Accommodative esotropia

accommodative esotropia

1. ETIOLOGY,CLINICAL FEATURES & MANAGEMENT OF ACCOMMODATIVE ESOTROPIA DR. SAMARTH MISHRA

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3. esotropia

4. . TYPES OF ESODEVIATIONS: INCOMITANT: Paralytic - neurogenic ( e.g abducens palsy,divergence palsy) - myogenic ( e.g myasthenia) Restrictive - musculofascial ( e.g duane’s ) -other restrictive conditions( e.g tumor,postoperative,dysthyroid,strabismus fixus ) c) Spastic

5. . CONCOMITANT: Accommodative -refractive( hypermetropic ) -non refractive,hyperaccommodative,hypoaccommodative B) Partially accommodative Non-accommodative -essential infantile. -essential acquired/late onset -- basic --convergence excess --divergence insufficiency -acute concomitant - microtropia -cyclic esotropia -sensory esotropia - nystagmus blockage syndrome - esophoria .

6. CLASSIFICATION OF ESOTROPIA :

7. . CLASSIFICATION: TYPE CRITERION NON-ACCOMMODATIVE esotropia at distance=near fixation. no change with refractive correction ACCOMMODATIVE: - refractive ( normal AC/A ratio) esotropia at distance >/= near fixation. ( fully corrected by hyperopic correction for distance )

8. . - Non-refractive : esotropia at near (high AC/A ratio) fixation>distance or manifesting only at near. (fully corrected by an additional hyperopic correction for near work) - mixed PARTIALLY ACCOMMODATIVE : esotropia partly corrected by the use of refractive correction .

9. CONVERGENT SQUINT/ ESOTROPIA/ ESODEVIATION: Denotes inward deviation of eye. Esotropia (manifest convergent squint) may be concomitant or incomitant . In a concomitant esotropia the variability of the angle of deviation is < 5 prism dioptres . It can be  a) unilateral : the same eye always deviates inwards & the second normal eye takes fixation.  b) alternating : either of the eyes deviates inwards & the other eye takes the fixation,alternately . ETIOLOGY: more common in childhood & hypermetropes . Congenital esotropia : may be associated with neurological disorders. May be hereditary . Infantile essential

10. . EARLY ONSET ESOTROPIA: - upto 4 months infrequent episodes of convergence is normal -True “congenital” esotropia observed at birth is very rare,their eye alignments remain in a state of flux till 4 months of age. - >4 months, ocular misalignment is abnormal. -therefore, it is imperative to observe these children closely in the first four months before establishing a diagnoss of esotropia . -early onset esotropia is an idiopathic condition developing <6 months of life in an otherwise normal infant with no significant refractive error & no limitation of ocular movt . - The multicentric congenital esotropia study has concluded that small angle esotropia <30pd may be observed as some of these may get spontaneously corrected.

11. . DIAGNOSIS: Angle > 30 prism dioptres and stable. Fixation is alternating in the primary position. May give a false impression of bilateral abduction deficits, as in bilateral 6 th n. palsy. Abduction can be demonstrated by uniocular patching (for a few hours) or doll’s head phenomenon. Nystagmus is usually horizontal. Confirmed by 4-6 months Cross-fixing in side gaze :- i.e the child uses the left eye in right gaze and vice versa.

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13. Alternating fixation in early onset esotropia

14. . - latent nystagmus is only seen when one eye is covered & the fast phase beats towards the fixing eye. i.e the direction of fast phase reverses according to which eye is covered. Refractive error  normal for age.( +1 to +2 D) Dissociated vertical deviation ( DVD )develops by 3 yrs. Asymmetric optokinetic nystagmus ..

