Acquired Esotropia Clinical Presentation

Updated: Sep 13, 2018
  • Author: Mauro Fioretto, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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The family of the patient may notice an inward deviation of one eye relative to the other eye. In assessing the patient, also evaluate the following:

  • Establish family history of strabismus or related diseases.

  • Note age of onset of strabismus. Photographs of patients at different ages often can help to determine if the esotropia was present prior to age 6 months and only recently appreciated by the patient's family versus truly acquired (after age 6 mo).

According to Burian and Miller, acute acquired comitant esotropia can be divided into 3 distinct categories: Type 1 (Swan type) refers to esotropia following the interruption of fusion by a period of monocular occlusion or vision loss 2). Type 2 (Burian-Franceschetti type) has no obvious underlying cause other than physical or psychological stress and often presents with modest hypermetropia and minimal accommodation. Type 3 (Bielschowsky type) has been described in myopic subjects. [2]



Visual Acuity

Carefully examine visual acuity in a manner appropriate for the patient's age.

For patients too young to subjectively quantify their visual acuity levels, objective methods are used.

For patients aged 1-3 years, subjective methods, such as Allen cards, often are used in addition to objective methods. Other methods can also be used, such as preferential looking or visual evoked potentials (VEP).

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.


Determine stereoacuity using polarized glasses and Randot stereogram or LANG test or TNO test.

Extraocular Movements

Check extraocular movements to ensure that the eye movements are completely extended, both in monocular and then in binocular vision.

Angle of Deviation

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, performing the alternate cover test is possible. 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 accommodative esotropia, the angle of deviation is often the same when measured at distance and near fixation (usually 20-40 PD), but it can vary depending on the accommodative convergence/accommodation (AC/A) ratio.

AC/A Ratio

Measure the AC/A ratio.

If the AC/A ratio is high, then the deviation measured at near will be significantly greater than that at distance.

In true accommodative esotropia, the AC/A ratio should be normal (approximately 4/1-6/1); distance and near measurements should be the same.

Complete Eye Examination

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 optic nerve.

Cycloplegic Refraction

Perform cycloplegic refraction on all children by using the retinoscope and trial lenses. Cycloplegia often can be 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.



Decompensation of a preexisting phoria or monofixation syndrome appears to be the most common etiology of acquired esotropia. Other possible etiologies include the following [3] :

  • Children who have been farsighted and have not worn glasses

  • Children who were initially responsive to glasses but later developed additional eye crossing (nonaccommodative esotropia) even with full hyperopic correction

  • Heredity

  • Abnormalities in pregnancy and delivery

  • Arnold-Chiari malformation

  • Scleral ectasia in high myopia that can lead to a "downslip" of the lateral rectus muscle relative to the globe, giving this muscle a depressing effect at the cost of its physiological action

  • Myopic epikeratophakia

  • Neurologic abnormalities

  • Deficits of abduction (sixth nerve palsy, sixth nerve pseudo-palsy in children with esotropia with manifest-latent nystagmus, unilateral or bilateral type 1 Duane syndrome)

  • Heroin detoxification: Eye misalignments can occur during heroin use and heroin detoxification and can cause persisting diplopia (double vision). [4]

  • Occult sinus disease: Sinusitis supposedly leads to inflammation and secondary contracture in adjacent extraocular muscles. [5]