Accommodative Esotropia Clinical Presentation

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



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 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 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.