Acquired Esotropia Treatment & Management

Updated: Sep 13, 2018
  • Author: Mauro Fioretto, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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Medical Care

The treatment of the patient with strabismus is based on the underlying cause. In the absence of organic pathology, the treatment plan is formulated based on the interpretation and analysis of the motility examination results and the overall ocular evaluation. Besides the establishment and stabilization of single binocular vision, the significance of normal ocular alignment for the development of a positive self-image and interpersonal eye contact cannot be overemphasized. The goals of treatment may include the following:

  • Obtaining optimal visual acuity in each eye

  • Obtaining and/or improving fusion

  • Obtaining a favorable functional appearance of the alignment of the eyes

Indications for and specific types of treatment need to be individualized for each patient. The treatment of the patient with strabismus may include any or all of the following:

  • Optical correction

  • Added lens power

  • Prisms to eliminate diplopia and to reestablish binocular vision

  • Active orthoptics/vision therapy

  • Amblyopia treatment

  • Pharmacologic agents

  • Extraocular muscle surgery in stable deviations too large to allow spontaneous binocular fusion

  • Chemodenervation


Surgical Care

Prescribing the full hypermetropic correction determined by cycloplegic refraction forms an essential part of initial management. Undercorrection of hyperopia remains a common cause of acquired esotropia. Prism adaptation may be of some value in reducing the frequency of surgical undercorrection in nonaccommodative cases; however, published data, including the results of the Prism Adaptation Study, [7] indicate persistent undercorrection rates of nearly 20%. Other approaches, including modifying dosage tables, operating for the near angle, and augmenting surgery based on the accommodative component, have been proposed and supported by data from a number of small clinical series. A review of published experience shows that augmentation of surgery using a combination of these approaches can provide excellent results. [8]

In patients with acquired esotropia, surgery is indicated when the deviation is greater than 15 PD and stable. If lateral rectus muscle weakness, incomitance, papilledema, or systemic neurologic deficit is evident, neuroimaging studies of the orbits and brain should be performed. Hyperopia greater than +1.50 D or any significant astigmatic refractive error should be treated with glasses prior to performing surgery. Because binocular vision commonly develops before esotropia, surgery is recommended to reestablish binocularity as soon as the pathological underlying causes are eliminated.

Pediatric strabismus surgery is performed under general anesthesia. The presence of any medical condition that precludes anesthetic administration or any life-threatening cause of esotropia (eg, brain tumor) should delay surgery.

Bilateral medial rectus recession is performed most commonly for correction of nonaccommodative esotropia. Initial surgery is designed to correct the entire deviation. Monocular medial rectus recession and lateral rectus resection or unilateral medial rectus recession alone also have been used successfully in this situation.

According to Clark and colleagues, medial rectus pulley posterior fixation, a technique of suturing the pulley to its muscle without scleral sutures, may be as effective as traditional scleral posterior fixation in primary treatment of acquired esotropia with a high AC/A ratio. [9]

Unilateral or bilateral lateral rectus resection is commonly performed for the correction of an eventual residual esotropia after bilateral medial rectus recession. Performing bilateral lateral rectus resection in patients with residual esotropia after bilateral medial rectus recession is considered appropriate because of the high success rate and the provision of a stable alignment during a long-term follow-up period. [10]

Expected surgical results

Clark and colleagues reported good surgical results with bilateral medial rectus recession in 5 of 6 patients with acquired esotropia. [11] Follow-up ranged from 3 months to 3 years. All 5 patients were orthophoric, and 4 of 5 patients had 40 seconds of stereopsis. The sixth patient had a recurrent esotropia of 25 D.

Kittleman and Mazow achieved a functional cure (defined as alignment of the visual axes within 10 PD of orthophoria) in 66% of patients. [12] They achieved a cosmetic cure (defined as alignment of the visual axes within 18 PD of orthophoria) in an additional 17% of patients. Seven patients required reoperation for a horizontal deviation. Some form of fusion was obtained in 85% of these patients, and 52% of patients obtained some degree of stereopsis.

Schoffler and Sturm studied 4 children with acute acquired concomitant esotropia who underwent repeated surgery for the sake of binocularity. [13] In all 4 patients, the final binocularity outcome, after repeated surgery, was high-grade stereopsis (Lang I/II positive). The duration from onset of esotropia to the time of regained stereovision was between 20 and 62 months. High-grade stereoacuity was only achieved after a second surgery in one patient. Their findings support the good binocular potential in patients with this type of acute acquired concomitant estropia. In this study, all 4 patients regained high-grade stereopsis, though they did have a complicated course and long-lasting absence of stereovision.



Consult a neurologist/neurosurgeon if neurologic abnormalities (eg, tumor, hydrocephalus) are suspected based on clinical and radiologic findings.



Dietary treatment is not useful in treating patients with any form of strabismus.



Physical activity is not useful in treating patients with any form of strabismus. Orthoptics/vision therapy can be very effective in treating patients with some forms of strabismus.



The most common complication associated with surgery for acquired esotropia is unsatisfactory alignment. Surgery usually is performed on the unoperated horizontal muscles in an effort to reestablish binocular function.


Further Outpatient Care

Regular follow-up care is indicated to monitor the patient's eye alignment.

Relief from the eventual diplopia may be achieved through prismatic correction, and the deviation may then resolve spontaneously. Botulinum toxin or surgical intervention may be necessary in cases that do not resolve. Botulinum toxin must be considered only in patients with spasm contraction of the medial center muscle due to neurogenic spikes. The temporary redaction of these contractions can restore binocular vision, and, eventually, the botulinum toxin can be repeated.