15. . VARIANTS: CIANCIA SYNDROME: ( early onset esotropia + B/L limitation of abduction with manifest-latent jerk nystagmus [fast phase towards fixing eye] ) LANG’S SYNDROME: (early onset esotropia + DVD + nystagmus+excyclodeviation )

16. . Treatment : -ocular alignment is most imp. -surgically by 1 year.[ latest by 2 years], only after correction of amblyopia or refractive error. -recession of both medial recti / unilateral medial recti with resection of lateral recti . -Very large angles require recessions of >6.5mm. -goal is to align eyes within 10D.

17. EARLY ONSET ESOTROPIA AFTER SURGICAL CORRECTION

18. SUBSEQUENT TREATMENT: - undercorrection : may require furthur recession of medial rectus ,resection of one or both lateral recti or surgery to other eye. - inferior oblique overaction : may develop subsequently. M/C around 2yrs. Parents shpuld therefore be warned that furthur surgery maybe necessary despite initial good result. Unilateral, and frequently becomes bilateral within 6months. It is over-elevation of eye in supra-adduction. - Amblyopia : devp in 50percent cases. - DVD : appear several yrs after. It is the elevation of non-fixing eye when covered or with visual inattention.

19. dissociated vertical deviation(DVD)

20. . DIFFERENTIAL DIAGNOSIS: Congenital b/l 6 th n. palsy. Secondary( sensory ) esotropia . Duane syndrome type 1 & 3. Mobius syndrome. Strabismus fixus Nystagmus blockage syndrome.

21. ACCOMMODATIVE ESOTROPIA:

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23. ACCOMMODATIVE ESOTROPIA: It is a condition where in excessive effort of accommodation results in an inward deviation of eyes. Occurs due to overaction of convergence associated with convergence reflex. Most often caused by uncorrected hypermetropia . It is of three types: a) refractive b)non refractive c)mixed

24. . Symptoms: - diplopia -eyestrain -headache -blurred vision -decreased depth percption -crossing/ inward deviation of the eyes.

25. . Refractive(hyperopic) accommodative esotropia :  usually develops at the age of 2 to 3 years & is associated with high hypermetropia (+4 to +7D).  mostly it is for near and distance.  fully correctable by the use of spectacles.  there is a tendency for the deviation in all cases of esotropia to diminish with the diminution of accommodation with age.  normal AC/A ratio.

26. . Since they have normal AC/A ratio ,the esodeviation is the same for distanceand near fixation i.e they lack convergence excess. However, in some children,who donot make an effort to clear retinal blur by accommodating or if hypermetropia is too high to overcome with accommodation, this uncorrected hyperopia leads to bilateral ametropic amblyopia but no esotropia .

27. . FULLY ACCOMMODATIVE : eliminated by optical correction of hypermetropia . BSV is present at all distances with glasses. Deviation still present when glasses are not worn. Amblyopia if present must be treated with appropriate patching regime. B) CONSTANT ACCOMMODATIVE ESOTROPIA: - reduces, but not fully on refractive correction. - amblyopia,B /L congenital superior oblique weakness are frequent.

28. . Non-refractive accommodative esotropia : -such cases donot accommodate for distance but obly for near fixation - chr . by abnormally high AC/A ratio. -A unit change increase in accommodation is accompanied by a disproportionately large increase in convergence. -occurs independently of refractive error,although hypermetropia coexists. - esotropia is greater for near than that for distance ( minimal or no deviation for distance ) -it is fully corrected by adding +3DS for near vision.

29. . Divided into: Convergence excess: - high AC/A ratio d/t increased accommodative convergence(accommodation is normal; convergence in increased) -normal near point of accommodation. -straight eyes with BSV for distance. - esotropia for near, usually with suppression. -straight eyes through bifocals.

30. . B) hypoaccommodative convergence excess: -high AC/A ratio d/t decreased accommodation( accommodation is weak , necessitating increased effort, which produces over convergence ) -remote near point of accommodation. -straight eyes with BSV for distance. - esotropia for near, usually with suppression

31. . Mixed accommodative esotropia : -caused by combination of hypermetropia and high AC/A ratio. - esotropia for distance is corrected by correction of hypermetropia , and the residual esotropia for near is corrected by an addition of +3DS lens.

