Esotropia

Esotropia: Description, Causes and Risk Factors:Abbreviation: ET.EsotropiaEsotropia is in-turning of one or both eyes. It may be intermittent or constant and may occur with near fixation, distance fixation, or both. The crossing may occur predominantly with one eye or may alternate between eyes. Esotropia may occur at any age and is the opposite of exotropia (outward eye turn).Types:Infantile Esotropia: When esotropia begins in the developmentally and neurologically normal child during the first 6 months of life, it is classified as "infantile." When it occurs after 6 months of age, it is referred to as "early-acquired." True "congenital" esotropia, which is present at birth, is considered extremely rare; however, the terms "infantile esotropia," "essential infantile esotropia," and "congenital esotropia" are often used interchangeably. The probable age of onset for infantile esotropia is at 2-4 months of age.
  • Acquired Esotropia: Acquired forms of esotropia occur at a later age than infantile esotropia. Usually, normal binocular vision has existed prior to the onset of the condition.
  • Accommodative disease. This acquired strabismus is associated with the activation of accommodation. The esotropia is attributed partly or totally to either uncorrected hyperopic refractive error and/or a high accommodative convergence/accommodation (AC/A) ratio. Accommodative esotropia has a better understood mechanism and a more straightforward treatment or management than any other form of strabismus. It is reduced partly or entirely by correcting the hyperopic refractive error and/or prescribing a near addition.
  • Nonaccommodative disease. An acquired strabismus that develops after 6 months of age, nonaccommodative esotropia is not associated with accommodative effort. Correcting any coexisting hyperopia and/or prescribing a near addition for children with nonaccommodative esotropia has minimal or no effect on the size of the disease.
  • Acute disease. When a convergent strabismus develops suddenly without any apparent etiology in a school-aged or older patient with previously normal binocular vision, it is called acute disease. The sudden diplopia that usually occurs in acute disease may result from an underlying and potentially lifethreatening disease process, thus it requires immediate evaluation. Its onset can often be traced to a precise hour of a particular day.
  • Mechanical disease. A convergent strabismus caused by a mechanical restriction or tightness of an extraocular muscle (e.g., fibrosis of muscle tissue, thyroid myopathy) or a physical obstruction (e.g., blowout fracture) of the extraocular muscles, is classified as a mechanical esotropia. Some patients with Duane syndrome have tightening of the medial and/or lateral recti muscles secondary to the primary underlying neurological miswiring and co-innervation. There is a limitation or absence of abduction, causing an increasing esotropia. The palpebral fissure narrows when the eye rotates inward (adduction). In addition, the patient may exhibit an upshoot or downshoot when the eye adducts.
  • Sensory disease. A convergent strabismus resulting from visual deprivation or trauma in one eye that limits sensory fusion is classified as a sensory esotropia. It may result from any number of conditions that limit visual acuity in one eye (e.g., uncorrected anisometropia, unilateral cataract, corneal opacity, optic atrophy, macular disease). It occurs most frequently in persons under 5 years of age. Approximately 4 percent of those with esotropia have sensory disease.
  • Consecutive disease. A convergent strabismus that occurs after surgical overcorrection of an exotropia, consecutive esotropia is frequently associated with other oculomotor anomalies (e.g., vertical or cyclotorsional deviations). It may result in amblyopia and loss of normal binocular vision in young children and diplopia in adults.
The exact cause of the disease is not fully understood. Six eye muscles, controlling eye movements, are attached to the outside of each eye. In each eye, two muscles move the eye right and left. The other four muscles move it up or down and control tilting movements. To line up and focus both eyes on a single target, all eye muscles of each eye must be balanced and working together with the corresponding muscles of the opposite eye. The brain controls the eye muscles, which explains why children with disorders that affect the brain, such as cerebral palsy, Down's syndrome, and brain tumors often have strabismus.In children the misalignment can be due to a variety of causes including maldevelopment of the eye or even tumors. Causes in adults can be quite varied and also require prompt medical attention. Double vision or strabismus can be the first sign of a serious medical condition including stroke, or brain injury.Risk Factors:Children who have been farsighted and have not worn glasses.
