Esotropia
Encyclopedia
Esotropia is a form of strabismus
, or "squint", in which one or both eye
s turns inward. The condition can be constantly present, or occur intermittently, and can give the affected individual a "cross-eyed" appearance. Esotropia is sometimes erroneously called "lazy eye", which describes the condition of amblyopia
—a reduction in vision of one or both eyes that is not the result of any pathological lesion of the visual pathway and cannot be resolved by the use of corrective lenses. Amblyopia can, however, arise as a result of esotropia occurring in childhood: In order to relieve symptoms of diplopia
or double vision, the child's brain will ignore or "suppress" the image from the esotropic eye, which when allowed to continue untreated will lead to the development of amblyopia. Treatment options for esotropia include glasses to correct refractive errors (see accommodative esotropia below), the use of prisms
and/or orthoptic exercises and/or eye muscle surgery
.
Someone with esotropia will squint with either the right or the left eye but never with both eyes simultaneously. In a left esotropia, the left eye 'squints', and in a right esotropia the right eye 'squints'. In an alternating esotropia the patient is able to alternate fixation between their right and left eye so that at one moment the right eye fixates and the left eye turns inward, and at the next the left eye fixates and the right turns inward. Where a patient tends to consistently fix with one eye and squint with the other, the eye that squints is likely to develop some amblyopia. Someone whose squint alternates is very unlikely to develop amblyopia because both eyes will receive equal visual stimulation. It is possible to encourage alternation through the use of occlusion or patching of the 'dominant' or 'fixing' eye to promote the use of the other. Many people have esotropia and they are born with this.
2. Concomitant versus incomitant
Esotropias can be concomitant, where the size of the deviation does not vary with direction of gaze—or incomitant, where the direction of gaze does affect the size, or indeed presence, of the esotropia. The majority of esotropias are concomitant and begin early in childhood, typically between the ages of 2 to 4 years. Incomitant esotropias occur both in childhood and adulthood as a result of neurological, mechanical or myogenic problems affecting the muscles controlling eye movements.
3. Primary, secondary or consecutive
Concomitant esotropias can arise as an initial problem, in which case they are designated as 'Primary', as a consequence of loss or impairment of vision, in which case they are designated as 'Secondary', or following overcorrection of an initial Exotropia
in which case they are described as being 'Consecutive'. The vast majority of esotropias are primary.
1. Constant esotropia
A constant esotropia, as the name implies, is present all the time, with and without glasses, if worn, and at all fixation distances. It may, however have an accommodative element (i.e. be influenced by the exertion of accommodative or 'focusing' effort) when looking at close objects, and this will lead to the esotropia being more noticeable when the affected individual looks at objects close to them.
2. Intermittent esotropia
Intermittent esotropias, again as the name implies, are not always present: They may be visible when looking at close objects but not when looking at distant ones (Near Esotropia) or, rarely, when looking at distant objects but not at close ones (Distance Esotropia). In very rare cases, they may only occur in repeated cycles of 'one day on, one day off' (Cyclic Esotropia). However, the vast majority of intermittent esotropias are accommodative in origin.
. The hyperope, in an attempt to "accommodate" or focus the eyes, converges the eyes as well, as convergence is associated with activation of the accommodation reflex
. The over-convergence associated with the extra accommodation required to overcome a hyperopic refractive error can precipitate a loss of binocular control and lead to the development of esotropia.
The chances of an esotropia developing in these cases will depend to some degree on the amount of hyperopia
present. Where the degree of error is small, the child will typically be able to maintain control because the amount of over-accommodation required to produce clear vision is also small. Where the degree of hyperopia is large, the child may not be able to produce clear vision no matter how much extra-accommodation is exerted and thus no incentive exists for the over-accommodation and convergence that can give rise to the onset of esotropia. However, where the degree of error is small enough to allow the child to generate clear vision by over-accommodation, but large enough to disrupt their binocular control, esotropia will result.
Where the esotropia is solely a consequence of uncorrected hyperopic refractive error, providing the child with the correct glasses and ensuring that these are worn all the time, is often enough to control the deviation. In such cases, known as 'fully accommodative esotropias', the esotropia will only be seen when the child removes their glasses. Many adults with childhood esotropias of this type make use of contact lenses to control their 'squint'.
