1. ESOTROPI A BY DR. ALSHYMAA MOUSTAFA OHTHALMOLOGY SPECIALIST

2. INTRODUCTION Esotropia (manifest convergent squint) may be concomitant or incomitant. In a concomitant esotropia the variability of the angle of deviation is within 5 Δ in different horizontal gaze positions. In an incomitant deviation the angle differs in various positions of gaze as a result of abnormal innervation or restriction.

3. CLASSIFICATION OF ET Accommodative Refractive 1.Fully accommodative 2.Partially accommodative Non-refractive 1.With convergence excess 2.With accommodation weakness Mixed Non-accommodative 1.Early onset (congenital, essential infantile) 2.Microtropia 3.Basic 4.Convergence excess 5.Convergence spasm 6.Divergence insufficiency 7.Sensory 8.Divergence paralysis 9.Consecutive 10.Acute onset 11.Cyclic

4. ACCOMMODATIVE ET

5. INTRODUCTION Near vision involves both accommodation and convergence. Accommodation is the process by which the eye focuses on a near target, by altering the curvature of the crystalline lens. Simultaneously, the eyes converge, in order to fixate bifoveally on the target. Both accommodation and convergence are quantitatively related to the proximity of the target and have a fairly constant relationship to each other (AC/A ratio) as described previously. Abnormalities of the AC/A ratio are an important cause of certain types of esotropia.

6. REFRACTIVE ACCOMMODATIVE ET AC/A ratio is normal and esotropia is a physiological response to excessive hypermetropia, usually between +2.00 and +7.00 D. The considerable degree of accommodation required to focus clearly on even a distant target is accompanied by a proportionate amount of convergence which is beyond the patient’s fusional divergence amplitude. It cannot therefore be controlled and a manifest convergent squint results. The magnitude of the deviation varies little (usually <10 Δ) between distance and near. The deviation typically presents at the age of 18 months to 3 years (range 6 months to 7 years).

7. Types of accommodative ET Fully accommodative esotropia: - It is characterized by hypermetropia with esotropia when the refractive error is uncorrected. -The deviation is eliminated and BSV is present at all distances following optical correction of hypermetropia. - This may occasionally be seen in a baby. Partially accommodative esotropia: -It is reduced but not eliminated by full correction of hypermetropia. -Amblyopia is frequent as well as bilateral congenital superior oblique weakness. -Most cases show suppression of the squinting eye although ARC may occur, but of lower grade than in microtropia.

8. Fully Accommodative ET in a child and baby

9. Partially Accommodative ET

10. NON-REFRACTIVE ACCOMMODATIVE ET The AC/A ratio is high so that a unit increase of accommodation is accompanied by a disproportionately large increase in convergence. This occurs independently of refractive error, although hypermetropia frequently coexists.

11. Types of Non-refractive accommodative ET Convergence excess : ○ High AC/A ratio due to increased accommodative convergence (accommodation is normal, convergence is increased). ○ Normal near point of accommodation. ○ Straight eyes with BSV for distance. ○ Esotropia for near, usually with suppression. ○ Straight eyes through bifocals. Hypoaccommodative convergence excess : ○ High AC/A ratio due to decreased accommodation (accommodation is weak, necessitating increased effort, which produces over-convergence). ○ Remote near point of accommodation. ○ Straight eyes with BSV for distance. ○ Esotropia for near, usually with suppression.

12. Convergence excess ET corrected by Bifocals

13. TREATMENT Correction of refractive error : ○ In children under the age of 6 years: -The full cycloplegic hypermetropic refraction revealed on retinoscopy should be prescribed, with a deduction only for the working distance. -In the child with fully accommodative refractive. esotropia this will control the deviation for both near and distance. ○ After the age of 8 years: -The refraction should be performed without cycloplegia and the maximal amount of ‘plus’ that can be tolerated (manifest hypermetropia) prescribed.

14. ○ For convergence excess esotropia: -Bifocals may be prescribed to relieve accommodation (and thereby accommodative convergence), thus allowing the child to maintain bifoveal fixation and ocular alignment at near. -The minimum ‘add’ required to achieve this is prescribed. -The most satisfactory form of bifocals is the executive type in which the intersection crosses the lower border of the pupil. -The strength of the lower segment should be gradually reduced and eliminated by the early teenage years.

15. -Bifocals are also used in hypoaccommodative esotropia where the AC/A ratio is not overly excessive and there is a reasonable chance of discarding bifocal correction with time. -At higher levels surgery is the better long-term option. -The ultimate prognosis for complete withdrawal of spectacles is related to the magnitude of the AC/A ratio and to the degree of hypermetropia and associated astigmatism. -Spectacles may be needed only for close work.

16. Surgery : -It is aimed at restoring or improving BSV, or at improving the appearance of the squint and so the child’s social functioning. -It should be considered only if spectacles do not fully correct the deviation and after every attempt has been made to treat amblyopia. ○ Bilateral medial rectus recessions are performed in patients in whom the deviation for near is greater than that for distance. ○ If there is no significant difference between distance and near measurements and equal vision in both eyes, some perform unilateral medial rectus recession combined with lateral rectus resection, whereas others prefer bilateral medial rectus recessions.

17. ○ In patients with residual amblyopia, surgery is usually performed on the amblyopic eye. ○ In partially accommodative esotropia, surgery to improve appearance is best delayed until requested by the child. This avoids early consecutive exotropia. It should aim to correct only the residual squint present with glasses. ○ The usual first procedure for convergence excess esotropia is recession of both medial rectus muscles. This relies on fusion to prevent a distance exotropia; a few patients become divergent after surgery and need a further procedure. ○ Medial rectus posterior fixation sutures (Faden operation) can also be used either as a first procedure, or in the case of under-correction, following bimedial recessions.

18. Thanks