Pseudoesotropia 

Updated: Oct 14, 2015
Author: Kalpana K Jatla, MD; Chief Editor: Hampton Roy, Sr, MD 

Overview

Background

Pseudoesotropia is a condition in which the alignment of the eyes is straight (also known as orthotropic); however, they appear to be crossed.[1]

Note the cross-eyed appearance of the right eye in Note the cross-eyed appearance of the right eye in the top image that corrects with elimination of the prominent epicanthal fold.
In these photos of the same child as in the previo In these photos of the same child as in the previous image, note the cross-eyed appearance of the left eye in the top image that corrects with elimination of the prominent epicanthal fold. Also, note that corneal light reflex demonstrates straight alignment.

Pathophysiology

This condition most commonly occurs in infants when a flat nasal bridge and prominent epicanthal folds tend to obscure the nasal portion of the sclera. This optical illusion causes the patient to have an appearance of eyes deviated nasally, and it is most apparent when the eyes are in side gaze or are focusing up close. A small interpupillary distance (ie, the distance between 2 pupils) also can give the appearance of pseudoesotropia.[2]

Epidemiology

Frequency

United States

Pseudoesotropia is a condition with variable frequency. This condition is one of the most common reasons for infant referrals to ophthalmologists.

Race

Infants or young toddlers of Asian descent with flat nasal bridges often have pseudoesotropia.

Sex

No gender predilection exists in pseudoesotropia.

Age

Pseudoesotropia is more frequent in infants and toddlers where facial structures have not yet fully developed.

 

Presentation

History

Parents may notice that their young child's eyes appear to turn in. The deviation is reported to be even more noticeable when the child has a head turn and the eyes are in lateral gaze. Parents may bring pictures showing how the eyes are "turned in" to the ophthalmologist.

Physical

A careful ocular examination (eg, pupillary light reflex) reveals that the eyes are straight.

Using the cover-uncover test, the examiner finds that the patient manifests no deviation.

A flat nasal bridge with wide epicanthus (the part of skin fold that runs from the upper to the lower eyelids) or a small interpupillary distance usually is noted. Since the nasal scleral portion is being covered by the epicanthus, the examiner can demonstrate the orthotropic appearance by pinching slightly the nasal bridge and revealing the nasal sclera.

Causes

A flat nasal bridge with wide epicanthus or a small interpupillary distance obscures the nasal portion of the sclera.

One paper reported 4 cases of pseudoesotropia caused by a negative angle kappa, a nasally dislocated macula in infants with high myopia.

 

DDx

 

Workup

Other Tests

A complete ocular examination is important since a patient may have true strabismus.

The corneal light reflex test, such as shining a flashlight in the patient's eyes from 3 meters away and examining the light reflex on the cornea, can be performed to differentiate pseudoesotropia and true esotropia.

With pseudoesotropia, light reflexes are aligned, while true esotropia has one corneal light reflex offset temporally.

 

Treatment

Medical Care

No treatment is required for pseudoesotropia. Parents can be reassured that their child most likely will outgrow the condition. Infants should be observed and reevaluated every 6 months because it is possible that true esotropia, particularly accommodative esotropia, may develop at a later date.

Consultations

Patients with suspected pseudoesotropia should be examined and receive follow-up care by an ophthalmologist since it is possible that true esotropia may develop at a later date.

 

Follow-up

Further Outpatient Care

Patients should receive follow-up care from an ophthalmologist, with reevaluation every 6 months because true esotropia may develop.

Prognosis

The prognosis is generally good. No treatment usually is required for pseudoesotropia, and most patients outgrow their appearance.

Patient Education

Reassure parents that their child most likely will outgrow this condition.