A second type of accommodative esotropia also exists, known as 'convergence excess esotropia'. In this condition the child exerts excessive accommodative convergence relative to their accommodation. Thus, in such cases, even when all underlying hyperopic refractive errors have been corrected, the child will continue to squint when looking at very small objects or reading small print. Even though they are exerting a normal amount of accommodative or 'focusing' effort, the amount of convergence associated with this effort is excessive, thus giving rise to esotropia. In such cases an additional hyperopic correction is often prescribed in the form of bifocal lenses, to reduce the degree of accommodation, and hence convergence, being exerted. Many children will gradually learn to control their esotropias, sometimes with the help of orthoptic exercises. However, others will eventually require extra-ocular muscle surgery to resolve their problems.
, is a specific sub-type of primary concomitant esotropia. It is a constant esotropia of large and consistent size with onset between birth and six months of age. It is not associated with hyperopia, so the exertion of accommodative effort will not significantly affect the angle of deviation. It is, however, associated with other ocular dysfunctions including oblique muscle over-actions, Dissociated Vertical Deviation
(DVD,) Manifest Latent Nystagmus, and defective abduction, which develops as a consequence of the infantile esotropes tendency to 'cross fixate'. Cross fixation involves the use of the right eye to look to the left and the left eye to look to the right; a visual pattern that will be 'natural' for the large angle esotrope whose eye is already deviated towards the opposing side.
The origin of the condition is unknown, and its early onset means that the affected individuals potential for developing binocular vision is limited. The appropriate treatment approach remains a matter of some debate. Some ophthalmologists favour an early surgical approach as offering the best prospect of binocularity whilst others remain unconvinced that the prospects of achieving this result are good enough to justify the increased complexity and risk associated with operating on those under the age of one year.
1. Identify and treat any underlying systemic condition.
2. Prescribe any glasses required and allow the patient time to 'settle into' them.
3. Use occlusion to treat any amblyopia present and encourage alternation.
4. Where appropriate, orthoptic exercises can be used to attempt to restore binocularity.
5. Where appropriate, prismatic correction can be used, either temporarily or permanently, to relieve symptoms of double vision.
6. In specific cases, and primarily in adult patients, botulinum toxin
can be used either as a permanent therapeutic approach, or as a temporary measure to prevent contracture of muscles prior to surgery
7. Where necessary, extra-ocular muscle surgery can be undertaken to improve cosmesis and, on occasion, restore binocularity.
Strabismus
Strabismus is a condition in which the eyes are not properly aligned with each other. It typically involves a lack of coordination between the extraocular muscles, which prevents bringing the gaze of each eye to the same point in space and preventing proper binocular vision, which may adversely...
, or "squint", in which one or both eye
Human eye
The human eye is an organ which reacts to light for several purposes. As a conscious sense organ, the eye allows vision. Rod and cone cells in the retina allow conscious light perception and vision including color differentiation and the perception of depth...
s turns inward. The condition can be constantly present, or occur intermittently, and can give the affected individual a "cross-eyed" appearance. Esotropia is sometimes erroneously called "lazy eye", which describes the condition of amblyopia
Amblyopia
Amblyopia, also known as lazy eye, is a disorder of the visual system that is characterized by a vision deficiency in an eye that is otherwise physically normal, or out of proportion to associated structural abnormalities of the eye...
—a reduction in vision of one or both eyes that is not the result of any pathological lesion of the visual pathway and cannot be resolved by the use of corrective lenses. Amblyopia can, however, arise as a result of esotropia occurring in childhood: In order to relieve symptoms of diplopia
Diplopia
Diplopia, commonly known as double vision, is the simultaneous perception of two images of a single object that may be displaced horizontally, vertically, or diagonally in relation to each other...
or double vision, the child's brain will ignore or "suppress" the image from the esotropic eye, which when allowed to continue untreated will lead to the development of amblyopia. Treatment options for esotropia include glasses to correct refractive errors (see accommodative esotropia below), the use of prisms
Prism (optics)
In optics, a prism is a transparent optical element with flat, polished surfaces that refract light. The exact angles between the surfaces depend on the application. The traditional geometrical shape is that of a triangular prism with a triangular base and rectangular sides, and in colloquial use...
and/or orthoptic exercises and/or eye muscle surgery
Eye surgery
Eye surgery, also known as orogolomistician surgery or ocular surgery, is surgery performed on the eye or its adnexa, typically by an ophthalmologist.-Preparation and precautions:...
.
