QUICK REFERENCE GUIDE
Care of the Patient with Strabismus:
Esotropia and Exotropia
American
Optometric
Association
American
Optometric
Association
American
Optometric
Association
A. DESCRIPTION AND CLASSIFICATION
American Optometric Association
Strabismus
is a manifest deviation of the primary
lines of sight of 1 prism diopter (PD) or more. This
misalignment of the eyes can be classified as to:
Direction (convergent, divergent, or vertical)
Deviation equal or varying with the direction of
gaze (comitant or incomitant)
Frequency (constant or intermittent)
Laterality (unilateral or alternating)
Time of onset (congenital or acquired)
Size (large, small, or intermediate)
Involvement of accommodative system
(accommodative or nonaccommodative)
State of vergence
system
(convergence
American
Optometric
Association
insufficiency or divergence excess, divergence
insufficiency or convergence excess, basic
esotropia or basic exotropia)
B. RISK FACTORS
Family history of strabismus, especially siblings
Uncorrected hyperopia and/or high
accommodative-convergence/accommodation
(AC/A) ratio
Unilateral cataract in infants or young children
Multiple handicaps (e.g., Down's syndrome,
cerebral palsy, and craniofacial dysostosis, such
as Apert-Crouzon syndrome)
C. COMMON SIGNS, SYMPTOMS, AND
COMPLICATIONS
Table l lists the signs, symptoms, and complications
of various forms of esotropia and exotropia.
D. EARLY DETECTION AND PREVENTION
Most types of strabismus cannot be prevented.
However, some forms of accommodative esotropia
may be avoided through the early detection and
correction of significant hyperopia.
Infants and
children
suspected
of having
strabismus
American
Optometric
Association
American
Optometric
Association
American
Optometric
Association
should be
examined
immediately.
The
prognosis
for
achieving normal binocular vision is significantly
improved if treatment is not delayed.
E. EVALUATION
American Optometric Association
The evaluation
of a patient with strabismus may
include, but not be limited to:
1. Patient History
General and eye health history
Probable time and nature of onset of strabismus
Deviating eye and frequency of deviation
Change in size of deviation
Family history of strabismus
Presence
orAmerican
absence
ofOptometric
diplopia Association
andAssociation
other visual
American
Optometric
symptoms
Evidence of neurologic, systemic, or
developmental disorders
Prior treatment and results
NOTE: This Quick Reference Guide should be used in conjunction with the Optometric Clinical Practice Guideline on
Care of the Patient with Strabismus (Reviewed 2004). It provides summary information and is not intended to stand
alone in assisting the clinician in making patient care decisions.
Published by:
American Optometric Association 243 N. Lindbergh Blvd. St. Louis, MO 63141
2. Ocular Examination
3. Patient Education
Patients and/or parents should be provided
information about:
Visual acuity
Ocular motor deviation
Monocular fixation
Extraocular muscle function
Sensorimotor fusion
Accommodation (amplitude, facility and
response)
Refraction (cycloplegic and noncycloplegic)
Ocular health assessment
F.
l.
MANAGEMENT
Basis for Treatment
Treatment of strabismus is directed toward four
goals:
Obtaining normal visual acuity in each eye
Obtaining and/or improving fusion
Eliminating any associated sensory adaptations
Obtaining a favorable functional appearance of
eye alignment
2. Available Treatment Options
Optical correction (full or partial)
Added lens power
Prisms
Active vision therapy
Nature of condition and risks of developing
amblyopia and impaired binocular depth
perception
Importance of timely examination and
management to reduce the risk for loss of vision
and fusion and the development of other related
symptoms
Prognosis and advantages and disadvantages of
various modes of treatment.
4. Prognosis and Followup
The prognosis for treatment of strabismus varies
depending on many factors including the specific
type and nature of the condition, age at onset, and
the presence or absence of fusion and amblyopia.
Patient compliance with the prescribed treatment is
also crucial to success of any treatment plan.
Followup evaluations are needed to assess the
patient's response to therapy and to alter or adjust
treatment as necessary. The schedule of followup
visits (Table 2) depends upon the patient's condition
and associated circumstances. These evaluations
should include but are not limited to:
Patient history
Visual acuity
Pharmacological agents
Characteristics of strabismus at distance and
near
Extraocular muscle surgery
Fusion status
Chemodenervation
Extraocular muscle function
Table 2 provides an overview of the evaluation,
management, and treatment options best suited for
each type of strabismus. Indications for and
specific types of treatment may need to be
individualized for each patient.
Refraction
Tolerance, efficacy, and side effects of therapy.
