eMedicine Specialties > Ophthalmology > Extraocular Muscles

Esotropia, Accommodative

Author: Christopher T Noyes, MD, Private Practice, Texas Family Medicine
Coauthor(s): Raghav R Gupta, MD, Consulting Staff, Department of Ophthalmology, Vista Ophthalmology, Medical Center of Plano, and Presbyterian Hospital of Plano
Contributor Information and Disclosures

Updated: Nov 7, 2007

Introduction

Background

Strabismus is misalignment of the eyes such that both eyes are not simultaneously directed at the same object. Esotropia is a type of strabismus characterized by an inward deviation of one eye relative to the other eye. Accommodative esotropia (refractive accommodative esotropia) is an esodeviation due to normal accommodation in uncorrected hyperopia. The AC/A (accommodative convergence/accommodation) ratio gives the relationship between the amount of convergence (in-turning of the eyes) that is generated by a given amount of accommodation (focusing effort). Amblyopia is reduced visual acuity due to an abnormal visual experience early in life.

Pathophysiology

A patient with uncorrected hyperopia must accommodate to clear a blurred retinal image. This process of accommodation will stimulate convergence and strain fusional divergence. When fusional divergence is overcome, the eyes cross. The patient with uncorrected hyperopia can see either a single blurred image or a double image in which one image is clear and one image is blurred. Over time, the blurred image can be suppressed; fixation can alternate; or, more commonly, amblyopia can occur.

Race

No racial predilection exists.

Sex

No gender predilection exists.

Age

This condition usually presents by the age of 2 years.

Clinical

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.

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 complete eye exam.
    • 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.

More on Esotropia, Accommodative

Overview: Esotropia, Accommodative
Differential Diagnoses & Workup: Esotropia, Accommodative
Treatment & Medication: Esotropia, Accommodative
Follow-up: Esotropia, Accommodative
References
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References

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

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

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

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

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

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

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Further Reading

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Keywords

refractive accommodative esotropia, accommodative esotropia, strabismus, eye misalignment, misalignment of eyes, inward deviation of eye, inward eye deviation, hyperope, hyperopia, farsighted, farsightedness

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Contributor Information and Disclosures

Author

Christopher T Noyes, MD, Private Practice, Texas Family Medicine
Christopher T Noyes, MD is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, 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

Medical Editor

Gerhard W Cibis, MD, Director of Pediatric Ophthalmology Service, Clinical Professor, Clinical Professor, Department of Ophthalmology, Department of Ophthalmology, University of Kansas; Director, Children's Mercy Hospital, University of Missouri at Kansas City
Gerhard W Cibis, MD is a member of the following medical societies: American Academy of Ophthalmology, American Ophthalmological Society, and Association for Research in Vision and Ophthalmology
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, Director of Corneal Services, St Luke's Cataract and Laser Institute, Florida
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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