Accommodative Esotropia Clinical Presentation

  • Author: Chris Noyes, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Mar 6, 2012
 

History

Parents of the patient may notice an inward or upward deviation of one eye relative to the other eye. The patient may see either a single blurred image or a double image in which one image is clear and one image is blurred. Family history of strabismus or related diseases is common. The age of onset of strabismus should be noted.

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Physical

Carefully examine visual acuity in a manner appropriate for the patient's age. For patients younger than 1 year, visual acuity is measured by objective means. For patients aged 1-3 years, subjective methods, such as Allen cards, are used in addition to objective methods. For patients aged 3-5 years, subjective methods, such as Allen cards, tumbling Es, or the letter chart, can be used. For patients older than 5 years, the Snellen alphabet chart almost always can be used. The patient usually will have hyperopia in the range of +3.00 to +10.00 diopters.

Determine stereo acuity using polarized glasses and Titmus test or Randot stereogram.

Check extraocular movements to ensure that the eye movements are full.

Measure or estimate the angle of deviation. The easiest method is to evaluate the centration of the corneal light reflex in each eye, while the patient fixes on objects at distance or near. In some cases, it is possible to perform the alternate cover test. Ask the patient to fix on an object. By alternately covering and uncovering each eye, the examiner can detect a shift in the eye's position with refixation. In esotropia, as an eye is uncovered, it turns out to fixate. In true accommodative esotropia, the angle of deviation is the same when measured at distance and near fixation and usually is 20-40 prism diopters.

Measure AC/A. If this ratio is high, then the deviation measured at near will be significantly greater than that at distance. In pure accommodative esotropia, the AC/A ratio should be normal; distance and near measurements should be the same.

Perform a complete eye examination. Examine the anterior segment to assess the cornea, anterior chamber, and lens. Examine the fundus with both direct and indirect ophthalmoscopes. Note the appearance of the macula and the optic nerve.

Perform cycloplegic refraction on all children by using the retinoscope and loose lenses. Cycloplegia is achieved with Mydriacyl 1% if the patient is younger than 1 year; it is achieved with Cyclogyl 1% if the patient is 1 year or older.

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Contributor Information and Disclosures
Author

Chris Noyes, MD  FAAFP, Private Practice - Texas Family Medicine

Chris Noyes, MD is a member of the following medical societies: American Academy of Family Physicians and Texas Academy of Family Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Raghav R Gupta, MD  Consulting Staff, Department of Ophthalmology, Vista Ophthalmology, Medical Center of Plano, and Presbyterian Hospital of Plano

Disclosure: eMedicine Honoraria Other

Specialty Editor Board

Gerhard W Cibis, MD  Clinical Professor, Director of Pediatric Ophthalmology Service, Department of Ophthalmology, University of Kansas School of Medicine

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.

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

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.

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, Pan-American Association of Ophthalmology, Sigma Xi, and Southern Medical Association

Disclosure: Nothing to disclose.

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.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous coauthor, D Brian Stidham, MD, to the development and writing of this article.

References

  1. Rutstein RP. Update on accommodative esotropia. Optometry. Aug 2008;79(8):422-31. [Medline].

  2. Li CH, Chen PL, Chen JT, Fu JJ. Different corrections of hypermetropic errors in the successful treatment of hypermetropic amblyopia in children 3 to 7 years of age. Am J Ophthalmol. Feb 2009;147(2):357-63. [Medline].

  3. Cho YA, Yi S, Kim SW. Clinical evaluation of cessation of hyperopia in 123 children with accommodative esotropia treated with glasses for best corrected vision. Acta Ophthalmol. Aug 27 2008;[Medline].

  4. Magli A, Iovine A, Gagliardi V, Fimiani F, Nucci P. LASIK and PRK in refractive accommodative esotropia: a retrospective study on 20 adolescent and adult patients. Eur J Ophthalmol. Mar-Apr 2009;19(2):188-95. [Medline].

  5. Birch EE, Wang J. Stereoacuity Outcomes After Treatment of Infantile and Accommodative Esotropia. Optom Vis Sci. Apr 22 2009;[Medline].

  6. Beers MH, Berkow R. The Merck Manual of Diagnosis and Therapy. 1999.

  7. Berson FG. Basic Ophthalmology for Medical Students and Primary Care Residents. 1993.

  8. Catalano RA, Nelson LB. Pediatric Ophthalmology: A Text Atlas. 1994.

  9. Helveston EM, Ellis FD. Pediatric Ophthalmology Practice. 1980.

  10. Kunimoto DY, et al. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 2004.

  11. Wright KW, et al. Pediatric Ophthalmology and Strabismus. 1995.

 
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