Appendix
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Ophthalmology

Esotropia

Esotropia, commonly referred to as an inward deviation of eyes, is a common clinical entity seen in the outpatient department. Esotropia may be congenital/acquired, constant/intermittent, unilateral/alternating. Clinical examination, pathophysiology, and predisposing factors are essential to understand and diagnose esotropia subtype and plan appropriate management. Congenital esotropia is the most common type of esodeviation seen in early childhood and commonly presents within the first six mont

v1 · Reviewed Nov 7, 2026 by Automated Clinical Reviewer (Strict Verbatim v1)
  • Congenital esotropia is the most common type of esodeviation seen in early childhood and commonly presents within the first six months of life with a large angle of esodeviation.
  • Deviation of eyes manifests within six months from birth.
  • These children typically have a large angle of deviation, usually more than 30 degrees, which is present for distance and near.
  • Sensory esotropia occurs because of poor vision in one eye in early childhood.
  • Ciancia syndrome – This is characterized by the presence of large-angle esodeviation (>60 prism diopters).
  • Congenital sixth nerve palsy – These can present as unilateral or bilateral cases.
  • Clinical examination, pathophysiology, and predisposing factors are essential to understand and diagnose esotropia subtype and plan appropriate management.
  • A detailed history and meticulous examination are needed for all cases of esotropia presenting to the outpatient department.
  • Complete history taking should include essential points like age of the patient, onset of deviation, nature of deviation – constant/intermittent, unilateral/alternating.
  • Other critical points to be recorded are abnormal head posture, complaints of double vision, headache, asthenopia, history of closing one eye in bright sunlight.
  • Any predisposing factors of viral illness, head trauma, and excessive near-vision work should be actively enquired.
  • An ocular examination should consist of a detailed analysis of the anterior and posterior segments.
  • Posterior segment examination should include a dilated fundus examination to rule out any pathology like macular scarring, optic nerve hypoplasia, retinoblastoma, along with an objective assessment of macular torsion.
  • Other necessary evaluations should include assessing visual acuity using age-appropriate methods, angle of deviation measured with Hirschberg tests, prism bar cover test for near and distance, fixation pattern assessment – alternate fixation, cross-fixation, and dominance of either eye.
  • Accommodation Convergence/Accommodation ratio (AC/A), fusional divergence amplitudes, binocular function, stereopsis, ocular movements, and refraction with atropine cycloplegia assessments are also essential in all cases of strabismus.
  • Any associated clinical features like inferior oblique overaction, dissociated vertical deviation, latent nystagmus should also be examined.
  • Imaging might be needed if any neurological signs or associations are expected on evaluation or cases with acute onset of esotropias.
  • Atropine refraction usually reveals a high underlying hypermetropia in the range of 2 to 6 diopters.
  • The near deviation in these cases is typically much more significant than the distance deviation.
  • Pseudoesotropia can be distinguished from true esotropia by the presence of prominent epicanthal folds, small interpupillary distance, negative angle kappa, or an excessive broad nasal bridge.
  • Ciancia syndrome – This is characterized by the presence of large-angle esodeviation (>60 prism diopters).
  • Congenital fibrosis syndrome – This is also called strabismus fixus.
  • Doll's head maneuver reveals limited abduction based on laterality.
  • Nystagmus blockage syndrome refers to a condition in which esotropia occurs in a child with congenital nystagmus.
  • Cyclic Esotropia – Alternate repeated strabismic and non-strabismic phases characterize this form.
  • Microtropia – This is characterized by a slight angle of heterotopia in the range of 1 to 5 degrees.
  • Refractive error correction – It is advisable to give full hypermetropic refractive correction, i.e., without drug correction applied, as examined after cycloplegic refraction for the patient.
  • Any hypermetropia more than +1.5D should be prescribed to the patient.
  • Amblyopia therapy is indicated when a patient is brought late with pre-set amblyopia and fixation preference for the other eye.
  • Most often, alternate eye patching might be advised to prevent fixation preference and thus prevent amblyopia in these cases.
  • Orthoptic treatment is useful in patients with refractive or non-refractive accommodative esotropias.
  • These exercises aim at overcoming the suppression and improving the negative fusional convergence.
