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Strabismus: Accommodative Esotropia

Uncorrected Estropia
Corrected Estropia
Photos by Sandra Brown, M.D.
Without glasses, this little girl's eyes are misaligned in the inward direction (esotropia). That is, one eye is viewing the target, the other is turned in. In other cases, the deviating eye is turned outward (exotropia) or upward (hypertropia) or downward (hypotropia).

In this patient, the problem is uncorrected hyperopia, a refractive error. In order to overcome her hyperopia, this child is accommodating fiercely. Accommodation is linked in her brain to convergence, and so her left eye turns inward. When the hyperopia is corrected with glasses, her eyes straighten out.

This is the term used to designate ocular misalignment. There are many, many causes. For example, one of the three cranial nerves (III, IV, VI) could be damaged. Some infants are born with excessive convergence, or congenital esotropia.

Apart from the cosmetic blemish, strabismus in early childhood is a danger because the nonfixating eye will quickly become amblyopic, that is, lose visual acuity. Amblyopia is a kind of disuse atrophy of the visual connections. If left untreated, visual loss from amblyopia may be permanent.

What to do?
Refer urgently to an ophthalmologist any patient with recent onset of strabismus, especially if there is diplopia, for two reasons: 1) a neurological problem could be behind it; and 2) amblyopia can develop quickly in a young child.

Refer non-urgently a child with long-standing strabismus and subnormal vision, which could represent amblyopia in need of treatment.

Adults with longstanding strabismus probably have had ophthalmic attention in the past. They need further evaluation only if their strabismus has changed recently, of if they desire eye muscle surgery to improve ocular alignment.

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