College of Medicine and Health Sciences

Department of Optometry
Esodeviations 1
Seminar Topic: Esodeviations

By: Destaye Shiferaw (1st year MSc. Student)

Moderator: Mr. Ayanaw Tsega (MSc.)

July 17,2015
EsodeviationsGondar, Ethiopia 2
 Outline
 Introduction

 Pseudoesotropia

 Infantile (congenital) esotropia

 Accommodative esotropia

 Non accommodative esotropia

 Recommended Readings

 References
Esodeviations 3
 Introduction

●
Latent or manifest
convergent misalignment
of the visual axes.
●
Most common types of
Esodeviation
strabismus
●
> 50% : pediatric
population
●
Potentially preventable

Esodeviations 4
 Introduction cont’d…
●
Latent esodeviation controlled by fusional
Esophoria mechanisms so that the eyes remain properly
aligned under normal binocular viewing conditions .

●
Esodeviation that is intermittently controlled
Intermittent esotropia by fusional mechanisms but becomes
manifest under certain conditions

Esotropia
●
Esodeviation that is not controlled by fusional
mechanisms, so the deviation is constantly
manifest.
●
represent the most common form of strabismus
Esodeviations 5
 Introduction cont’d…

●
Innervational
Anatomical
can result from
●

●
Mechanical
●
Refractive
●
Accommodative

Esodeviations 6
 Introduction cont’d…
●
Etiology
●
Age of onset
●
state of comitance

By
●
sensorial adaptations
●
Mode of onset
●
Age of pt at onset

●
State of fixation behavior
●
Size Angle of deviation
●
State of fixation behavior
Esodeviations 7
 Pseudoesotropia
 False appearance of esotropia
despite accurately aligned visual
axes

◦ Wide and flat nasal bridge

◦ Prominent epicanthal folds
◦ Narrow PD

 Corneal light reflex and cover

testing results are normal.

Esodeviations 8
 Pseudoesotropia cont’d…

 True esotropia can develop in children

with pseudoesotropia, so beware that
reassessment is required if the
apparent deviation does not improve.

Esodeviations 9
 Infantile (congenital) esotropia
 onset between birth and 6 months of age

 Incidence~ 1% (most series)

 Equal sex & racial distributions

Esodeviations 10
 Infantile cont’d...
 Few children who are eventually diagnosed
with classic infantile esotropia are actually
born with esotropia.

 Exact date is not precisely established in most

cases

 Presence of esotropia by age 6 months

accepted as a defining element of infantile
esotropia.

 This criterion has been used in clinical studies.

Esodeviations 11
 Infantile cont’d...
 FHx of esotropia/strabismus is often present

 Well defined genetic patterns are unusual

 Other than strabismus, children with infantile

esotropia are usually normal esotropes

 30% of children with neurologic and

developmental problems, including cerebral
palsy and hydrocephalus.

Esodeviations 12
 Infantile cont’d...

What causes infantile esotropia?

 Causes of congenital strabismus are neither

purely motor nor purely sensory in most
cases; rather, there is a difficulty in coupling
the two systems.

 The debate regarding its etiology has

focused on the implications of two
conflicting theories.

Esodeviations 13
 Infantile cont’d...

1. Worth's "sensory" concept

◦ Infantile esotropia resulted from a deficit

in a supposed fusion centre in the brain.

◦ Restoring binocularity considered hopeless

 No way to provide this absent neural

function.

Esodeviations 14
 Infantile cont’d...
2. Chavasse

◦ Primary problem is mechanical

◦ Potentially curable if the deviation

eliminated in infancy.

Esodeviations 15
 Infantile cont’d...

What are the clinical features?

Deviation

◦ Large (> 30Δ )

◦ Constant

◦ Change little with age (children without

brain damage)

◦ Initially, similar deviation at D & N

Esodeviations 16
 Infantile cont’d...
Cross-fixation

 Use of the adducted eye for

fixation of objects in the
contra lateral temporal field

 There may be an apparent

abduction deficit because of
cross fixation

Esodeviations 17
 Infantile cont’d...