  • Children who were initially responsive to glasses but later developed additional eye crossing (nonaccommodative esotropia) even with full hyperopic correction.
  • Abnormalities in pregnancy and delivery.
  • Arnold-Chiari malformation.
  • Scleral ectasia in high myopia that can lead to a "downslip" of the lateral rectus muscle relative to the globe, giving this muscle a depressing effect at the cost of its physiological action.
  • Myopic epikeratophakia.
  • Neurologic abnormalities.
  • Deficits of abduction.
  • Sixth nerve palsy.
  • Sixth nerve pseudo-palsy in children with esotropia with manifest-latent nystagmus.
  • Unilateral or bilateral type 1 Duane syndrome.
  • Heroin detoxification: Eye misalignments can occur during heroin use and heroin detoxification and can cause persisting diplopia (double vision).
  • Occult sinus disease: Sinusitis supposedly leads to inflammation and secondary contracture in adjacent extraocular muscles.
Esotropia does run in families. However, affected family members do not necessarily share the same type and/or severity of esotropia. A family history of esotropia is a very good reason for an evaluation by a pediatric ophthalmologist.Internationally: Of those children with esotropia, 10.4% of them are diagnosed with acquired esotropia.Mortality/Morbidity: Organic pathologies have been diagnosed in patients initially presenting with strabismus. In a recent study, 11.52% of patients with strabismus had posterior segment abnormalities. The most common diagnoses included Toxoplasma chorioretinitis, morning glory anomaly, Toxocara retinopathy, retinopathy of prematurity, and Coats disease. The mean age of onset of the deviation was found to be significantly lower in patients with esotropia. No correlation existed between the degree of visual impairment and the direction of deviation. This fact emphasizes the importance of performing a fundus examination in each patient presenting with strabismus.Symptoms:If you have esotropia the following are some of the symptoms you may experience:Suppression (turning off) of one image. Diagnosis:Identify esotropia as a pathological condition. In some cases, esotropia is not self-correcting but actually becomes worse. Infantile esotropia normally develops over the first six months and affects about 1 percent of full-term newborns. It may occur during transient episodes, causing a delay in the diagnosis.Measure the alternate prism test to measure the angle of deviation in the eyes. An angle of deviation greater than 20 prism diopters is considered to be infantile disease. Patients that have a deviation between 20 and 40 have some chance of resolving the disease, but a deviation of greater than 40 prism diopters will rarely resolve itself.Tests include:Standard ophthalmic exam.
  • Visual acuity.
  • Retinal exam.
  • Neurological examination.
Check for amblyopia, which should be strongly suspected in cases of infantile esotropia, especially in the crossed eye.Check for additional ocular motor signs such as impaired binocularity, incomitance and scotomas. Patients that attain a nearly normal alignment within the first two years probably have normal sensory and motor functions.Treatment:All forms of disease should be considered for treatment. Ocular alignment should be established as soon as possible, especially in young children, to maximize binocularity, prevent or facilitate treatment of amblyopia, and normalize appearance. In almost all cases, clinically important refractive errors should be corrected. Amblyopia treatment is usually started before surgery, because this may reduce the angle of strabismus or increase the likelihood of good postoperative binocularity.Choice of TherapyThe following treatment modalities are used alone or in combination as required to achieve the therapeutic goal:Correction of refractive errors.
  • Bifocals.
  • Prism therapy.
  • Amblyopia treatment.
  • Extraocular muscle surgery.
  • Treatment plans are formulated in consultation with the patient and parent/caregiver. The plans should be responsive to their expectations and preferences, including the family's/caregiver's perception of the existing alignment, which may differ from the ophthalmologist's, and what they hope to achieve with treatment. It is important that the family/caregiver and ophthalmologist agree on the goals of treatment before surgery is performed.
NOTE: The above information is for processing purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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