eMedicine Specialties > Ophthalmology > Extraocular Muscles

Esotropia, Acquired: Differential Diagnoses & Workup

Author: Antonio Pascotto, MD, Consulting Ophthalmologist, Istituto Diagnostico Varelli, Clinica Mediterranea, Napoli, Italy
Coauthor(s): Mauro Fioretto, PhD, Professor and Program Director, Department of Ophthalmology, Ospedale Santo Spirito, Casale Monferrato (AL), Italy; Sergio Claudio Saccà, PhD, Professor of Ophthalmology, Department of Neurological and Visual Sciences, Ospedale San Martino, Italy; Vincenzo Orfeo, MD, Head, Operating Unit, Clinica Mediterranea, Naples, Italy
Contributor Information and Disclosures

Updated: Oct 16, 2006

Differential Diagnoses

Workup

Imaging Studies

• Consider neuroimaging studies in the absence of expected findings (eg, hypermetropia) or fusion potential or in the presence of atypical features or neurologic signs.
• CT scan of orbits - Axial and coronal views, 3-mm cuts
  • Evaluation of fractures
  • Assessment of potential extraocular muscle entrapment
  • Presence of orbital mass
• Chest x-ray
  • Lung nodules suggestive of lung carcinoma
  • May identify suspicious breast lesion
• CT scan of neck/thorax/abdomen - To evaluate for systemic malignancy
• B-scan ultrasonography - If any doubt of globe integrity
• Radiographic imaging studies (eg, MRI of brain and brainstem) if neurologic signs or craniofacial anomalies are present

Other Tests

• Bagolini striated glasses test
  • Most tests for fusion, suppression, and Anomalous Retinal Correspondence (ARC) create artificial viewing circumstances. Normally, the visual environment is not that of a red filter in front of one eye or a combination of red-green filters; separately viewed slides in illuminated tubes are nothing more than a laboratory analysis of retinal correspondence.
  • The striated glasses popularized by Bagolini allow the patient to view the normal visual environment with a faint reference line placed on the background viewed by each eye. The reference line for each eye is placed at right angles by arranging the glasses in the trial frame so that the striations before the right eye and the left eye are perpendicular to each other. For example, the striations are placed at 135° in the trial frame in front of the right eye and at 45° in front of the left eye. The patient views a fixation light at any distance chosen by the examiner; ordinary room illumination is maintained. The patient reports on the fixation light and observed streaks extending out into the peripheral field of vision.
  • Patients with esotropia of 10 D or more give varied responses, depending on whether they have Normal Retinal Correspondence (NRC), ARC monocular vision, or an absence of binocular vision.
    • The esotropic patient with NRC sees 2 fixation lights in homonymous diplopia, with a separate streak through each lens and without a break in either streak. Compensating for the esotropic angle with base-out prisms eliminates the diplopic fixation light, and the streaks then intersect at the fixation light.
    • The patient with ARC and suppression sees 1 fixation light and 2 streaks forming an X; after being questioned, the patient recognizes the suppression scotoma projecting from the nasal retina of the deviated eye as a gap of 5-6° around the fixation light in the streak seen by that eye.
    • The scotoma can be studied further by removing the striated glass from in front of the fixating eye and slowly rotating the striated glass before the nonfixating eye. As the streak rotates, the gap in the streak around the fixation light persists, beautifully outlining the scotoma for 360°. Furthermore, ARC is made evident by the patient's claim that the streak seen by the deviated eye passes through the fixation light as the patient mentally connects the 2 ends of the gap in this streak. When the light is held in front of the eyes, base-out prism power equal to the esotropic deviation produces crossed diplopia for the fixation light, and each light has its separate streak passing through it.
    • The patient devoid of single binocular vision sees only 1 light and 1 streak. The patient may claim to see 2 streaks if rapidly alternating but will admit under questioning that the 2 streaks are not perceived simultaneously.
  • The patient with exotropia of 10 D or more may report NRC with heteronymous diplopia, ARC with suppression, or an absence of binocular vision.
    • The large profound scotoma of the temporal retina, extending up to the hemiretinal line in the exotropic patient with ARC, prevents all but the best observers from appreciating the extremely peripheral small streak seen outside the suppression scotoma of the deviated eye. Consequently, many exotropic patients report seeing only 1 streak.
    • Those patients who can detect the small peripheral ends of the streak describe the ends on the axis that coincides with the light, supporting the diagnosis of ARC. Furthermore, base-in prism power placed in front of the eyes that equals the deviation angle creates homonymous diplopia of the fixation light, each image having a separate streak.
  • The Bagolini striated glasses test requires a degree of maturity that seldom is found in a child younger than 8 years. Describing or drawing the suppression scotoma gap in 1 of the streaks presents great difficulty to the young child.

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