eMedicine Specialties > Ophthalmology > Extraocular Muscles

Esotropia, Infantile: Follow-up

Author: Vicente Victor D Ocampo, MD, Consulting Staff, Department of Ophthalmology, Asian Hospital and Medical Center, Philippines
Coauthor(s): C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution
Contributor Information and Disclosures

Updated: Feb 27, 2007

Follow-up

Further Outpatient Care

  • Surgical correction is the first step in the visual rehabilitation of children with infantile esotropia. Patients who are aligned successfully early in life still need careful postoperative monitoring for amblyopia, nystagmus, inferior oblique overactions, dissociated vertical divergence, and accommodative esotropia.
  • A follow-up visit usually is scheduled 3-4 months after the initial postoperative consult. At this point, occlusion therapy can be restarted if amblyopia is present. In cases of significant overcorrection or undercorrection, while the patient may be seen earlier, reoperations seldom are performed before the third to fourth month postoperative period. If alignment is optimal (eg, within 8 PD of orthophoria) and acuity is equal in both eyes, subsequent follow-up visits are scheduled every 6 months until age 6 years. At this point, the risk of strabismic amblyopia is decreased, and yearly visits are sufficient. After age 10, consultations are performed on an as-needed basis.
  • The infant typically is seen 3-10 days after the surgery. Visual acuity is checked, an afferent pupillary defect is ruled out, and a good red reflex is elicited from both fundi. Furthermore, conjunctival incisions are inspected with a penlight for dehiscence and infection. Most importantly, alignment is assessed, and eye movements are observed for gross underaction and a slipped muscle. If no excessive inflammation is noted, use of antibiotic-corticosteroid ointments may be stopped at this time.

Inpatient & Outpatient Medications

  • Aside from the antibiotic-steroid ointment used in the immediate postoperative period, no other medications are needed.

Complications

  • Complications of initial surgical correction of infantile esotropia include the following:
    • Marked overcorrection and undercorrection
    • Infection
    • Scleral perforation
    • Foreign body granuloma at the suture site
    • Allergic reaction to suture material
    • Conjunctival inclusion cyst
    • Conjunctival scarring
    • Anterior segment ischemia
    • Change in eyelid position
    • Lost muscle
    • Slipped muscle
    • Oculocardiac reflex

Prognosis

  • It is accepted that better ocular alignment and visual prognosis can be achieved if surgical correction is performed before age 2 years. Long-term follow-up studies on esotropic infants who underwent surgical alignment by age 2 years have shown that close to 60% achieve a small angle (<20 PD) cosmetically acceptable strabismus. Although some binocular vision is achieved, it generally is subnormal, often involving peripheral fusion. Factors contributing to poor ocular alignment and visual prognosis include persistent preoperative amblyopia, latent manifest nystagmus, and myopia from -2.5 to 5.0 D.

Patient Education

  • Parents and other caregivers must be educated on the various presentations of infantile esotropia to ensure early detection and management.

Miscellaneous

Medicolegal Pitfalls

  • Proper diagnosis: Some ocular tumors, particularly intraocular retinoblastoma, may present initially as esodeviation. As such, a careful history and a thorough physical examination, with the pupils fully dilated, must be performed. Furthermore, careful refraction must be performed to determine a refractive component in the patient's esodeviation.
  • Timing of surgery: The appropriate age in which to perform surgery remains to be determined.
  • Complications of ocular alignment surgery: Complications may lead to further progression of the esotropia and may warrant additional surgery.
  • Visual prognostication, especially when amblyopia is present on initial consult: The rehabilitation of the infantile esotrope is a long process, and, at best, the prognosis for adequate binocular vision remains guarded.
 


More on Esotropia, Infantile

Overview: Esotropia, Infantile
Differential Diagnoses & Workup: Esotropia, Infantile
Treatment & Medication: Esotropia, Infantile
Follow-up: Esotropia, Infantile
References
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Further Reading

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Keywords

congenital esotropia, infantile esotropia, essential infantile esotropia, strabismus, inward deviation of eyes

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Contributor Information and Disclosures

Author

Vicente Victor D Ocampo, MD, Consulting Staff, Department of Ophthalmology, Asian Hospital and Medical Center, Philippines
Vicente Victor D Ocampo, MD is a member of the following medical societies: American Academy of Ophthalmology and Philippine Ocular Inflammation Society
Disclosure: Nothing to disclose.

Coauthor(s)

C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution
C Stephen Foster, MD, FACS, FACR, FAAO is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association of Immunologists, American College of Rheumatology, American College of Surgeons, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, American Uveitis Society, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Royal Society of Medicine, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Gerhard W Cibis, MD, Clinical Professor, Director of Pediatric Ophthalmology Service, Department of Ophthalmology, University of Kansas, Kansas City
Gerhard W Cibis, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Ophthalmological Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

J James Rowsey, MD, Former Director of Corneal Services, St Luke's Cataract and Laser Institute, Florida
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, Pan-American Association of Ophthalmology, Sigma Xi, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
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, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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