Esotropia: Classification and Diagnosis PDF

Esotropia: Classification and Diagnosis Maureen Plaumann, OD, PhD Esotropia Types Many different ways to classify esotropia Age of onset Relationship to Accommodation Size of the Angle Early Onset “Esotropia” Pseudoesotropia Infantile Esotropia Later Onset Esot...

Esotropia: Classification and Diagnosis Maureen Plaumann, OD, PhD Esotropia Types Many different ways to classify esotropia Age of onset Relationship to Accommodation Size of the Angle Early Onset “Esotropia” Pseudoesotropia Infantile Esotropia Later Onset Esotropia Acute Acquire Comitant Esotropia Acquired Divergence Insufficiency Esotropia Consecutive Esotropia Sensory Esotropia Accommodation and Esotropia Accommodative Esotropia Partially Accommodative Esotropia Non-Accommodative Esotropia Small Angle Esotropia Mictropia Mictropia with Identity Monofixation Syndrome Early Onset “Esotropia” Pseudoesotropia Infantile Esotropia Psuedoesotropia Not a true strabismus; appears ET though visual axes are aligned Less scleral seen nasally Prominent epicanthal folds Flat, wide nasal bridge Narrow IPD Courtesy of AAPOS (-) angle kappa Nose bridge will become more prominent and epicanthal folds more displaced around 2 years of age What if it’s not truly Pseudo? Look carefully at Hirshberg, Bruckner Make sure in primary gaze Clinical Pearls F/u in 6 – 12 months About 12% will develop true strabismus Infantile Esotropia (formerly “Congenital”) ET develops within first 6 months of life Alignment and oculomotor control is not rudimentarily established until 3 months But most of the time it is not noted since birth Usually begins at age 2 to 5 months Approximately 8% of all esotropias Prevalence: 0.1-1% of population Infantile Esotropia Risk Factors Prematurity/low birth weight Family history Neurodevelopmental Delays Etiology Multifactorial (Defects with sensory fusion or motor fusion system) Not caused by accommodation Infantile Esotropia Features Large angle, constant esotropia (40-60pd, Distance and near) Typically normal AC/A Alternating or “Cross Fixation” Common Courtesy of AAPOS If unilateral, remember to treat amblyopia Often with AC or dense suppression Infantile Esotropia Features (Continued) Generally comitant, though may have A/V pattern Overacting Inferior Obliques (OAIO) common Dissociated Vertical Deviation (DVD) common Latent or Manifest Nystagmus  OAIO + DVD Robert P. Rutstein. “Rutstein’s Atlas of Binocular Vision.” Ridgevue Publishing, 2014. Apple Books. https://books.apple.com/us/book/rutsteins-atlas-of-binocular-vision/id883322912 Later Onset Esotropia Acute Acquire Comitant Esotropia Acquired Divergence Insufficiency Esotropia Consecutive Esotropia Sensory Esotropia Acute Acquired Comitant Esotropia Onset often sudden Typically a large angle (>40pd) Not related to refractive error Normal AC/A Diplopia likely Acute Acquired Comitant Esotropia Etiology Often unknown Serious CNS pathology (Cerebellar or brainstem tumors) Physical or emotional stress Fusion disruption (prolonged occlusion) Near work? Acute Acquired Comitant Esotropia Acute Acquired Comitant Esotropia Work-up Ocular motility exam Comitancy does NOT rule out potential underlying disease No amblyopia, no suppression, no AC Good prognosis for normal BV (assuming no pathology) Refer for neuro-imaging to rule-out Acquired Divergence Insufficiency Esotropia Low AC/A Generally, gradual onset inward eye turn at distance Patients post-cataract surgery may have sudden onset acquired DI Horizontal diplopia Acquired Divergence Insufficiency Esotropia Adult onset Rarely occurs < 50 years old Can be associated with neurological findings May be due to VI palsy R/o midbrain lesions with MRI  Acquired Divergence Insufficiency Esotropia Robert P. Rutstein. “Rutstein’s Atlas of Binocular Vision.” Ridgevue Publishing, 2014. Apple Books. https://books.apple.com/us/book/rutsteins-atlas-of-binocular-vision/id883322912 Consecutive Esotropia Esotrope when they were previously an exotrope Etiology Post-strabismus surgery (large proportion) Post-optical correction Surgeons may choose to purposefully over-correct XTs Monitor these patients for diplopia Sensory Esotropia Esotropia because of poor vision in one eye d/t disease Ex: cataract, corneal clouding, ONH disorders, retinal diseases More commonly ET when VA loss younger (but not always) No binocular fusion because of poor vision in one eye Large angle ET Sensory ET Accommodation and Esotropia Accommodative Esotropia Partially Accommodative Esotropia Non-Accommodative Esotropia Accommodative Esotropia Average onset = 2 – 3 years old (4 months – 7 years) Onset intermittent Gradually increases frequency and duration Moderate angle size (15 – 40pd), varies with accommodation and fatigue (can be larger at end of day) Accommodative Esotropia Accommodative Esotropia Initially, no sensory adaptations Expect that these kids see double, though they may not always be able to say this Watch for head turn or monocular eye closing (winking) If left untreated, can develop amblyopia/suppression/AC Accommodative Esotropia Three types of Accommodative ET Refractive (Normal AC/A) Non-Refractive (High AC/A) Combination Refractive Accommodative Esotropia Refractive = Uncorrected hyperopia Prescription +2 to +6 Normal AC/A Correcting with full plus found on cycloplegic retinoscopy eliminates ET at distance and near Non-Refractive Accommodative Esotropia Do NOT have a large amount of hyperopia Prescription usually maxing out at +2 High AC/A ET much greater at near (EP to ortho at distance) Bifocal will straighten out the eyes at near Combination Accommodative Esotropia Have a high amount of hyperopia AND high AC/A ET still greater at near but also present at distance Full cycloplegic ret straightens eyes at distance, still troping at near Give a bifocal on top of the full distance plus and it fully straightens the eyes out at near too  Combination Accommodative Esotropia Robert P. Rutstein. “Rutstein’s Atlas of Binocular Vision.” Ridgevue Publishing, 2014. Apple Books. https://books.apple.com/us/book/rutsteins-atlas-of-binocular-vision/id883322912 Accommodative Esotropia All three types have these characteristics in common Comitant deviation (except may have A/V pattern) Fully responds to appropriate lenses Need to identify hyperopia amount with cyclopentolate Follow-up important to confirm straight with plus Prognosis is great if catching early Accommodative Esotropia – Education Key factors to review with parents/family/patient Plus lenses not often making vision clearer, patients may not appreciate them at first but NEED to wear full-time Remind parents they will see the turn with glasses OFF Common question: Will my kid always need glasses? “As they get older, they would be great candidates for contact lenses” Partially Accommodative Esotropia Have an accommodative component However, still with residual ET even with FULL plus Confirm refraction to make sure not fully accommodative If under-plussed, an Accommodative ET may look partial Partially Accommodative Esotropia Onset similar to (fully) Accommodative ET Peak age of onset: 2 – 3 years Very likely to develop/already have amblyopia/suppression/AC Prognosis for BV poor, Cosmetic prognosis often good Non-Accommodative Esotropia Rounding out relationship between accommodation and ET Recall the ETs discussed in “Later Onset” – most of those are Non-accommodative Catch all term for ET not related to hyperopia/refractive error or accommodation Small Angle Esotropia Mictropia Mictropia with Identity Monofixation Syndrome Microtropia Small angle Esotropia