ACCOMMODATIVE ESOTROPIA

Rishabh Gupta
M.Optom 1st Year
Esotropia
■ Esotropia is a condition (strabismus) in which a person is unable to align both eyes
simultaneously under normal viewing conditions. When both eyes do not point at an object at the
same time, it results in the appearance of one eye "turning" inwards in relation to the other. This
eye turning may be constant, in which an eye turns all the time, or it may be intermittent. It may
also alternate so that either eye turns at any given time.
■ Accommodative Esotropia is a convergent strabismus that present only during the exercise of
accommodation.

What causes an Accommodative Esotropia?

• Accommodative Esotropia is caused by an accommodation that over-reacts to a stimulus even
when minimal refractive error is present. Let’s say that for a near task, “X” amount of
accommodation is needed, but with accommodative esotropia much more focusing results, which
in turn causes an eye turns inward.
Accommodative Esotropia
■ It occurs before the age of 2 – 2 and half years when accommodation is well developed.
■ It is a condition where 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.
■ There are different types of accommodative esotropia based on AC/A ratio.

Types of Accommodative Esotropia :-

 Fully Accommodative type

 Convergence Excess type
 Divergence insufficiency type
 Partial Accommodative type
 Mixed type
Symptoms
■ Accommodative Esotropia is often associated with a variety of symptoms, including :-
• Seeing double (diplopia)
• Difficulty judging distances
• Eyestrain
• Headaches
• Blurred vision
• Sleepiness
• Difficulty concentrating,
• Movement of print while reading, and loss of comprehension after short periods of reading
or performing close activities.
Fully Accommodative :-

• Also called as refractive accommodative esotropia, usually seen Hyperopia of 3-3.50 D.

• Mostly it is for near and distance.
• Fully correctable by the use of spectacles.
• Normal AC/A ratio.
• Since they have normal AC/A ratio ,the esodeviation is the same for distance and near fixation
• After correction visual axis aligns and esotropia disappears.
• BSV is present at all distances with glasses.

TREATMENT :-

• Complete Correction of refractive error, under cycloplegia, irrespective of child's age.

• Fully hyperopic correction
• Glasses should be worn throughout the waking hours
• Regular follow ups and repeat the cycloplegic refraction and change the glasses whenever required.
• If suppression is present then anti suppression exercises
• Exercises to relax accommodation.
Uncorrected Corrected
 • Exercises to improve negative fusional vergence
• Exercise to improve binocular convergence.

Convergence Excess :-
• Such cases do not accommodate for distance but only for near fixation
• Characterized 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)
• Binocular single vison with full BVA is present for distance but there is usually a manifest
convergent deviation for near vison even with glasses.

TREATMENT :-

• Bifocals prescribed. relieves accommodation 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.
Fitting guidelines for Executive Bifocal :-
• Age less than 5 years – Line should bisect the pupil
• Age s 6-7 years – Executive line should below the pupillary margin.
• Child’s 8 years or above – Executive line should be at limbal margin

Miotic Therapy :-
• Miotics drops are instilled in the eyes, to increase the peripheral accommodation, which
increases the depth of focus which gives clear vison and demand of accommodation is
reduced and gives pinhole effect.
• Drugs of choice are – Pilocarpine, Di-iso Propyl Fluro Phosphonate, Phospholine iodide.

Surgery.

Divergence insufficiency :-

• In these cases there is a manifest convergent squint for distance but esophoria for near.
• Sometimes it is associated with congenital myopia.
• Peripheral stimulations of accommodations may result in a failure of accommodation to relax
on distant fixations so that there is some convergent squint when distant objects are viewed.

TREATMENT :-
• Exercises to improve negative fusional vergence
 • Exercises to relax accommodation
• Temporary basis BO prisms are given .
• Surgery is also required if correction and exercises are not sufficient.

Partially accommodative type :-

• These cases, the visual axes are convergent in all circumstances but the deviation increases when
accommodation is exerted and when the hypermetropic correction is removed.

Mixed type :-

• Caused by combination of hypermetropia and high AC/A ratio.

• Correct Refractive error along with improving Negative fusional vergence.
• Relaxation of accommodation.

Standards to discharge patent :-

• VA should be equal and good in both the eyes

• BSV with and without glasses
• Phoria with and without glasses
• No suppression and diplopia.