Amblyopia
No BV  25%-40%

Typical RE  only the better fixates in all

fields of gaze, making the
Equal VA amblyopic eye appear to have
an abduction weakness.

Esodeviations 18
 Infantile cont’d...
IO overaction
◦ Up to 75%

◦ Most frequent during

the 2nd year of life

◦ Unilateral/bilateral
Overelevation in adduction of
the left eye
◦ Early surgical correction does
not prevent the development
of io overaction.
Esodeviations 19
 Infantile cont’d...

DVD
◦ ~ 75%

◦ Manifest / latent

◦ Very asymmetrical

◦ Elevation/abduction &
excyclotorsion

Esodeviations 20
 Infantile cont’d...
Anomalous head posture

 A child who does not have amblyopia

switches fixation at the midline as an object
is brought from one side to the other and
does not maintain fixation and adopt a
progressive head turn.

 Patients with infantile esotropia have

persistent monocular smooth pursuit
asymmetry that does not resolve.

Esodeviations 21
 Infantile cont’d...
Nystagmus

◦ May be present in both manifest rotary and latent

horizontal forms.

◦ The former is uncommon and tends to diminish

during the first decade of life.

◦ Latent nystagmus with fast phase toward the

unconcluded eye is found in approximately 50% of
patients.

Esodeviations 22
 Infantile cont’d...
Diagnosis of infantile esotropia

◦ Measurements to detect amblyopia may be

difficult in very young children

◦ Variation of the light reflex test in which the

deviation is neutralized by prisms held apex-
to-apex before both eyes may be required.

◦ Refractive errors tend to be similar to those

of normal children of the same age.

Esodeviations 23
 Infantile cont’d...
 Nystagmus may confound attempts at
monocular acuity measurement

◦ Fogging may provide a more accurate acuity

measurement

Esodeviations 24
Management of infantile esotropia
●
1. Excellent visual acuity in each
Goals
eye

●
2. Perfect SBV in all gaze
positions at D & N

3. A normal esthetic appearance.

●

Esodeviations 25
 Management cont’d….

 Cycloplegic refraction

 Surgery

 Botulinum toxin injection

Esodeviations 26
 Differential Diagnosis for infantile esotropia
Refractive accommodative esotropia

Bilateral abducens paralysis

Early-onset accommodative esotropia

Duane syndrome type I &III

Nystagmus blockage syndrome

Möbius’ syndrome

Sensory esotropia

Esotropia association with CNS manifestations (albinism,

cerebral palsy, mental retardation)
Esodeviations 27
 Accommodative Esotropia

 Convergent deviation of the eyes associated

with activation of the accommodative reflex.

 All accommodative esodeviations are acquired

 Attributed totally or partly to either

uncorrected hyperopic refractive error and/or
a high AC/A ratio.

Esodeviations 28
 Accommodative …cont’d…
 Characterized by two mechanisms that may
occur in variable proportions in the same
individual.

1. High hyperopia (average+4.50 D)

2. A larger eso tendency at near fixation than

can be controlled comfortably by fusional
divergence.

 A 3rd cause may be anisometropia ≥1D,

especially in patients who have lower overall
hyperopia (less than +3.00 D). 29
Esodeviations
 Accommodative cont’d…
 Characteristics :
 Onset:
◦ between 6 months & 7 years

 Asthenopia
◦ as fusional divergence amplitudes are stressed

 Deviation
◦ Small to moderate (10-35 Δ) usually occurs
frequently at near.
◦ Depending on the AC/A ratio, may be larger or
similar to the esotropia at distance.

Esodeviations 30
 Accommodative …cont’d…
 Sensory adaptations

 Uncorrected hyperopia (2-6D) &/or a high AC/A ratio.

