Esodeviations

Symptoms

diplopia (mainly in acquired or incomitant cases)

eye strain, headache, and asthenopia with near work

signs of amblyopia (fixation preference or reduced reading performance)

children with congenital esotropia often suppress and report no diplopia

Clinical Findings

Pseudoesotropia

• appearance of inward deviation due to wide nasal bridge or epicanthal folds
• hirschberg light reflex and cover test are normal
• requires reassurance and observation, not surgery

Cycloplegic refraction

• mandatory in every child with esotropia to reveal latent hyperopia
• use cyclopentolate 1% or atropine 1%

Infantile (congenital) esotropia

• onset ≤6 months; large-angle (>30 pd) constant deviation
• cross-fixation behavior and minimal hyperopia
• associated with inferior oblique overaction, dvd, and latent nystagmus

Accommodative esotropia

• onset 1–6 years with hyperopia ≥+2.00 d
• refractive: glasses alone eliminate the deviation
• non-refractive (high ac/a): greater esotropia at near; requires bifocals
• partially accommodative: residual deviation remains after full correction

Sensory esotropia

• results from severe monocular vision loss (cataract, optic nerve hypoplasia, rb)
• disruption of fusion causes the eye to turn inward

Motility signs

• cover test shows outward movement of nonfixating eye to take up fixation
• check for incomitance (deviation increasing in side gaze)

Etiology

Primary types

• congenital/infantile: developmental large-angle deviation
• accommodative: hyperopia-driven convergence excess

Secondary/acquired

• sensory: monocular vision loss (e.g., retinal disease, dense cataract)
• paralytic/incomitant: cn vi palsy (trauma, icp, tumor) or duane syndrome type i
• restrictive: thyroid myopathy of the medial rectus

Red Flags

acute-onset esotropia with diplopia in an adult (rule out cn vi palsy/raised icp)

new esotropia in a child with associated neurological signs

high-ac/a esotropia failing bifocal management

unilateral vision loss presenting as sensory esotropia

Investigations

Clinical examination

• visual acuity with best correction; stereopsis and color vision testing
• manifest and cycloplegic refractions (essential for all pediatric cases)
• ocular motility and incomitance evaluation

Neurological and systemic

• cranial nerve assessment
• thyroid function tests if restrictive disease is suspected
• myasthenia workup (ice test, achr antibodies) if deviation is variable

Imaging

• mri brain/orbits if acute non-accommodative, incomitant, or paretic deviation

Treatment

Refractive management

• correct hyperopia ≥+2.00 d; prescribe full cycloplegic refraction for patients <6 years
• push plus in manifest refraction for patients >6 years until distance vision blurs
• glasses must be worn full-time

High AC/a ratio

• prescribe bifocals (executive or flat-top +2.50 to +3.00 add)
• bifocal line should be at the lower pupillary border

Surgical management

• congenital esotropia almost always requires surgery (typically at 6–24 months)
• muscle surgery for residual or non-accommodative deviations

Secondary/sensory

• treat underlying cause of vision loss and provide polycarbonate protective lenses

Differential Diagnosis

• pseudoesotropia
• infantile vs accommodative esotropia
• acquired non-accommodative esotropia
• cn vi palsy
• sensory-deprivation esotropia
• divergence insufficiency
• medial rectus restriction
• duane retraction syndrome type i
• esophoria (aligned under binocular conditions)

Related Strabismus Conditions

• Exodeviations
• Strabismus Syndromes