eMedicine Specialties > Ophthalmology > Extraocular Muscles
Esotropia, Acquired: Treatment & Medication
Updated: Oct 16, 2006
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- The treatment of the patient with strabismus is based on the underlying cause. In the absence of organic pathology, the treatment plan is formulated based on the interpretation and analysis of the motility examination results and the overall ocular evaluation. Besides the establishment and stabilization of single binocular vision, the significance of normal ocular alignment for the development of a positive self-image and interpersonal eye contact cannot be overemphasized. The goals of treatment may include the following:
- Obtaining optimal visual acuity in each eye
- Obtaining and/or improving fusion
- Obtaining a favorable functional appearance of the alignment of the eyes
- Indications for and specific types of treatment need to be individualized for each patient. The treatment of the patient with strabismus may include any or all of the following:
- Optical correction
- Added lens power
- Prisms to eliminate diplopia and to reestablish binocular vision
- Active orthoptics/vision therapy
- Amblyopia treatment
- Pharmacologic agents
- Extraocular muscle surgery in stable deviations too large to allow spontaneous binocular fusion
- Chemodenervation
Surgical Care
Prescribing the full hypermetropic correction determined by cycloplegic refraction forms an essential part of initial management. Undercorrection of hyperopia remains a common cause of acquired esotropia. Prism adaptation may be of some value in reducing the frequency of surgical undercorrection in nonaccommodative cases; however, published data, including the results of the Prism Adaptation Study, indicate persistent undercorrection rates of nearly 20%. Other approaches, including modifying dosage tables, operating for the near angle, and augmenting surgery based on the accommodative component, have been proposed and supported by data from a number of small clinical series. A review of recent experience shows that augmentation of surgery using a combination of these approaches can provide excellent results.
- In patients with acquired esotropia, surgery is indicated when the deviation is greater than 15 PD and stable. If lateral rectus muscle weakness, incomitance, papilledema, or systemic neurologic deficit is evident, neuroimaging studies of the orbits and brain should be performed. Hyperopia greater than +1.50 D or any significant astigmatic refractive error should be treated with glasses prior to performing surgery. Because binocular vision commonly develops before esotropia, surgery is recommended to reestablish binocularity as soon as the pathological underlying causes are eliminated.
- Pediatric strabismus surgery is performed under general anesthesia. The presence of any medical condition that precludes anesthetic administration or any life-threatening cause of esotropia (eg, brain tumor) should delay surgery.
- Bilateral medial rectus recession is performed most commonly for correction of nonaccommodative esotropia. Initial surgery is designed to correct the entire deviation. Monocular medial rectus recession and lateral rectus resection or unilateral medial rectus recession alone also have been used successfully in this situation.
- Expected surgical results
- Clark and colleagues reported good surgical results with bilateral medial rectus recession in 5 of 6 patients with acquired esotropia. Follow-up ranged from 3 months to 3 years. All 5 patients were orthophoric, and 4 of 5 patients had 40 seconds of stereopsis. The sixth patient had a recurrent esotropia of 25 D.
- Kittleman and Mazow achieved a functional cure (defined as alignment of the visual axes within 10 PD of orthophoria) in 66% of patients. They achieved a cosmetic cure (defined as alignment of the visual axes within 18 PD of orthophoria) in an additional 17% of patients. Seven patients required reoperation for a horizontal deviation. Some form of fusion was obtained in 85% of these patients, and 52% of patients obtained some degree of stereopsis.
- According to a recently published study by Clark and colleagues, medial rectus pulley posterior fixation, a technique of suturing the pulley to its muscle without scleral sutures, may be as effective as traditional scleral posterior fixation in primary treatment of acquired esotropia with a high AC/A ratio.
- Unilateral or bilateral lateral rectus resection is commonly performed for the correction of an eventual residual esotropia after bilateral medial rectus recession. Performing bilateral lateral rectus resection in patients with residual esotropia after bilateral medial rectus recession is considered appropriate because of the high success rate and the provision of a stable alignment during a long-term follow-up period (Jang, 2004).
Consultations
Consult a neurologist/neurosurgeon if neurologic abnormalities (eg, tumor, hydrocephalus) are suspected based on clinical and radiologic findings.
Diet
Dietary treatment is not useful in treating patients with any form of strabismus.
Activity
Physical activity is not useful in treating patients with any form of strabismus. Orthoptics/vision therapy can be very effective in treating patients with some forms of strabismus.
Medication
Drugs are used only to diagnose the disease.
Cycloplegics/Mydriatics
For the diagnosis of acquired esotropia.
Cyclopentolate (Cyclogyl, I-Pentolate)
Blocks muscle of ciliary body and sphincter muscle of iris from responding to cholinergic stimulation, thus causing mydriasis and cycloplegia.
