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Infantile esotropia
- 1. Infantile esotropia Dr Anisha Rathod MS,FPOS(Pediatric Ophthalmology And Strabismus)
- 2. – THE AUTHOR HAS NO FINANCIAL INTEREST IN THE SUBJECT MATTER BEING PRESENTED FINANCIAL DISCLOSURE
- 3. Definition – Large angle esotropia – Birth-6 months of age – Deviation increase in 1st few months of life – Limited abduction on versions – Doll’s head maneuver-Normal LR function
- 4. Normal Neonatal Alignment – 30%-Straight eyes – 70% -Transient exotropia – <1%-Esotropia
- 5. Classification – CEOS(Congenital esotropia observational study) – 43%-Congenital – 23%1st month of life – Pseudoesotropia – Infantile accommodative esotropia – Cross fixation – Congenital fibrosis syndrome
- 6. Infantile<6 months – Congenital – Early accommodative – DRS 1 – Mobius syndrome – 6th nerve palsy – Nystagmus blockade syndrome
- 7. Acquired>6 months Comitant – Accomodative ET – Sensory ET – Divergence insufficiency – Cyclic ET – Stress induced ET Incomitant – 6th nerve palsy – Thyroid eye disease – Medial wall # accommodative ET
- 8. Etiology – CFOM ESOTROPIA – Duane’s syndrome – Infantile myasthenia gravis. – LR weakness,Maturation of 6th nerve function – Hyperopia-accommodative convergence. – Abnormal muscle anatomy – Lack of cortical fusion. – Worth’s theory-Congenital absensce of central fusion potential – Chavasse theory-Primary motor disalignement +poor BSV.
- 9. Characteristics – Large angle constant esotropia – Amblyopia – Alternate fixation by either eye – Hyperopia+2.25 to +5 D – Motor abnormality-IO overaction,DVD,Latent nystagmus. – Smooth pursuit asymmetry- Disruption of BSV. – Down’s syndrome – Albinism – Cerebral palsy – Hydrocephalus, – Intracranial tumors
- 10. Evaluation – Fixation preference-Amblyopia – Ductions+versions assessment. – OKN-Saccadic eye movements – Cover-uncover test – Krimsky light reflex-distance/near – Cycloplegic refraction+dilated fundus examination.
- 11. Ductions and versions – Abduction deficit-6th nerve palsy/Oblique dysfunction – Some abduction limitation-Infantile esotropia – (Doll’s eye manuever)-Vestibular stimulation by spinning the child – Brisk abduction saccade-LR functioning – Limited abduction-Tight MR
- 12. Latent nystagmus – Bilateral – Manifests on occlusion of one eye. – Jerk type-fast phase in fixing eye – Decreasing velocity slow phase – Latent nystagmus also seen in congenital monocular cataracts
- 13. Pseudoesotropia – Orthotropic – Cross appearance – Wide nasal bridge with epicathal folds. Resolves 2-3 yrs of age as epicathal folds diminish +nose enlarges. – Nasally turned eye buried under epicanthal fold. – Small percentage end up with true deviation.
- 14. Infantile accommodative esotropia – Babies young as 2 months of age. – More than +2 D – High Ac/A ratio – Full hypermetropic correction. – Acquired acute esotropia-Urgent consultation-restablishing BSV.
- 15. Cianca syndrome – Large angle esotropia with cross fixation – Eyes appear “Stuck”in towards nose – Large angle deviation->60PD – Bilateral limited abduction with intact abduction saccades – Fixing eye in adduction – Nystagmus on attempted adduction-Jerk nystagmus with fast phase in direction of fixing eye(abduction)represents end point nystagmus – Face turn to fixing eye – Abduction-secondary to tight MR. – Face turn-Tight MR +fixing eye on adduction. – Good LR function – Brisk abduction saccades – Sx of choice-MR recession 7mm posterior to insertion site.
- 16. Cross fixation – Limited abduction+tight MR – Large face turn in adduction – Right eye fixates for objects in left visual field and vice versa. – Cross fixation sign of equal vision with small degree of amblyopia,if they can hold and fixate via smooth pursuit without refixation from fellow eye.
- 17. Congenital fibrosis syndrome – Autosomal dominant trait – Horizontal/vertical strabismus-Tight rectus muscle-FDT – Large angle constant esotropia with severe limitation of abduction – OKN –Abduction saccade movement brisk,small amplitudes-Intact LR function
- 18. Duane’s syndrome
- 19. Duane’s Syndrome Type I: OS -limited abduction -retraction in adduction
- 20. Duane’s Syndrome Type II: OS -limited adduction -retraction in adduction
- 21. Duane’s Syndrome Type III: OS -limited adduction and abduction -retraction in adduction/abduction
- 23. Congenital 6th nerve palsy
- 24. Mobius syndrome
- 26. Nystagmus blockade syndrome – Begins in early infancy (ie, congenital nystagmus—CN) – Accompanied by esotropia. reduction of the Nystagmus when esotropia increases. – Eye follows a target moving laterally towards the primary position and then into abduction, the nystagmus increases and the esotropia decreases. –
- 27. Cyclic ET – Rare condition – Alternating manifest esotropia – Supression+BSV – May Last 24 hours – Treatment-Correction of full manifest angle during intermittent phase.
- 28. Stress induced ET Large angle esotropia Illness/Accident Breakdown of fusional divergence Spasm of near synkinetic reflex with sustained convergence with miosis+accommodative spasm
- 29. Treatment Congenital esotropia – Hypermetropic spectacle correction – Small ET<40-+3D/more – Large angle esotropia>40PD-+D/more – Amblyopia treatment before Surgery. – Sx-Tight MR muscle – Bilateral MR recession-Near deviation-Fusional convergence. – Older patients-Amblyopic eye MR recession+LR resection – Goal of Sx-Alignment8-10PD for peripheral fusion. – Tropia>10PD-Further Sx=Spectacle correction. – Residual esotropia>10PD longer than 6-8wks after Sx – Base out prism glasses.
- 30. Botox injections – Principle- Incomitant deviation to adopt face turn+obtain fusion Complications- Secondary ptosis. Consecutive exotropia(2-3months) Disadvantage-Multiple injections needed to sustain effect.
- 31. Accomodative ET – Presents at 2.5 years – 1)Refractive:Hyperopia 4-7D – Deviation near=distance – Normal AC/A ratio – 2)Non refractive ET: – Refraction normal for age 1.5D – Deviation near>distance – High AC/A ratio – 3)Mixed accommodative ET – Hyperopia 3D – Deviation near> but present at distance as well – High AC/A ratio.
- 32. Management – Correction of refractive error – Plus bifocals for accommodative ET – Miotic therapy(ecthiopate/pilocarpine) – Temporary measure for non cooperative children – Peripheral accomodation hence less effort by patient – Disadvantages:Miosis,ciliary spasm,iris cysts,cataract ,RD.
- 33. Sx for Accomodative ET – If not corrected with spectacles – Bilateral MR reces deviation>near – Bilateral MR recession/recess-resection deviation near=distance. – Recess-resect=Amblyopia in one eye.
- 34. –Thank You