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A-Pattern Esotropia and Exotropia Clinical Presentation

  • Author: James L Plotnik, MD, FACS; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Oct 13, 2015
 

History

Inward or outward deviation of the eyes is the most common presenting problem.

The vertical variation in the magnitude of the horizontal deviation may not be obvious to the parents or the patient.

A head tilt (chin up or down) may be present, as the individual adopts a head posture that allows the eyes to remain in the position of minimal deviation. This compensatory maneuver minimizes diplopia and allows binocular viewing.

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Physical

Measurements of the amplitude of horizontal deviation are obtained by prism and alternate cover testing in primary position and, then, with the eyes 25° in upgaze and 25° in downgaze. Measurements should be made while the patient wears proper refractive correction and fixates on an accommodative target at distance. Note any underaction and overaction of the oblique muscles on versions and any compensatory abnormal head posture. Examine the palpebral fissure configuration (presence of a mongoloid appearance).

Clinical findings of A-pattern esotropia are as follows:

  • Esotropia increases in midline upgaze and decreases in midline downgaze.
  • Eyes may be straight in downgaze and primary gaze.
  • Patients may demonstrate a chin-up posture, a compensatory maneuver that requires the eyes to be in downgaze for straight-ahead viewing. This posture places the eyes in the position of gaze where less inward deviation (more divergence) of the eyes occurs, possibly allowing single binocular vision.

Clinical findings of A-pattern exotropia are as follows:

  • Exotropia increases in midline downgaze and decreases in midline upgaze.
  • Eyes may be straight in upgaze and primary gaze.
  • Patients may demonstrate a chin-down posture, a compensatory maneuver that requires the eyes to be in upgaze for straight-ahead viewing. This posture places the eyes in the position of gaze where less outward deviation (more convergence) of the eyes occurs, possibly allowing single binocular vision.

Patients with A-patterns may manifest signs of superior oblique overaction, including overdepression in adduction, incyclotorsion of the involved eye(s), and/or associated vertical strabismus.[8]

  • Patients may demonstrate a tight superior oblique muscle on forced duction testing.
  • Most patients with congenital overaction of the superior oblique muscles do not manifest subjective complaints of torsion; instead, they manifest objective evidence of intorsion by indirect ophthalmoscopy. This may be most noticeable in downgaze.
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Causes

See Pathophysiology.

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Contributor Information and Disclosures
Author

James L Plotnik, MD, FACS Consulting Staff, Department of Ophthalmology, Division of Pediatric Ophthalmology, Arizona Pediatric Eye Specialists

James L Plotnik, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus

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

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.

References
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