TABLE 1
Common Signs, Symptoms and Complications
Condition
Signs, Symptoms, and Complications
Accommodative Esotropia
Small to moderate (generally 10-35 PD), often variable, angle of deviation
which occurs more frequently at near
Occurs in children with previously normal binocular vision
Due totally or partly to either uncorrected hyperopia and/or a high AC/A
ratio
May be precipitated by a febrile illness
Average amount of hyperopia is 4.75D for normal AC/A ratios and 2.25D
for high AC/A ratios
May have minimal refractive error and esotropia only at near
May report diplopia or closure of one eye during near work
Acute Esotropia or Exotropia
Develops suddenly at any age in persons with previously normal binocular
vision
May result from underlying disease process
Consecutive Esotropia or Exotropia
Occurs after surgical over-correction of an exodeviation or esodeviation
Complications include amblyopia, suppression, and anomalous
correspondence
Esotropia may be associated with decompensated heterophoria, late-onset
accommodative esotropia, abducens nerve palsy, divergence
paralysis/divergence insufficiency, or acute acquired comitant esotropia
Exotropia is usually associated with decompensated exophoria or acquired
ocularmotor nerve palsy
Consecutive esotropia, usually constant and unilateral, is frequently
associated with other oculomotor anomalies (e.g., vertical or cyclo
deviations)
Spontaneous consecutive exotropia may be related to a sensory deficit, weak
binocular function, or excessive hyperopic refractive error (>4.50D)
Begins in neurologically normal children during the first six months of life
Complications include amblyopia, loss of stereopsis, and reduced potential
for normal binocular vision
Infantile esotropia may be associated with a large-angle, constant esotropia
(generally 40-60PD), low hyperopia, amblyopia, and ocular motility
disorders
May be associated with other neurological syndromes or defects
Limited potential for normal binocular vision and good stereopsis
Infantile or Early-acquired Esotropia or Exotropia
Infantile exotropia usually exhibits a large, constant deviation (generally 3080PD) with associated ocular motility disorders
Intermittent Exotropia
Occurs at any age in persons with previously normal binocular vision
Rarely amblyopiogenic because of alternating fixation pattern, but provides
limited potential for normal binocular vision and good stereopsis
Variable periods of strabismus and of normal binocular alignment with good
stereopsis (>60 seconds of arc when fusing)
Significant deviation at one or more fixation distances, becoming more
apparent when patient is fatigued, or after prolonged dissociation
Minimal or no amblyopia
Reduced positive fusional vergence amplitudes and facility
Reports of discomfort during or following prolonged visual activity, closing
one eye in bright sunlight
Diplopia or suppression
Mechanical Esotropia or Exotropia
Associated accommodative dysfunction
Minimal esotropia or exotropia in primary position
Occurs at any age in persons with previously normal binocular vision
Increased deviation in right or left gaze
Caused by a mechanical restriction or a physical obstruction of the
extraocular muscles or adjacent structures
Restricted horizontal versions and ductions
Microtropia
Occurs in children under 3 years of age
Results from a primary sensory deficit or treatment of a larger angle
esotropia or exotropia
May occur idiopathically or secondary to anisometropia
Sensory Esotropia or Exotropia
Esotropia occurs most frequently in persons <5 years of age; exotropia
predominates in persons >5 years of age
Results from a unilateral decrease in vision that limits or disrupts sensory
fusion (e.g., uncorrected anisometropia, unilateral cataract, trauma)
Frequent compensatory head turns
Absence of amblyopia
Constant and usually unilateral esotropia or exotropia of <10PD
May exhibit amblyopia, eccentric fixation, anomalous correspondence,
deficient stereopsis, and anisometropia
Constant unilateral esotropia or exotropia
High degrees of anisometropia
Vertical deviations associated with overaction of oblique muscles
Complications include amblyopia, loss of stereopsis, and limited potential
for normal binocular vision
TABLE 2*
Frequency and Composition of Evaluation and Management Visits for Esotropia and
Exotropia
Type of Patient
Frequency of
Evaluation**
Treatment Options
Management Plan
Accommodative
esotropia
<6 years: every 4-6 mo
6-10 years: every 6-12 mo
>11 years: every 12 mo
Optical correction
Vision therapy
Provide refractive correction; treat any
amblyopia; use added plus at near if needed
to facilitate fusion; prescribe vision therapy
to develop/enhance normal sensory and
motor fusion.
Acute esotropia and
exotropia
Every 3-12 months
Prisms
Vision therapy
Surgery
Use prisms to eliminate diplopia and reestablish binocular vision; prescribe vision
therapy; in stable deviations over 20-25 PD,
consult with ophthalmologist regarding
extraocular muscle surgery.
Consecutive esotropia
and exotropia
Variable, depending on
etiology
Optical correction
Prisms
Vision therapy
Surgery
Provide refractive correction; prescribe prism
and/or vision therapy to prevent amblyopia,
eliminate diplopia, and establish normal
sensory fusion, if applicable.
Infantile or earlyacquired esotropia or
exotropia
<2 years: every 3 mo
2-5 years: every 4-6 mo
6-10 years: every 12 mo
>11 years: every 12-24 mo
Optical correction
Prisms
Vision therapy
Surgery
Provide refractive correction; treat any
amblyopia; use prism to establish normal
sensory fusion, if applicable; consult with
ophthalmologist regarding extraocular muscle
surgery.
Intermittent exotropia
<5 years: every 4-6 mo
5-10 years: every 6-12 mo
>11 years: every 12-24 mo
Optical correction
Prisms
Vision therapy
Surgery
Provide refractive correction; use added
minus lens power or base-in prism if needed
to facilitate fusion; prescribe vision therapy;
if deviation persists or increases, consult with
ophthalmologist regarding extraocular muscle
surgery.
Mechanical esotropia or
exotropia
Variable, depending on
etiology
Prisms
Surgery
No therapy if strabismus is not present in the
primary position of gaze and no diplopia.
Consider prisms and/or surgery to treat head
turn.
Microtopia
Every 3-12 months
Optical correction
Prisms
Vision therapy
Provide refractive correction; treat any
amblyopia; prescribe vision therapy and/or
prism to establish bifoveal fusion, if
applicable.
Sensory esotropia or
exotropia
Every 3-12 months
Optical correction
Prisms
Vision therapy
Surgery
Consult with ophthalmologist regarding
treatment of any underlying ophthalmic
disease; provide refractive correction; treat
any amblyopia; prescribe vision therapy
and/or prism, if applicable; if deviation
persists or increases, consult with
ophthalmologist regarding extraocular muscle
surgery.
Adapted from Figure 2 in the Optometric Clinical Practice Guideline on Care of the Patient with Strabismus: Esotropia and Exotropia
** Vision therapy would require additional visits.
