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Acquired Esotropia Treatment & Management

  • Author: Mauro Fioretto, MD; Chief Editor: Hampton Roy, Sr, MD  more...
Updated: Aug 23, 2016

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:[4]

  • 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,[5] 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 published experience shows that augmentation of surgery using a combination of these approaches can provide excellent results.[6]

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.

According to 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.[10]

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.[11]

Expected surgical results

Clark and colleagues reported good surgical results with bilateral medial rectus recession in 5 of 6 patients with acquired esotropia.[7] 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.[8] 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.

Schoffler and Sturm studied 4 children with acute acquired concomitant esotropia who underwent repeated surgery for the sake of binocularity.[9] In all 4 patients, the final binocularity outcome, after repeated surgery, was high-grade stereopsis (Lang I/II positive). The duration from onset of esotropia to the time of regained stereovision was between 20 and 62 months. High-grade stereoacuity was only achieved after a second surgery in one patient. Their findings support the good binocular potential in patients with this type of acute acquired concomitant estropia. In this study, all 4 patients regained high-grade stereopsis, though they did have a complicated course and long-lasting absence of stereovision.



Consult a neurologist/neurosurgeon if neurologic abnormalities (eg, tumor, hydrocephalus) are suspected based on clinical and radiologic findings.



Dietary treatment is not useful in treating patients with any form of strabismus.



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.

Contributor Information and Disclosures

Mauro Fioretto, MD Professor of Ophthalmology, University Eye Clinic of Genova; Head of Ophthalmology Department, Hospital of Casale Monferrato, Italy

Disclosure: Nothing to disclose.


Antonio Pascotto, MD Consulting Ophthalmologist, Pascotto, Istituto per la Salute degli Occhi, Clinica Mediterranea, Italy

Disclosure: Nothing to disclose.

Sergio Claudio Saccà, PhD Professor of Ophthalmology, Department of Neurological and Visual Sciences, Ospedale San Martino, Italy

Disclosure: Nothing to disclose.

Vincenzo Orfeo, MD Head, Operating Unit, Clinica Mediterranea, Naples, Italy

Vincenzo Orfeo, MD is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

J James Rowsey, MD Former Director of Corneal Services, St Luke's Cataract and Laser Institute

J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Sigma Xi, Southern Medical Association, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Michael J Bartiss, OD, MD Medical Director, Ophthalmology, Family Eye Care of the Carolinas and Surgery Center of Pinehurst

Michael J Bartiss, OD, MD is a member of the following medical societies: American Academy of Ophthalmology, North Carolina Medical Society, American Academy of Pediatrics, American Association for Pediatric Ophthalmology and Strabismus

Disclosure: Nothing to disclose.

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