V-Pattern Esotropia and Exotropia

Updated: Dec 09, 2021
  • Author: Neepa Thacker, MBBS, MS, DNB, FRCS; Chief Editor: Donny W Suh, MD, MBA, FAAP, FACS  more...
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Duane first described V-pattern strabismus in 1897. [1] Other investigators also studied these phenomena, contributing to the understanding of them. Costenbader and colleagues recommended measuring the horizontal deviations in upgaze and downgaze as part of all routine motility examinations. [2]

Two types of V patterns can occur, as shown in the images below.

V-pattern exotropia is an exodeviation with greater exotropia in upgaze than in downgaze.

V-pattern exotropia. V-pattern exotropia.

V-pattern esotropia is an esodeviation with greater esotropia in downgaze than in upgaze.

V-pattern esotropia. V-pattern esotropia.

Comitant horizontal deviations are those in which the angle of deviation is the same in all gaze positions. Incomitant horizontal deviations are those in which the angle of deviation varies in different gaze positions. Horizontal deviations may have lateral incomitances and vertical incomitances. In lateral incomitances, significant differences exist in the amount of horizontal deviation in primary gaze versus side gaze, whereas, in vertical incomitances, significant differences exist in the amount of horizontal deviation in upgaze versus downgaze.

When the eyes diverge more than 10 prism diopters (PD) from upgaze to downgaze, an "A" pattern is present; when the eyes converge more than 15 PD from upgaze to downgaze, a "V" pattern is present.

Other types of vertical incomitances, which are less common, include X, Y, and lambda patterns. This discussion is limited to V-pattern strabismus.



Multiple factors may be responsible for V-pattern strabismus, and, in a given individual, one or more factors may contribute toward its cause.

Inferior oblique muscle overaction

The most widely accepted mechanism contributing to the causation of V-pattern strabismus is associated with inferior oblique muscle overaction and/or relative underaction of the superior oblique muscles, as shown in the images below.

Patient with V-pattern exotropia and inferior obli Patient with V-pattern exotropia and inferior oblique muscle overaction.
Patient with V-pattern esotropia and inferior obli Patient with V-pattern esotropia and inferior oblique muscle overaction.

Inferior oblique muscle overaction produces significant horizontal deviation in upgaze. In upgaze, the horizontal action of the inferior oblique muscles is abduction; therefore, inferior oblique muscle overaction produces relative divergence in elevation. A V-pattern results in greater exotropia (or less esotropia) in upgaze and greater esotropia (or less exotropia) in downgaze. Not all V-pattern strabismus is associated with oblique muscle dysfunction.

Classification of eye movement abnormalities ans strabismus (CEMAS) has suggested that superior oblique overaction be described as overdepression in adduction and inferior oblique overaction be described as over elevation in adduction

Facial and orbital configuration

An association exists between individuals with hypoplasia of the malar bones, anti-Mongoloid lid slants, and S-shaped contours of the lower lid, and overaction of the inferior oblique muscles and V-pattern strabismus. Patients with craniosynostosis have shallow orbits, and the angle between the visual axis and the insertion of the inferior oblique muscle is increased. This increased angle increases the abduction ability of the inferior oblique muscles in upgaze, resulting in a V-pattern. Contributing to this condition is the complex interplay of these factors with excyclotorsion of the globe.

Effect of the pulley systems

Upward displacement of the pulley systems around the lateral rectus muscle may cause V-pattern strabismus.

Horizontal muscle overaction

Initially, this theory was believed to be responsible for V-pattern strabismus, but no convincing evidence supports it. In V-pattern esotropia, the medial rectus muscle was believed to overact, thereby increasing esotropia in downgaze, and, in V-pattern exotropia, the lateral rectus muscle overaction was responsible for increased exotropia in upgaze.

Vertical rectus muscle imbalance

One theory states that V-pattern strabismus occurs because of underacting superior recti muscles and corresponding overacting inferior oblique muscles. This hypothesis was applied when nasal and temporal displacements were used to treat A- and V-patterns. This theory has been abandoned.

Abnormal oblique muscle insertions

Alterations of the angle of the insertion of the oblique muscle with the visual axis can reduce cyclorotation and abduction forces and increase the vertical function of the oblique muscle.

Anomalous horizontal rectus muscle insertions

Among the suggested causes of V-pattern strabismus are anomalies of the horizontal rectus scleral insertions. They may be inserted above or below the usual positions.

Ocular Torsion as a cause of Pattern Strabismus

Association of excyclotorsion with V pattern and incyclotorsion with A pattern was first reported by Piper in 1963. He reported that the apparent rotation of the insertion of the rectus muscle due to torsion of the globe is the etiologic factor for pattern strabismus.

For example in V-pattern strabismus with inferior oblique overaction the eye will be extorted. This will rotate the insertions of the rectus muscle counterclockwise in the right eye and clockwise in the left eye. An abducting force will be created by the superior rectus in upgaze and adducting force from inferior oblique in downgaze resulting in a V pattern.  

Acquired form

V patterns are acquired after superior oblique muscle palsy and are a prominent feature of bilateral superior oblique muscle palsies.




United States

Although the exact prevalence of V-pattern strabismus in a given population is not known, 12.5-50% of patients with horizontal strabismus have an associated A or V pattern. V-pattern esotropia is not as commonly seen as V-pattern exotropia.


Patients may experience diplopia that affects their everyday activities, such as driving and reading. In addition, the inability of patients to fuse in different gaze positions can interfere with other activities, including sports and recreation. The cosmetic appearance of V-pattern strabismus coupled with its social implications may be bothersome to patients. Over time, the associated anomalous head position could lead to secondary neck pain and similar problems.


No racial predilection exists.


No sexual predilection exists.


No age predilection exists.