 Sometimes precipitated by trauma or illness

 Amblyopia

 Diplopia may occur (especially in older children)

Esodeviations 31
 Early Detection and Prevention
 Children suspected of having accommodative
esotropia should be examined immediately.

 The prognosis for achieving normal BV is excellent

provided treatment is not delayed.

 Better results usually occur when treatment is

initiated during the intermittent phase.

 If untreated, the patient may develop a gradual

nonaccommodative esotropia, accompanied by
amblyopia, suppression, and anomalous
correspondence.
Esodeviations 32
 a. Refractive Accommodative Esotropia
 Esotropia restored to orthotropia at all fixation

distances and in all gaze positions by optical

correction of the underlying hypermetropia.

 Deviation is
◦ 20Δ - 30Δ (generally)
◦ ~D = N fixation

 Hyperopia +4.00D (average)

Esodeviations 33
 Refractive ..cont’d…

 Mechanism involves 3 factors:

◦ 1 Uncorrected Hyperopia
◦ 2 Accommodative Convergence
◦ 3 Insufficient Fusional Divergence

Esodeviations 34
Consequences of uncorrected high hypermetropia ,AC/A, ratio

Esodeviations 35
 Management
 Optical correction

 Correction of the full amount of hyperopia

◦ As determined under cycloplegia

 Any concomitant amblyopia should be treated as well.

 Significant delay in initiating treatment following the

onset of esotropia increases the likelihood that a
portion of the esodeviation will fail to respond to
antiaccommodative therapy.

Esodeviations 36
 Management cont’d…
 Surgical correction

 May be required when a patient with refractive

accommodative esotropia fails to regain fusion with
glasses or subsequently develops a
nonaccommodative component to the deviation.

 However, rule out latent uncorrected hyperopia before

proceeding with surgery.

Esodeviations 37
 b. Partially Accommodative Esotropia

 Accommodative factors contribute but do not

account for the entire deviation.
 show a  in the angle of esotropia with glasses
but have a residual esotropia

 results from decompensation of a fully

accommodative esotropia.

 Most cases show suppression of the squinting eye

although ARC may occur
Esodeviations 38
Partially cont’d…

 An interval of weeks to months between the

onset of accommodative esotropia and the
application of full cycloplegic refraction often
results in some residual esotropia, even after
the proper glasses are worn .

Esodeviations 39
 Partially cont’d…
Treatment

 Amblyopia management

 Prescription of the full hyperopic correction

 Strabismus surgery

Esodeviations 40
 c. High AC/A Esotropia
 Esotropia

◦ N>D fixation
◦ Unrelated to an URE, and
◦ Caused by an abnormally high AC/A ratio in
the presence of a normal near point of
accommodation.

 Because more accommodation is required at

near fixation than at distance, the angle of
esotropia is greater at near.

Esodeviations 41
High AC/A cont’d…

 A unit  accommodation disproportionately large 

in convergence

 Excess convergence tonus results from

accommodation, and esotropia develops in the setting
of insufficient fusional divergence.

 High AC/ A esotropia may occur in patients with large

degrees of hyperopia , normal levels of hyperopia,
emmetropia, or even myopia.

Esodeviations 42
 High AC/A cont’d…

 moderate degrees of hypermetropia are encountered

most frequently

 Etiology is unrelated to the underlying refractive error

but is closely linked with an abnormal synkinesis
between accommodation and accommodative
convergence

 The effort to accommodate elicits an abnormally high

accommodative convergence response.

Esodeviations 43
 High AC/A cont’d…
 If motor fusion can cope with the increased
convergence tonus at near fixation, an esophoria
results.

 If motor fusion is insufficient, nonrefractive

accommodative esotropia will become manifest.

 Most patients with nonrefractive accommodative

esotropia present between the ages of 6 months and 3
years

Esodeviations 44
High AC/A cont’d…
Diagnosis

 based on the presence of a significant

esodeviation at near fixation on an
accommodative fixation target with the
refractive error fully corrected and the
presence of a high AC/A ratio as established
with the gradient method to distinguish this
condition from nonaccommodative
convergence excess.

