1) Infantile esotropia is a type of crossed eyes that develops within the first 6 months of life in an otherwise normal infant, with no significant refractive error or eye movement limitations.
2) The cause is unknown but theories involve a congenital deficit in the brain's "fusion center" or a primary motor misalignment disrupting binocular vision.
3) Treatment involves early surgical alignment of the eyes through muscle surgery like bilateral medial rectus recession, along with non-surgical measures to enhance binocularity and improve vision, with the goal of aligning the eyes within 10 prism diopters of orthophoria.
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Infantile esotropia by dr adnan
1. Presenter : Dr. Mahamud Adnan
DO resident, NIO & H.
Infantile Esotropia &
Management
2. Chairman : Dr. Shovana Alam
Associate Professor
Pediatric ophthalmology, NIO & H
Moderator : Dr.Nusrat Shahrin
Assistant Surgeon
Pediatric ophthalmology, NIO & H.
3. Milestone of Vision :
• At birth-
Eyes move randomly, no central fixation
• At 6 weeks-
Apparent fixation reflex , can follow bright light at
short distance
4. Cont.
Milestone of Vision :
• At 4-6 months -
Convergence established .
Foveal reflex developed at 4
th
month .
Central fixation developed at 6 months.
• At 6 years -
Foveal development is complete &
visual acuity achieved 6/6.
6. Cont.
Phoria = latent deviations
Tropia = manifest deviations
Orthophoria
It implies perfect ocular alignment in the
absence of any stimulus for fusion.
7. Cont.
Esotropia :
The term ‘esotropia’ is derived from two Greek
words ‘eso’ means ‘inward’ and ‘trepe’ means
‘turn’
In esotropia, the eyes are crossed, that is, while
one eye looks straight ahead and the other eye
is turned in toward the nose.
8.
9.
10.
11. Cont.
Pseudo-esotropia :
is the clinical impression of ocular deviation
when no squint is present.
Wide nasal bridge
Prominent epicanthal folds
Narrow interpupillary distance
Negative angle kappa
Usually with the formation of the bridge of
the nose, it disappears.
12. Classification of Esotropia
Accommodative
1.Refractive:
• Fully accommodative
• Partially
accommodative
2.Non-refractive:
• With convergenc
excess
• With accommodation
weakness
3.Mixed
Non-accommodative
Early onset(Infantile)
Microtropia
Basic
Convergence excess
Convergence spasm
Divergence insufficiency
Divergence Paralysis
Sensory
Cyclic
13. Infantile Esotropia
• Definition:
Infantile or congenital esotropia is an
idiopathic condition developing within first 6
months of life in an otherwise normal infant with
no significant refractive error or no limitation of
ocular movements.
• Prevalence : 27/10,000 live births.
14.
15. Etiology
• The cause of infantile esotropia remains unknown.
Worth Theory
– “Sensory” concept
– Congenital deficit in a “fusion center” in the brain
Chavasse Theory
Primary motor misalignment
Disruption of binocular vision
Potentially curable if ocular alignment is
achieved in infancy.
16. Risk Factors
• Family history
• Secondary ocular history
• Prematurity
• Low birth weight.
• Perinatal or gestational complication
17. Characteristics
• Idiopathic
• Within 1st 6 months of life
• No significant refractive error(Normally +1.5 D)
• Family history(+/-) but not well defined genetic
pattern
• Otherwise patient is normal
18. Signs
• Apparent , large angle( >30 PD )
• Alternate fixation in primary position.
• Cross fixation in side gaze.
• Poor potential for BSV
• Amblyopia (+/-)
• Nystagmus - horizontal.
• Emmetropia / Mild Hypermetropia / Myopia
21. Evaluation
History:
1.Age of onset
2.Head posture
3.Birth history
4.Family history of strabismus
5.Previous ocular history
- use of spectacles
- occlusion therapy
- previous surgery
22. Examination
• Visual acuity :
In preverbal child
- Fixation and following
- Comparison (occlusion of one eye)
- Fixation behaviour test
- Rotation test
- Preferential looking test
- Visual evoked potential
33. Surgical treatment
Time of surgery:
• Between 6 months to 2 years of age
• Recent studies favour early surgery as soon
as diagnosis is made
• Wait up to 6 months of age in intermittent
esotropia or small to moderate angle
deviations
34. Cont.
Before proceeding to surgery:
• Deviation should be constant and stable
• Accommodative element should be absent
• Sensory esotropia should have been ruled
out
• Amblyopia should be treated optimally
• Counseling of parents.
35. Surgical Approaches
• Bilateral Medial Rectus recession
• Ipsilateral MR recession with LR resection
• Adjustment of vertical muscles - Weakening IO
39. Post Surgical Outcomes
1. Under correction .
2. Over correction .
3. DVD :
- SR recession with or without posterior
fixation suture
- IO anterior transposition.
40. Cont.
4. IO overaction :
- Disinsertion
- Recession
- Myectomy
4. Amblyopia-subsequently develops in 50% of
cases
42. Ciancia syndrome
A severe form of infantile esotropia, referred to
as Ciancia syndrome.
Features:
Large angle deviation(>50 PD)
Abducting nystagmus
Mild abduction deficit
43. Take home message
• Onset of Infantile esotropia is around 4 months
of age
• This produces profound deficits in binocular
vision if not correct promptly.
• We should operate early (<2 years) to promote
the development of binocular vision and some
stereopsis.