Atropine
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Adult
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Renal
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Duration
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  • Miotics have been tried as an alternative to glasses in uncooperative patients or those not compliant with glass usage.
  • Botulinum Toxin – This has been studied and proven helpful in infantile esotropia and new-onset acquired esotropia.
  • Botulinum has also been studied for residual esotropia following bilateral medial rectus recessions and lateral rectus resections.
  • Surgery for refractive accommodative esotropia should always be avoided.
  • Any associated vertical deviation or A/V pattern might need surgical correction.
  • In this conservative management in the form of bifocals, orthoptic exercises should be preferred.
  • Surgery might be indicated in patients with a large angle of residual deviation, which conservative methods cannot correct.
  • Bilateral medial rectus recession with or without bilateral Faden procedure to medial rectus can be planned based on the angle of deviation for near.
  • Surgical intervention might be indicated for cosmetic correction in these cases.
  • In children, any associated aphakia or traumatic cataracts should be corrected, along with a trial of occlusion therapy.
  • Eventually, these can be planned for squint correction once the maximum best-corrected visual acuity is achieved.
  • Surgical squint correction using unilateral recession-resection procedure should be preferred in the amblyopic eye or the eye with poor visual acuity.
  • Botulinum toxin or surgical correction by bimedial rectus recession or recession resection procedure for medial and lateral rectus respectively might be needed.
  • The dose of surgical correction should be based on the deviation on the day of esotropia.
  • Ocular deviation and AC/A ratio can be reassessed after six weeks of spectacle usage.
  • Children with a high AC/A ratio or eyes aligned for distance and a residual esotropia for near should be considered for bifocals.
  • The timing of surgery and surgical procedures may vary with the type of esotropia, amount of deviation, presence of associated clinical features, amblyopia, and compliance with non-conservative management.
  • The final decision should be taken based on the child's co-operation to measure squint and understanding of the parents and the examiner.
  • The surgery for dissociated vertical deviation should be deferred as a primary procedure and can be combined later as a staged procedure if needed.
  • Few studies showed improvement with occlusion therapy in these cases.
  • Favorable outcomes in stereopsis have also been reported with timely surgical intervention for the nonaccommodative component.
  • The complications associated with the management of esotropia are related to loss of binocularity, chances of amblyopia, issues with compliance with treatment, and long-term follow-ups.
  • Apart from these, these children are highly likely to lose confidence because of cosmetic concerns, developing antisocial behaviors, and underperforming in schools.
  • Complications associated with surgical intervention include residual esotropia, consecutive exotropia, infection, suture-related granuloma, anterior segment ischemia, slipped or lost muscle, or an oculocardiac reflex.
  • Apart from these, the risk of general anesthesia-related complications needs to be borne in mind before planning any surgical intervention in these cases.
  • Postoperative care involves close collaboration between the parents, treating ophthalmologists, optometrists for regular refraction, and the counselor.
  • The nurses and counselor play an essential role in making parents understand how to use postoperative eye drops, maintain hygiene, cleaning of eyelashes and lid margins to prevent infection.
  • These patients need long-term close follow-ups, keeping in mind the need for correcting refractive errors, cycloplegic refraction at least once every six months, maintenance of amblyopia therapy, orthoptics exercise, repeat six-monthly squint evaluation for the development of under or overcorrection.
  • It is now considered that early ocular alignment before the age of 2 years results in better visual acuity and preservation of binocular fusion to some extent, often involving peripheral fusion.
  • Studies have shown that better long-term stability, better stereopsis, and sensorimotor development have been associated with the early alignment of eyes.
  • It is important to note that the reoperation rates in congenital esotropia have been reported as high as 50%.
  • review
    Esotropia. StatPearls [Internet] — Kirandeep Kaur, Bharat Gurnani — StatPearls Publishing, 2023

Decision support only. Verify against local protocols and current labeling. Source: www.ncbi.nlm.nih.gov