Classification of esotropia
1. Right, left or alternatingSomeone with esotropia will squint with either the right or the left eye but never with both eyes simultaneously. In a left esotropia, the left eye 'squints', and in a right esotropia the right eye 'squints'. In an alternating esotropia the patient is able to alternate fixation between their right and left eye so that at one moment the right eye fixates and the left eye turns inward, and at the next the left eye fixates and the right turns inward. Where a patient tends to consistently fix with one eye and squint with the other, the eye that squints is likely to develop some amblyopia. Someone whose squint alternates is very unlikely to develop amblyopia because both eyes will receive equal visual stimulation. It is possible to encourage alternation through the use of occlusion or patching of the 'dominant' or 'fixing' eye to promote the use of the other. Many people have esotropia and they are born with this.
2. Concomitant versus incomitant
Esotropias can be concomitant, where the size of the deviation does not vary with direction of gaze—or incomitant, where the direction of gaze does affect the size, or indeed presence, of the esotropia. The majority of esotropias are concomitant and begin early in childhood, typically between the ages of 2 to 4 years. Incomitant esotropias occur both in childhood and adulthood as a result of neurological, mechanical or myogenic problems affecting the muscles controlling eye movements.
3. Primary, secondary or consecutive
Concomitant esotropias can arise as an initial problem, in which case they are designated as 'Primary', as a consequence of loss or impairment of vision, in which case they are designated as 'Secondary', or following overcorrection of an initial Exotropia
Exotropia
Exotropia is a form of strabismus where the eyes are deviated outward. It is the opposite of esotropia. People with exotropia often experience crossed diplopia. Intermittent exotropia is a fairly common condition. "Sensory exotropia" occurs in the presence of poor vision...
in which case they are described as being 'Consecutive'. The vast majority of esotropias are primary.
Concomitant esotropia
Concomitant esotropia can itself be subdivided into esotropias that are ether constant, or intermittent.1. Constant esotropia
A constant esotropia, as the name implies, is present all the time, with and without glasses, if worn, and at all fixation distances. It may, however have an accommodative element (i.e. be influenced by the exertion of accommodative or 'focusing' effort) when looking at close objects, and this will lead to the esotropia being more noticeable when the affected individual looks at objects close to them.
2. Intermittent esotropia
Intermittent esotropias, again as the name implies, are not always present: They may be visible when looking at close objects but not when looking at distant ones (Near Esotropia) or, rarely, when looking at distant objects but not at close ones (Distance Esotropia). In very rare cases, they may only occur in repeated cycles of 'one day on, one day off' (Cyclic Esotropia). However, the vast majority of intermittent esotropias are accommodative in origin.
Accommodative esotropia
Accommodative esotropia is often seen in patients with moderate amounts of hyperopiaHyperopia
Hyperopia, also known as farsightedness, longsightedness or hypermetropia, is a defect of vision caused by an imperfection in the eye , causing difficulty focusing on near objects, and in extreme cases causing a sufferer to be unable to focus on objects at any distance...
. The hyperope, in an attempt to "accommodate" or focus the eyes, converges the eyes as well, as convergence is associated with activation of the accommodation reflex
Accommodation reflex
The accommodation reflex is a reflex action of the eye, in response to focusing on a near object, then looking at distant object , comprising coordinated changes in vergence, lens shape and pupil size...
. The over-convergence associated with the extra accommodation required to overcome a hyperopic refractive error can precipitate a loss of binocular control and lead to the development of esotropia.
The chances of an esotropia developing in these cases will depend to some degree on the amount of hyperopia
Hyperopia
Hyperopia, also known as farsightedness, longsightedness or hypermetropia, is a defect of vision caused by an imperfection in the eye , causing difficulty focusing on near objects, and in extreme cases causing a sufferer to be unable to focus on objects at any distance...
present. Where the degree of error is small, the child will typically be able to maintain control because the amount of over-accommodation required to produce clear vision is also small. Where the degree of hyperopia is large, the child may not be able to produce clear vision no matter how much extra-accommodation is exerted and thus no incentive exists for the over-accommodation and convergence that can give rise to the onset of esotropia. However, where the degree of error is small enough to allow the child to generate clear vision by over-accommodation, but large enough to disrupt their binocular control, esotropia will result.