32. MEDICAL TREATMENT:  For fully accommodative (refractive) esotropia : - refractive error should be corrected. -in children <6 yrs , full cyclopegic refraction revealed on retinoscopy should be prescribed. [with a deduction for working distance] -< 8yrs refraction should be performed without cycloplegia & the maximal amount of ‘plus’ that can be tolerated ( manifest hypermetropia ) prescribed.  For convergence excess (non refractive) esotropia : - bifocals prescribed. :relieves accommoation and thereby accommodative convergence. -most satisfactory form of bifocals is the executive type in which the intersection crosses the lower border of pupil. -strength of lower segment should be gradually reduced & eliminated by the early teenage years. -in some cases bilateral faden operation on medial rectus alone is sufficient. TREATMENT:

33. Uncorrected corrected with spectacles

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35. . SURGERY : -aim of surgery: to restore/enhance BSV/to improve the appearance of squint. -surgery is controversial & is not recommended in fully accommodative refractive esotropia . -only if spectacles donot correct deviation and after every attempt has been made to treat amblyopia . -B/L medial rectus recessions ( done for pts in whom deviation for near> distance) -unilateral medial rectus recession combined with lateral rectus resection can be done. -in patients with residual amblyopia surgery is usually performed on amblyopic eye.

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38. Some other esotropia : NEAR ESOTROPIA: signs: -no significant refractive error. - orthophoria or small esophoria with BSV for distance. -normal near point of accommodation. T/T: B/L medial rectus recession. DISTANCE ESOTROPIA : affects healthy young adults who are often myopic. signs: -intermittent or constant esotropia for distance. -minimal or no deviation for near. -normal B/L abduction - fusional divergence amplitudes may be reduced. T/T: with prisms,until spontaneous resolution. Surgery in persistant cases only.

39. . ACUTE( LATE ONSET) ESOTROPIA: -presents around 5-6 yrs for no apparent reason. Signs: Sudden onset of diplopia . Normal ocular motility No significant refractive error. Underlying 6 th n. palsy must be excluded. -T/T: prisms/surgery/ botulinum toxin(lasts for short duration). SECONDARY ( SENSORY) ESOTROPIA: Caused by U/L reduction in V/A which interferes/ abolishes fusion. E.g in cataract, optic atrophy,macular scarring, retinoblastoma. Fundus examination under mydriasis is therefore essential in all children with strabismus .

40. .  CONSECUTIVE ESOTROPIA : -follows surgical over- corection of an exodeviation . -if it occurs following surgery for an intermittent exotropia in a child, it should not be allowed to persist for more than 6 weeks without furthur intervention.  CYCLIC ESOTROPIA: -very rare condition characterised by alternating manifest esotropia with suppression & BSV, each lasting 24hrs. -may persist for months/years. -pt may eventually develop constant esotropia requiring surgery.

41. . MICROTROPIA (MONOFIXATION SYNDROME): -two types: 1)park’ monofixation syndrome 2) lang’s microtropia - may be primary or follow surgery for a large deviation. - may occur in apparent isolation but often associated with other conditions. e.g anisometropic amblyopia . -it is more a description of binocular status than a specific diagnosis. Chr : -very small angle of manifest deviation. -central suppression scotoma . -ARC with reduced stereopsis & variable peripheral fusional amplitudes. - anisometropia often present. -defective stereo-acuity. T/T: Correction of refractive error & occlusion for amblyopia ,

42. . PSEUDO-ESOTROPIA: -pseudo- esotropia is a condition in which the alignment of the eyes is straight(= orthotropic),however, they appear to be crossed. -due to prominent epicanthus or telecanthus . -Needs reassurance.

43. Crossed eyed appearance gets corrected with elimination of prominent epicanthic fold : note the corneal light reflex.

44. . thank you