FIG.

641.4 Inferior oblique muscle overaction.

It is important that parents realize that early successful surgical alignment is

only the beginning of the treatment process. Because many children may
redevelop strabismus or amblyopia, they need to be monitored closely during the
visually immature period of life.
Accommodative esotropia is defined as a “convergent deviation of the eyes
associated with activation of the accommodative (focusing) reflex.” It usually
occurs in a child who is between 2 and 3 yr of age and who has a history of
acquired intermittent or constant crossing. Amblyopia occurs in the majority of
cases.
The mechanism of accommodative esotropia involves uncorrected hyperopia,
accommodation, and accommodative convergence. The image entering a
hyperopic (farsighted) eye is blurred. If the amount of hyperopia is not
significant, the blurred image can be sharpened by accommodating (focusing of
the lens of the eye). Accommodation is closely linked with convergence (eyes
turning inward), as both are required to view an object at near. If a child's
hyperopic refractive error is large or if the amount of convergence that occurs in
response to each unit of accommodative effort is great, esotropia may develop.
The treatment for accommodative esotropia is to prescribe the full hyperopic
(farsighted) correction. These glasses eliminate a child's need to accommodate
and therefore correct the esotropia (Fig. 641.5 ). Although many parents are
initially concerned that their child will not want to wear glasses, the benefits of
binocular vision and the decrease in the focusing effort required to see clearly
provide a strong stimulus to wear glasses, and they are generally accepted well.
The full hyperopic correction sometimes straightens the eye position at distance
fixation but leaves a residual deviation at near fixation. This may be observed,
treated with bifocal lenses, or treated with surgery.

FIG. 641.5 Accommodative esotropia. Control of deviation with corrective lenses.

It is important to warn parents of children with accommodative esotropia that

the esodeviation may appear to increase without glasses after the initial
correction is worn. Parents frequently state that before wearing glasses, their
child had a small esodeviation, whereas after removal of the glasses, the
esodeviation becomes quite large. Parents often blame the increased
esodeviation on the glasses. This apparent increase is a result of a child's using
the appropriate amount of accommodative effort after the glasses have been
worn. When these children remove their glasses, they continue to use an
accommodative effort to bring objects into proper focus and increase the
esodeviation.
Most children maintain straight eyes once initially treated. Because hyperopia
generally decreases with age, patients may outgrow the need to wear glasses to
maintain alignment. In some patients, a residual esodeviation persists even when
wearing their glasses. This condition commonly occurs when there is a delay
between the onset of accommodative esotropia and treatment. In others, the
esotropia may initially be eliminated with glasses, but crossing redevelops and is
not correctable with glasses. The crossing that is no longer correctable with
glasses is the deteriorated or nonaccommodative portion. Surgery for this portion
of the crossing may be indicated to restore binocular vision.
Exodeviations are the second most common type of misalignment. The
divergent deviation may be intermittent or constant. Intermittent exotropia is the
most common exodeviation in childhood. It is characterized by outward drifting
of 1 eye, which usually occurs when a child is fixating at distance. The deviation
is generally more frequent with fatigue or illness. Exposure to bright light may
cause reflex closure of the exotropic eye. Because the eyes initially can be kept
straight most of the time, visual acuity tends to be good in both eyes and
binocular vision is initially normal.
The age at onset of intermittent exotropia varies but is often between age 6 mo
and 4 yr. The decision to perform eye muscle surgery is based on the amount and
frequency of the deviation. If the deviation is small and infrequent, it is
reasonable to observe the child. If the exotropia is large or increasing in
frequency, surgery is indicated to maintain normal binocular vision.
Constant exotropia may rarely be congenital. Congenital exotropia may be
associated with neurologic disease or abnormalities of the bony orbit, as in
Crouzon syndrome. Exotropia that occurs later in life may represent a
deterioration of an intermittent exotropia that was present in childhood. Surgery
can restore binocular vision even in long-standing cases.

Noncomitant Strabismus
When an eye muscle is paretic, palsied, or restricted, a muscle imbalance occurs
in which the deviation of the eye varies according to the direction of gaze.
Recent onset of a paretic muscle can be suggested by the symptom of double