Esodeviations 45
 Management

 No consensus exists on the best management of

high AC/ A esotropia.
 Several options are available:

 Bifocals

 Long-acting cholinesterase inhibitors

 Surgery

 Observation

Esodeviations 46
 Nonaccommodative Esotropia
a. Sensory Deprivation Esodeviation

 Monocular vision loss from causes, such as cataract,

corneal scarring, optic atrophy or prolonged blurred
or distorted retinal images

 After all obstacles to balanced sensory inputs have

been removed, any secondary amblyopia is treated, if
possible.

 Surgery for residual esotropia may be indicated.

Esodeviations 47
 Nonaccommodative cont’d...

b. Divergence Insufficiency

 Characteristic finding: esodeviation, generally in adult

patients, that is greater at distance than at near.

 The deviation does not change with vertical or horizontal

gaze, and fusional divergence is reduced.

 Divergence paralysis may represent a more severe form

of divergence insufficiency.

 Paralysis of divergence cannot generally be documented,

the term divergence insufficiency is preferred.
Esodeviations 48
 Nonaccommodative...cont’d...
 Divergence insufficiency can be divided into a
primary isolated form and a secondary form
associated with other neurologic abnormalities
stemming from pontine tumors or severe head
trauma.

 A thorough clinical evaluation can frequently

distinguish between the 2 forms of divergence
insufficiency.

 Primary isolated divergence insufficiency is

frequently a benign condition that predominantly
occurs in patients older than 50 years: symptoms
may resolve within several months.
Esodeviations 49
 Nonaccommodative...cont’d...

 Secondary divergence insufficiency may obtain

relief from symptoms with treatment of the
underlying neurologic.

 Management of diplopia consists of base-out

prisms and, sometimes, surgery.

Esodeviations 50
Nonaccommodative...cont’d...

c. Surgical (Consecutive) Esodeviation

 Following surgery for exodeviation

 Slipped/lost LR muscle

 Treatments

 BO prisms,
 +ve lenses or
 surgery
Esodeviations 51
 Nonaccommodative...cont’d...
d. Acute esotropia

 Convergent strabismus develops without any apparent

etiology in a patient with previously normal binocular
vision, it is called acute esotropia.

 Sudden diplopia usually occurs in acute esotropia may

result from an underlying and potentially life-
threatening disease process
 Requires immediate evaluation.

Esodeviations 52
Causes of Acute Esotropia

 Neoplasm  Hydrocephalus
 Head trauma  Multiple sclerosis
 Intracranial  Meningitis/encephalitis
aneurysm  Myasthenia gravis
 Hypertension  Ophthalmoplegic
 Diabetes mellitus migraine
Chemotherapy
 Atherosclerosis
Esodeviations 53
 Recommended Readings

 Esophoria
 Hypoaccommodative esotropia
 Basic esotropia
 Cyclic esotropia
 Recurrent esotropia
 Nystagmus blockage syndrome
 Mechanical restrictive esotropia
 Sixth Cranial Nerve Paralysis
 Spasm of the Near Synkinetic Reflex
 Esotropia associated with impaired sight

Esodeviations 54
 References
1. Yanoff. Ocular disease. In: Gary R. Diamond. Pediatric and adult
strabismus. Part 11, section 3 ocular Manifestations. 1328-
1335.

2. Duane's. Duane's Foundations of Clinical Ophthalmology. In:

Marshall M. Parks, Pauler. Mitchell, Maynard B, Wheeler.
Concomitant Esodeviations.

3. American optometric association. Strabismus: esotropia and

exotropia : optometric clinical practice guideline: care of the
patient with strabismus. 1995.

4. American academy of ophthalmology. Basic and Clinical Science

Course. Pediatric Ophthalmology and Strabismus: section 6.
revision 2011-2012

Esodeviations 55
Thank you

Esodeviations 56