Where the esotropia is solely a consequence of uncorrected hyperopic refractive error, providing the child with the correct glasses and ensuring that these are worn all the time, is often enough to control the deviation. In such cases, known as 'fully accommodative esotropias', the esotropia will only be seen when the child removes their glasses. Many adults with childhood esotropias of this type make use of contact lenses to control their 'squint'.
A second type of accommodative esotropia also exists, known as 'convergence excess esotropia'. In this condition the child exerts excessive accommodative convergence relative to their accommodation. Thus, in such cases, even when all underlying hyperopic refractive errors have been corrected, the child will continue to squint when looking at very small objects or reading small print. Even though they are exerting a normal amount of accommodative or 'focusing' effort, the amount of convergence associated with this effort is excessive, thus giving rise to esotropia. In such cases an additional hyperopic correction is often prescribed in the form of bifocal lenses, to reduce the degree of accommodation, and hence convergence, being exerted. Many children will gradually learn to control their esotropias, sometimes with the help of orthoptic exercises. However, others will eventually require extra-ocular muscle surgery to resolve their problems.
Congenital esotropia
Congenital esotropia, or infantile esotropiaInfantile esotropia
Infantile esotropia is an ocular condition of early onset in which one or either eye turns inward. It is a specific sub-type of esotropia and has been a subject of much debate amongst ophthalmologists with regard to its naming, diagnostic features, and treatment.- Name and features :Historically...
, is a specific sub-type of primary concomitant esotropia. It is a constant esotropia of large and consistent size with onset between birth and six months of age. It is not associated with hyperopia, so the exertion of accommodative effort will not significantly affect the angle of deviation. It is, however, associated with other ocular dysfunctions including oblique muscle over-actions, Dissociated Vertical Deviation
Dissociated Vertical Deviation
Dissociated Vertical Deviation is an ocular condition which occurs in association with a squint, typically Infantile Esotropia.- Mechanism :...
(DVD,) Manifest Latent Nystagmus, and defective abduction, which develops as a consequence of the infantile esotropes tendency to 'cross fixate'. Cross fixation involves the use of the right eye to look to the left and the left eye to look to the right; a visual pattern that will be 'natural' for the large angle esotrope whose eye is already deviated towards the opposing side.
The origin of the condition is unknown, and its early onset means that the affected individuals potential for developing binocular vision is limited. The appropriate treatment approach remains a matter of some debate. Some ophthalmologists favour an early surgical approach as offering the best prospect of binocularity whilst others remain unconvinced that the prospects of achieving this result are good enough to justify the increased complexity and risk associated with operating on those under the age of one year.
Incomitant esotropia
Incomitant esotropias are conditions in which the esotropia varies in size with direction of gaze. They can occur in both childhood and adulthood, and arise as a result of neurological, mechanical or myogenic problems. These problems may directly affect the extra-ocular muscles themselves, and may also result from conditions affecting the nerve or blood supply to these muscles or the bony orbital structures surrounding them. Examples of conditions giving rise to an esotropia might include a VIth cranial nerve (or Abducens) palsy, Duane's syndrome or orbital injury.Treatment
The prognosis for each esotrope will depend upon the origin and classification of their condition. However, in general, management will take the following course:1. Identify and treat any underlying systemic condition.
2. Prescribe any glasses required and allow the patient time to 'settle into' them.
3. Use occlusion to treat any amblyopia present and encourage alternation.
4. Where appropriate, orthoptic exercises can be used to attempt to restore binocularity.
5. Where appropriate, prismatic correction can be used, either temporarily or permanently, to relieve symptoms of double vision.
6. In specific cases, and primarily in adult patients, botulinum toxin
Botulinum toxin
Botulinum toxin is a protein produced by the bacterium Clostridium botulinum, and is considered the most powerful neurotoxin ever discovered. Botulinum toxin causes Botulism poisoning, a serious and life-threatening illness in humans and animals...
can be used either as a permanent therapeutic approach, or as a temporary measure to prevent contracture of muscles prior to surgery
7. Where necessary, extra-ocular muscle surgery can be undertaken to improve cosmesis and, on occasion, restore binocularity.
External links
- International Orthoptic Association
- What is Esotropia? All Types and Treatments
- FAQs: Eye Muscle Surgery for Esotropia
- British Orthoptic Society Squint Information
- American Association for Paediatric Ophthalmology and Strabismus - Information on Accommodative Esotropia
- Australian Orthoptic Association
- Site from East Anglian UK NHS Trust with excellent explanations and photographs of all types of squint.