This document discusses the evaluation and management of esotropia in children. It begins by defining esotropia as inward turning of one or both eyes. It then describes the different types of esotropia including esophoria, intermittent esotropia, and constant esotropia. For evaluation, it recommends assessing visual acuity, stereopsis, ocular alignment and motility. Management involves treating any amblyopia or refractive error first through non-surgical means such as glasses, patching, or botulinum toxin injection. For persistent esotropia, surgical options include recession or resection of the medial or lateral rectus muscles. The document outlines approaches for different types of esotropia

1. EVALUATION OF ESOTROPIA IN
CHILDREN
 Asso Prof Dr. Khair
Ahmed Chowdhury
 Dr. Chandan Kumar
Paul
 Dr. Sadia Yeasmin
Saki

2. INTRODUCTION
 The term is derived from 2 greek words: Eso
meaning inward & Trepo meaning turn
 50% of ocular deviation in pediatric age group
 In Esotropia, the eyes are crossed, that is one eye
looks straight ahead, other eye is turns in toward
the nose

3. INTRODUCTION..
Three commonly recognized forms:
 Esophoria
 Intermittent esotropia
 Esotropia

4. ESOPHORIA
 Latent esodivation that is corrected by fusional
mechanism
 Eyes remain properly aligned under normal
binocular viewing condition

5. INTERMIITENT ESODEVIATION
 Intermittently controlled by fusional mechanism
 Manifest during fatigue, illness, stress, covering one
eye

6. ESOTROPIA
 Esodeviation that is not controlled by fusional
mechanism
 Constant deviation

7. TYPE OF ESOTROPIA
A. Concomitant esotropia
1. Accommodative esotropia :
Refractive
Non refractive
mixed

8. 2. Non accommodative esotropia :
- Early onset ,congenital
- Microtropia
- Convergence excess
- Convergence spasm
- Divergence insufficiency
- Divergence paralysis
- Sensory
- Consecutive
- Acute onset
- Cyclic
- Basic

9. B. Incomitant esotropia
6th nerve palsy
Medial wall fracture
Congenital fibrosis of extraocular muscle
Duane retraction syndrome
Mobius syndrome

10. MANAGEMENT
# History taking :
 History taking from parents :-
1.Prenatal : Period of gestation
Problems in utero
Drug history ( alcohol)
TORCH
2.Postnatal :
LBW
Septicemia

11. HISTORY..
 Age of onset
 Duration
 Uni ocular / binocular
 Association:
Headache
Discomfort / AHP
Blurring of vision
Double vision

12. HISTORY..
 Family history
 General health:
- Child with cerebral palsy
- Poor health
- Stress
 Variability

13. HISTORY…
 History of acquired paresis:
- Trauma
- Neurological disease
 Previous ocular history:
- Use of spectacles
- Occlusion therapy
- Any surgery

14. SYMPTOMS
 Blurring of vision
 Discomfort
 Diplopia
 Cosmetic embarrassment / AHP
 Intermediate duration at the time of stress
and inattention

15. CLINICAL EXAMINATION
 Careful VA assessment
 Test for stereopsis:
Titmus
Frisby
Lang
 Measument of vergence:
Synaptophore
RAF rule
 Test for sensory abnormality:
Worth 4 dot test
4d prism test

17. CLINICAL TEST..
 Test for ocular deviation:
Hirschberg’s corneal reflex test
Bruckner’s test
Krimsky test
Cover uncover test
Prism bar cover test
 Ocular motility test
 Diplopia test
hess chart

19. CLINICAL TEST..
 Cycloplegic refraction :
by retinoscope
 Slit lamp evaluation for anterior segment
 Dilated fundus examination
 Examination under anaesthesia

20. INFANTILE ESOTROPIA
Treatment
Aim: -Align visual axis
-Enhance binocularity
-Improve visual acuity

21. NON SURGICAL TREATMENT
 Full cycloplegic refraction
 Correct refractive error
 Treat amblyopia
 Botulinum toxin inection into MR

22. NON-SURGICAL TREATMENT
Without spectacle With spectacle

23. SURGICAL TREATMENT
 Time of surgery:
• Between 6 months to 2 years of age
• Wait up to 6 months of age in intermittent
esotropia or small to moderate angle
deviations

24.  Before proceeding to surgery:
• Deviation should be constant and stable
• Fixation should be alternating
• Sensory esotropia should have been ruled
out
• Amblyopia should be treated optimally
• Counselling with parents.

