Esotropia

Key Features

• Pseudoesotropia can result from prominent epicanthal folds that give the appearance of crossed eyes when they are actually straight

• Esotropia is deviation of the eyes toward the nose and may involve one or both eyes

Clinical Findings

• Congenital esotropia (infantile esotropia)

  • Has its onset in the first year of life in healthy infants

  • Deviation of the eyes toward the nose is large and obvious

  • Also occurs in premature infants or children with a complicated perinatal history associated with CNS problems such as intracranial hemorrhage and periventricular leukomalacia

• Accommodative type of acquired esotropia is most common

  • Onset is usually between ages 2 and 5 years

  • Deviation is variable in magnitude and constancy and is often accompanied by amblyopia

  • Can be associated with a high hyperopic refraction; another type of deviation is worse with near than with distant vision and is usually associated with lower refractive errors

• Esotropia is associated with certain syndromes

  • In Möbius syndrome (congenital facial diplegia), a sixth nerve palsy causing esotropia is associated with palsies of the 7th and 12th cranial nerves and limb deformities

  • Duane syndrome can affect the medial or lateral rectus muscles (or both); may be an isolated defect or may be associated with a multitude of systemic defects (eg, Goldenhar syndrome)

• After age 5 years, any esotropia of recent onset should arouse suspicion of CNS disease

Diagnosis

• Observation of the reflection of a penlight on the cornea, the corneal light reflex, is an accurate means of determining if the eyes are straight

• If strabismus is present, the corneal light reflex will not be centered in both eyes

• Observation of eye movements may reveal restriction of eye movements in certain positions of gaze

• Alternate cover testing of the eyes while the child is fixating on a near and/or distant target will reveal refixation movements if the eyes are crossed

• Motility, cycloplegic refraction, and a dilated funduscopic examination by an ophthalmologist are necessary to determine the etiology of esotropia

• Some children require imaging studies and neurologic consultation

Treatment

• Surgery is typically performed between 6 months and 2 years of age in order to obtain optimal results

• Management of accommodative esotropia includes glasses with or without bifocals, amblyopia treatment and, in some cases, surgery

• Underlying neurologic disease should be referred to the appropriate specialists for further management