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Esotropia with High AC/A Ratio Clinical Presentation

  • Author: Chris Noyes, MD, FAAFP; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Jul 26, 2016
 

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.

The age of onset of strabismus should be noted. Family history of strabismus or related diseases is common.

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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.[2] 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 stereograms.

Check extraocular movements to ensure that eye movements are full.

Measure or estimate angle of deviation. This measurement can be performed most easily by evaluating 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. The examiner asks 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, the uncovered eye turns out to fixate. The angle of deviation is greater with near fixation than at distance and usually is 20-40 prism diopters.

Measure AC/A ratio. Patients with nonrefractive accommodative esotropia have a high AC/A ratio, which results in a deviation measured at near that is significantly greater than that at distance. In contrast, the AC/A ratio is normal (ie, distance and near measurements are the same) in pure accommodative esotropia.

Perform 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 older than 1 year.

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Contributor Information and Disclosures
Author

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

Chris Noyes, MD, FAAFP is a member of the following medical societies: American Academy of Family Physicians, Texas Medical Association, 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: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department 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, Association for Research in Vision and Ophthalmology, American Glaucoma Society

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, 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

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, American Ophthalmological Society

Disclosure: Nothing to disclose.

Acknowledgements

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
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  2. Webber AL, Wood JM, Gole GA, Brown B. Effect of Amblyopia on the Developmental Eye Movement Test in Children. Optom Vis Sci. 2009 May 4. [Medline].

  3. Scott AB, Miller JM, Shieh KR. Bupivacaine injection of the lateral rectus muscle to treat esotropia. J AAPOS. 2009 Apr. 13(2):119-22. [Medline].

  4. Rowe FJ, Noonan CP. Botulinum toxin for the treatment of strabismus. Cochrane Database Syst Rev. 2009 Apr 15. CD006499. [Medline].

  5. Polling JR, Eijkemans MJ, Esser J, Gilles U, Kolling GH, Schulz E, et al. A randomised comparison of bilateral recession vs. unilateral recession-resection as surgery for infantile esotropia. Br J Ophthalmol. 2009 Mar 30. [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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