at distance.
- Bifocal glasses are often effective to correct vision at near.
Combination Accommodative Esotropia
- High hyperopia combined with a high AC/A ratio.
- The inward deviation is significant at near and distance.
- Full cycloplegic plus often straightens the distance vision, but the near vision is still affected.
- Bifocals that combine full distance plus with an appropriate near vision are effective.
Accommodative Esotropia (General)
- All three types have features in common, including comitant deviation (except possibly an A/V pattern), and reacting to appropriate spectacles.
- Identifying hyperopia degree is critical via cycloplegic refraction.
- Careful monitoring is crucial when the problem is found early.
Accommodative Esotropia (Education)
- Emphasize to parents that full-time use of the plus lenses (not only at distance, but also at near.) is essential.
- Addressing concerns about the child needing glasses for the rest of their life and about needing contact lenses later can be helpful.
Partially Accommodative Esotropia
- Accommodative component with residual inward deviation even with full-plus correction.
- Refractive error confirmation is key to determine if the problem is accommodative.
- Under-plussed accommodative esotropia may present to seem only partially apparent.
Partially Accommodative Esotropia (Additional Characteristics)
- Onset similar to fully accommodative esotropia, peaking between 2 and 3 years of age.
- Amblyopia and/or suppression along with AC, is more probable.
- Binocular vision (BV) prognosis could be poor, but cosmetic prognosis is still positive.
Non-Accommodative Esotropia
- Summarizes cases of inward-turning eyes that are not directly linked to accommodation or refractive errors.
- It encompasses several esotropia types addressed in "Later Onset" cases.
- Recognizes those cases of esotropia unrelated to hyperopia and refractive errors.
Small Angle Esotropia (specific subtypes)
- Microtropia: Small-angle esotropia (<10 prism diopters) often associated with hyperopic anisometropic refractive amblyopia, with the possibility of a partially accommodative component.
- Microtropia with Identity: A subset of microtropia where the deviation is fixed (no movement on a cover test) and the strabismic eye is often amblyopic.
- Monofixation Syndrome: Cosmetically straight eyes but often exhibiting a "flick" on cover testing and a generally larger deviation on alternate cover test compared to unilateral cover test, typically accompanied by amblyopia.
Cases
- Detailed case histories of Peter (5 years old) and Quincy (12 years old), highlighting clinical findings and management strategies.
- Discussions about classification and potential causes of each patient's esotropia are included.
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Description
Test your knowledge on the characteristics and features of Acquired Comitant Esotropia and its various types, including accommodative and divergence insufficiency. Understand the implications of hyperopia and the importance of early detection for better prognosis in binocular vision.