Induces mydriasis in 30-60 min and cycloplegia in 25-75 min. These effects last up to 24 h.
Adult
1 gtt of 1% solution usually adequate to induce cycloplegia; if necessary, repeat in 5-10 min
Pediatric
Infants: 1 gtt of 0.5% solution into each eye 5-10 min before examination
>1 year: 1 gtt of 0.5%, 1%, or 2% solution to induce cycloplegia; if necessary, repeat in 5-10 min
Decreases effects of carbachol and cholinesterase inhibitors
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Exercise caution in patients (eg, elderly) where increased intraocular pressure may be present; can cause toxic anticholinergic systemic adverse effects (common in children, especially infants), but incidence rare when used sparingly; compressing lacrimal sac by digital pressure for 1-3 min, following application, may minimize systemic absorption
Tropicamide (Mydriacyl, Opticyl, Tropicacyl)
Blocks sphincter muscle of iris and muscle of ciliary body from responding to cholinergic stimulation.
Adult
Cycloplegia: 1-2 gtt; may repeat in 5 min
Mydriasis: 1-2 gtt 15-20 min before examination; may repeat q30min prn
Pediatric
Administer as in adults, taking care to wipe away any medication that spills onto skin of eyelids and face (infants lack significant amounts of skin keratin and, hence, can experience significant systemic absorption directly through skin)
None reported
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
May cause potentially dangerous CNS disturbances in infants and children; may increase intraocular pressure
More on Esotropia, Acquired |
| Overview: Esotropia, Acquired |
| Differential Diagnoses & Workup: Esotropia, Acquired |
 Treatment & Medication: Esotropia, Acquired |
| Follow-up: Esotropia, Acquired |
| References |
| « Previous Page | Next Page » |
References
Clark AC, Nelson LB, Simon JW. Acute acquired comitant esotropia. Br J Ophthalmol. Aug 1989;73(8):636-8. [Medline].
Clark RA, Ariyasu R, Demer JL. Medial rectus pulley posterior fixation: a novel technique to augment recession. J AAPOS. Oct 2004;8(5):451-6. [Medline].
Costello PA, Simon JW, Jia Y, Lininger LL. Acquired esotropia: subjective and objective outcomes. J AAPOS. Jun 2001;5(3):193-7. [Medline].
Firth AY. Heroin and diplopia. Addiction. Jan 2005;100(1):46-50. [Medline].
Fukai S, Arai N, Hayakawa T, Kimura H. Studies on the botulinum therapy for esotropia improvement of retinal correspondence. Nippon Ganka Gakkai Zasshi. Jun 1993;97(6):757-62. [Medline].
Goldman HD, Nelson LB. Acute acquired comitant esotropia. Ann Ophthalmol. Dec 1985;17(12):777-8. [Medline].
Jang GJ, Park MR, Park SC. Bilateral lateral rectus resection in patients with residual esotropia. Korean J Ophthalmol. Dec 2004;18(2):161-7. [Medline].
Kittleman WT, Mazow ML. Reoperations in esotropia surgery. Ann Ophthalmol. May 1986;18(5):174-7. [Medline].
Ludwig IH, Smith JF. Presumed sinus-related strabismus. Trans Am Ophthalmol Soc. 2004;102:159-65; discussion 165-7. [Medline].
Lyons CJ, Tiffin PA, Oystreck D. Acute acquired comitant esotropia: a prospective study. Eye. Oct 1999;13 (Pt 5):617-20. [Medline].
Mohney BG. Common forms of childhood esotropia. Ophthalmology. Apr 2001;108(4):805-9. [Medline].
Mohney BG. Acquired nonaccommodative esotropia in childhood. J AAPOS. Apr 2001;5(2):85-9. [Medline].
Repka MX, Wentworth D. Predictors of prism response during prism adaptation. Prism Adaptation Study Research Group. J Pediatr Ophthalmol Strabismus. Jul-Aug 1991;28(4):202-5. [Medline].
Thomas AH. Divergence insufficiency. J AAPOS. Dec 2000;4(6):359-61. [Medline].
Troost BT, Abel L, Noreika J, Genovese FM. Acquired cyclic esotropia in an adult. Am J Ophthalmol. Jan 1981;91(1):8-13. [Medline].
Further Reading
Keywords
acquired esotropia, acute esotropia, cyclic esotropia, progressive esotropia with myopia, nonaccommodative esodeviation, acquired nonaccommodative esotropia, ANAET, esotropia associated with impaired sight, sixth nerve palsy, abducens nerve palsy, infantile esotropia, diplopia, concomitant esotropia, atypical strabismus,
