Accommodative Esotropia
- Synonyms
Accommodative component in esotropia
Accommodative esotropia component (eye condition)
Right accommodative esotropia
Left accommodative esotropia
Bilateral accommodative esotropia
- ICD 10
Diagnosis code: H50.43
Definition
A misalignment of the eyes or childhood strabismus associated with the accommodation reflex.
Epidemiology Don't use plagiarised sources.Get your custom essay just from $11/page
Accommodative esotropia affects 2% of the world’s population. It is prevalent among patients with average amounts of hyperopia. The condition is attributed to accommodative convergence that is linked to hyperopia. Infants have straight eyes, but as they begin to learn how to see clearly, the divergence is not enough, and the child gets esotropia.
Accommodative esotropia usually develops between infancy and late childhood. It is usually common for 2 year old children. This condition accounts for 50% of all childhood related esotropias. It is classified into refractive, non-refractive, and partially decompensated or accommodative.
Most cases of esotropia involve moderate hyperopes. In extreme cases of hyperopes, the patient will suffer from blurred vision. Accommodative esotropia has no racial or sex predilection.
The main risk factors for accommodative esotropia include:
- Family history
- May develop after an illness or trauma
- Symptoms can manifest again during the onset of presbyopia
- Hyperopia that is more than +2.00
Pathophysiology/Etiology
A patient suffering from uncorrected hyperopia needs to accommodate to see clearly. In the process of accommodation, convergence and fusional divergence are triggered. When fusional divergence is unable to compensate for the convergence, the patient’s eyes cross. A patient suffering from uncorrected hyperopia sees one blurred image or double blurred images where one image is clear, and the other is blurred. Eventually, the blurred image is suppressed, fixation is alternated, and amblyopia develops.
Clinical History
Practitioners often factor the history of the patient when treating accommodative esotropia. Parents of the affected person may have an inward deviation of one eye relative to the other. The patient may visualize either one blurred image or double blurred images. A family history of strabismus and any related disease is also crucial in the diagnosis of the condition. It is also important to note the age at which the patient developed strabismus.
Differential DX
When diagnosing accommodative esotropia, there is a need to differentiate it from conditions such as:
- Abducens Nerve Palsy (Sixth Cranial Nerve Palsy)– A condition that may lead to papilledema, ocular motility, and may also affect the eyes and other cranial nerves.
- Acquired esotropia– a type of eye misalignment. It is a condition characterized by crossed eyes
- Duane syndrome- a congenital restrictive strabismus disorder. This condition may occur together with other congenital diseases.
- Esotropia with High AC/A Ratio- A type of strabismus with a high accommodative convergence/ accommodation ratio.
- Infantile Esotropia– An inward deviation of one’s eyes present occurring when a child is six months. This condition is attributed to maldevelopment of eye movements, motion processing, and stereopsis. This condition may lead to amblyopia.
- Pseudoesotropia- a condition where the eye alignment is okay, but they seem crossed.
Examination
The diagnosis of accommodative esotropia involves the following:
- Examination of the patient’s visual acuity-objective and subjective methods will be used depending on the patient’s age. For example, for patients below one year, objective methods are employed, whereas for patients above one year, subjective methods like Allen cards, the letter chart, tumbling Es, or Snellen alphabet are used.
- Measure stereo acuity using Titmus Test, Randot stereogram, or polarized glasses
- Examine extraocular movements to make sure the patient has full eye movements
- Measure angle of deviation by evaluating the centration of the eye’s corneal light reflex. By covering and uncovering the eye, you will be able to note a shift in the position of the eye with refixation. In accommodative esotropia, the angle of deviation is 20-40 prism diopters.
- Measure the AC/A ration. In accommodative esotropia, the ratio is normal, and the distance and measurements are the same
- Perform an eye examination to assess the anterior chamber, cornea, and lens.
- Conduct a cycloplegic refraction with a retinoscope.
Work Up
“See Examination”
Treatment
Hyperopic correction
The primary treatment for accommodative esotropia is spectacle correction. The correction is made on the basis of cycloplegic refraction. This treatment is used for infantile-onset and juvenile-onset of accommodative esotropia. This treatment should be given on the first sighting of the condition because delays would result in loss of stereopsis, development of amblyopia, and loss of fusion ability.
The patient will be re-evaluated after two months. The condition is corrected if it is within 8-10 prism diopters, and the patient recovers good fusion. The lack of asthenopic symptoms also shows that the treatment was successful. Another cycloplegic refraction will be conducted if the distance esotropia is still high. If there is still a distance deviation, surgery is recommended.
Many claim that surgery is not effective in accommodative esotropia. However, some studies have proven that surgery can be successful. According to Hutchinson and colleagues, surgery led to alignment within ten prism diopters of orthophoria. However, surgery comes with the risk of complications like corneal striae, corneal haze, and a decline of best-corrected visual acuity.
Follow up (F/u)
Research
References
Mohney BG. Common forms of childhood esotropia. Ophthalmology 2001; 108: 805– 809.
Von Noorden GK. Binocular Vision and Ocular Motility: Theory and Management of Strabismus, 5th ed. St Louis: Mosby, 1996.
Baker JD, Parks MM. Early‐onset accommodative esotropia. Am J Ophthalmol 1980; 90: 11– 18
Links
https://eyewiki.aao.org/Accommodative_Esotropia
https://emedicine.medscape.com/article/1199512-overview
https://aapos.org/glossary/accommodative-esotropia
https://iovs.arvojournals.org/article.aspx?articleid=2124239