Esotropia is a form of strabismus, or "squint", in which one or both eyes turns inward. The condition can be constantly present, or occur intermittently, and can give the affected individual a "cross-eyed" appearance. Esotropia is sometimes erroneously called "lazy eye", which describes the condition of amblyopia - a reduction in vision of one or both eyes which is not the result of any pathological lesion of the visual pathway and which cannot resolved by the use of corrective lenses. Amblyopia can, however, arise as a result of esotropia occurring in childhood: In order to relieve symptoms of diplopia or double vision, the child's brain will ignore or "suppress" the image from the esotropic eye, which when allowed to continue untreated will lead to the development of amblyopia. Treatment options for esotropia include glasses to correct refractive errors (see accommodative esotropia below), the use of prisms and/or orthoptic exercises and/or eye muscle surgery.
Someone with esotropia will squint with either the right or the left eye but never with both eyes simultaneously. In a left esotropia, the left eye 'squints', and in a right esotropia the right eye 'squints'. In an alternating esotropia the patient is able to alternate fixation between their right and left eye so that at one moment the right eye fixates and the left eye turns inward, and at the next the left eye fixates and the right turns inward. Where a patient tends to consistently fix with one eye and squint with the other, the eye that squints is likely to develop some amblyopia. Someone whose squint alternates is very unlikely to develop amblyopia because both eyes will receive equal visual stimulation. It is possible to encourage alternation through the use of occlusion or patching of the 'dominant' or 'fixing' eye to promote the use of the other.
2. Concomitant versus Incomitant
Esotropias can be concomitant - where the size of the deviation does not vary with direction of gaze - or incomitant - in which the direction of gaze does affect the size, or indeed presence, of the esotropia. The vast majority of esotropias are concomitant and begin early in childhood, typically between the ages of 2 to 4 years. Incomitant esotropias occur both in childhood and adulthood as a result of neurological, mechanical or myogenic problems affecting the muscles controlling eye movements.
3. Primary, Secondary or Consecutive
Concomitant esotropias can arise as an initial problem, in which case they are designated as 'Primary', as a consequence of loss or impairment of vision, in which case they are designated as 'Secondary', or following overcorrection of an initial Exotropia in which case they are described as being 'Consecutive'. The vast majority of esotropias are primary.
1. Constant Esotropia
A Constant esotropia, as the name implies, is present all the time, with and without glasses, if worn, and at all fixation distances. It may, however have an accommodative element (i.e. be influenced by the exertion of accommodative or 'focusing' effort) when looking at close objects, and this will lead to the esotropia being more noticeable when the affected individual looks at objects close to them.
2. Intermittent Esotropia
Intermittent esotropias, again as the name implies, are not always present: They may be visible when looking at close objects but not when looking at distant ones (Near Esotropia) or, rarely, when looking at distant objects but not at close ones (Distance Esotropia). In very rare cases, they may only occur in repeated cycles of 'one day on, one day off' (Cyclic Esotropia). However, the vast majority of intermittent esotropias are accommodative in origin.
The chances of an esotropia developing in these cases will depend to some degree on the amount of hyperopia present. Where the degree of error is small, the child will typically be able to maintain control because the amount of over-accommodation required to produce clear vision is also small. Where the degree of hyperopia is large, the child may not be able to produce clear vision no matter how much extra-accommodation is exerted and thus no incentive exists for the over-accommodation and convergence that can give rise to the onset of esotropia. However, where the degree of error is small enough to allow the child to generate clear vision by over-accommodation, but large enough to disrupt their binocular control, esotropia will result.
Where the esotropia is solely a consequence of uncorrected hyperopic refractive error, providing the child with the correct glasses and ensuring that these are worn all the time, is often enough to control the deviation. In such cases, known as 'Fully Accommodative Esotropias', the esotropia will only be seen when the child removes their glasses. Many adults with childhood esotropias of this type make use of contact lenses to control their 'squint'.
A second type of accommodative esotropia also exists, known as 'Convergence Excess Esotropia'. In this condition the child exerts excessive accommodative convergence relative to their accommodation. Thus, in such cases, even when all underlying hyperopic refractive errors have been corrected, the child will continue to squint when looking at very small objects or reading small print. Even though they are exerting a normal amount of accommodative or 'focusing' effort, the amount of convergence associated with this effort is excessive, thus giving rise to esotropia. In such cases an additional hyperopic correction is often prescribed in the form of bifocal lenses, to reduce the degree of accommodation, and hence convergence, being exerted. Many children will gradually learn to control their esotropias, sometimes with the help of orthoptic exercises. However, others will eventually require extra-ocular muscle surgery to resolve their problems.
The origin of the condition is unknown, and its early onset means that the affected individuals potential for developing binocular vision is limited. The appropriate treatment approach remains a matter of some debate. Some ophthalmologists favour an early surgical approach as offering the best prospect of binocularity whilst others remain unconvinced that the prospects of achieving this result are good enough to justify the increased complexity and risk associated with operating on those under the age of one year.
1. Identify and treat any underlying systemic condition
2. Prescribe any glasses required and allow the patient time to 'settle into' them.
3. Use occlusion to treat any amblyopia present and encourage alternation.
4. Where appropriate, orthoptic exercises can be used to attempt to restore binocularity.
5. Where appropriate, prismatic correction can be used, either temporarily or permanently, to relieve symptoms of double vision.
6. In specific cases, and primarily in adult patients, Botulinum Toxin can be used either as a permanent therapeutic approach, or as a temporary measure to prevent contracture of muscles prior to surgery
7. Where necessary, extra-ocular muscle surgery can be undertaken to improve cosmesis and, on occasion, restore binocularity.