25. SURGICAL APPROACHES
• Bilateral Medial Rectus recession
• Ipsilateral MR recession with LR resection
• Muscle surgery-combination of recession and
resection
• Adjustment of vertical muscles-Weakening IO

26. Before operation
After operation

27. COMPLICATION OF TREATMENT
 Under correction
 Over correction
 DVD
 IO over action
 Amblyopia

28. INFANTILE ESOTROPIA
 It is an idiopathic esotropia
 Developed within first 6 months of life
 No significant refractive error
 No limitation of ocular movement

29. 1st image: fixating with right eye
2nd image: fixating with left eye

30. INITIAL TREATMENT
 Either recession of both MR
 Unilateral MR recession with LR resection
 Associated significant IO over action should
be addressed

31. SUBSEQUENT TREATMENT
 Under correction
 Inferior oblique over action
 DVD
 Amblyopia

32. ACCOMMODATIVE ESOTROPIA

33. TYPES
 Refractive Accommodative Esotropia :
# Fully accommodative
# Partially accommodative
 Non refractive accommodative esotropia :
# Convergence excess
# Hypo accommodative convergence
excess

34. REFRACTIVE ACCOMMODATIVE ESOTROPIA

36. NON-REFRACTIVE ACCOMMODATIVE
ESOTROPIA

37. HYPO ACCOMMODATIVE CONVERGENCE
EXCESS

38. TREATMENT OF REFRACTIVE ACCOMMODATIVE
ESOTROPIA
Medical Management :
 Full Hypermetropic correction : under
cycloplegia – revealed on Retinoscopy
 Spectacles ; full time
 Gradual reduction of hypermetropic correction;
if binocular fusion is maintained.
 Amblyopia correction
 Counselling

39. TREATMENT OF NONREFRACTIVE
ACCOMMODATIVE ESOTROPIA
Medical management
Bifocal spectacles :-
* Reduces or eliminate the need to
accommodate for near fixation

40. Surgical treatment
If spectacle dose not full correct the
deviation
1. Bilateral medial rectus- Recessions
performed with or without posterior
fixation

41. 2. If no significant difference between
distance and near , equal vision in both eye
- MR recession combined with LR resection
Or bilateral medial rectus recession.

42. MICROTROPIA
It is a small angle (<10 )
Treatment
- correction of refractive error
- occlusion for amblyopia

43. NEAR ESOTROPIA (NON ACCOMMODATIVE
CONVERGENCE EXCESS)
 Older children and young adult
Treatment:
- Bilateral MR recessions

44. DISTANCE ESOTROPIA
Healthy young adults who are often
myopic
Treatment :
- With prisms
- Surgery in persistent case

45. ACUTE (LATE ONSET) ESOTROPIA
 Around 5-6 years of age
Treatment :
- prism
- botulinum toxin
- surgery

46. SECONDARY ( SENSORY) ESPTROPIA
 cataract
 optic atrophy
 macular scarring
 retinoblastoma
dilated fundus evaluation

47. CONSECUTIVE ESOTROPIA
 surgical over correction of an
exodeviation

48. CYCLIC ESOTROPIA
persist for month or year
eventually develop a constant
esotropia requiring surgery

49. INCOMITANT STRABISMUS
 Patching
 Correction of RE
 Botulinium toxin injection
 Surgery:
- Horizontal muscle procedure
- Vertical muscle procedure

50. FOLLOW UP
At each visit evaluate amblyopia
 measure the degree of deviation with
prism
In the absence of amblyopia the child
is re evaluated in 3-6 weeks after a
new prescription is given.

51. TAKE HOME MESSAGE
Esotropia produces profound deficit in
binocular vision if not address in
proper time
Proper recognition, early treatment
and appropriate counselling can
provide most successful outcome