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Nungki Rusydiana Purnaningrum


 Is a latent or manifest convergent misalignment of the

visual axes.
 The most common type of strabismus
 More than 50% of ocular deviatians in pediatric
• More common in Caucasian and African American
• Males : females = equal
• Prevalence increases with :
 Age (prevalence at 48–72 months > 6–11 months),
 Moderate anisometropia,
 Moderate amounts of hyperopia
• Risk factors :
 anisometropia and hyperopia,
 Neurodevelopmental impairment,
 prematurity,
 low birth weight,
 craniofacial or chromosomal anomalies,
 maternal smoking during pregnancy,
 family history of strabismus

• Amblyopia develops in  50% children who have


 False appearance of
esotropia when the
visual axes are
actually aligned
 Both corneal light
reflex testing and
cover testing are • Flat, broad nasal bridge

Infantile (Congenital) Esotropia

 Present by 6 months of age

 Ocular instability of infancy, should resolve by 3 months of
 If Esotropia present after age 2 months, constant, and ≥30
PD: probably require surgical intervention
 30% with neurologic and developmental problems: CP,
hydrocephalus, and prematurity
 Associated with an increased risk of development of
mental illness by early adulthood (2.6 times higher)
 The Worth “sensory” concept : congenital
deficit in a “fusion center” in the brain 
restoring binocularity is futile.
 Chavasse theory : problem in motor
development  potentially curable if
ocular alignment is achieved in infancy.
 Alternating fixation  equal visual
behavior / visual acuity
 Fixation preference  associated
 Cross-fixation  use of adducted
eye for fixation of objects in the
contralateral temporal field
 Versions and ductions are often
 Deviation is comitant,  30Δ.
 Overelevation in adduction,
dissociated strabismus complex
 Abduction deficit
 Fusion maldevelopment nystagmus
 Low hyperopia (1.00-2.00 D)

large-angle esotropia (>50Δ), abducting

nystagmus, and mild abduction deficits
 Full cycloplegic refraction to correct hyperopic refractive
 Mild to moderate amblyopia at the time of surgery: more
successful postoperative alignment
 Alignment within 8Δ–10Δ of orthotropia → monofixation
syndrome: peripheral fusion, central suppression, and
favorable appearance
 Surgery to achieve ocular alignment:
 Procedure : recession of both medial rectus muscles,
 resection of the ipsilateral lateral rectus muscle
 botulinum toxin injection to medial rectus muscle
Accommodative Esotropia

 Convergent deviation associated with accommodative

 Acquired
 Onset between 6 months and 7 years
 Usually intermittent at onset, becoming constant
 Often hereditary
 Sometimes precipitated by trauma or illness
 Frequently associated with amblyopia
 Diplopia possible (especially with onset at an older age)
Accommodative Esotropia
 Refractive accommodative esotropia
 uncorrected hyperopia, accommodative convergence, and insufficient
fusional divergence.
 The angle of esotropia : 20Δ - 30Δ, equal at distance and near fixation.
 Average of +4.00 D of hyperopia.
 Management : correction of hyperopia under cycloplegia

 High accommodative convergence/accommodation ratio esotropia

 excess convergence tonus / amount of accommodation required to focus with
full cycloplegic refraction.
 only at near or is much larger at near.
 averages +2.25 D.
 Management :
 Bifocals to reduce / eliminate accommodation for near fixation;
 Long-acting cholinesterase inhibitors.
 Surgery.
 Observation.
 Partially accommodative esotropia
 reduction in the angle of esotropia when wearing glasses but have a
residual esotropia despite treatment of amblyopia and provision of
the full hyperopic correction.
 Management: surgery for the deviation that persists while the patient
wears the full hyperopic correction.
Acquired Nonaccommodative
 Basic Acquired Nonaccommodative Esotropia
 Comitant esotropia that develops after age 6 months and
not associated with accommodative component
 Caused by temporary but prolonged disruption of
binocular vision
 Therapy : amblyopia treatment, surgical correction,
botulinum toxin injection
 Cyclic Esotropia
 Comitant and occurs intermittently every other day
 Management : occlusion therapy, surgical treatment

 Sensory Esotropia
 Monocular vision loss may cause sensory (deprivation)
 Obstacles preventing clear and focused retinal images and
symmetric visual stimulation must be identified and
remedied promptly
 Divergence Insufficiency
 Esodeviation that is greater at distance than at near.
 The deviation is comitant in vertical and horizontal gaze, and fusional
divergence is reduced.
 Management of diplopia : base-out prisms, botulinum toxin injection
of the medial rectus muscles, strabismus surgery.

 Spasm of the Near Reflex

 Is a spectrum of abnormalities of the near response.
 Excessive convergence, accommodation, and miosis.
 Treatment : cycloplegic agents , hyperopic correction for patients
with significant hyperopia, and bifocals.
 Consecutive Esotropia
 Esotropia following a history of exotropia
 Can be a spontaneous develop after surgery for exotropia.
 Treatment : baseout prisms, hyperopic correction,
alternating occlusion, botulinum injection, strabismus
Nystagmus and Esotropia
 Fusion maldevelopment nystagmus syndrome (FMNS; also known as latent
and manifest latent nystagmus) is an infantile esotropia.
 Ciancia syndrome  severe form of infantile esotropia associated with
an abducting nystagmus.
 Nystagmus blockage syndrome occurs in children with congenital
nystagmus who use convergence to “damp,” or decrease the amplitude
or frequency of, their nystagmus.
Incomitant Esotropia
Esodeviation varies in size in different positions of gaze.

Sixth Nerve Palsy

 Pathogenesis
 Congenital  benign and transient.
 Caused by the increased intracranial pressure associated with birth process 
resolves spontaneously.
 Associated with intracranial lesions and may have other associated neurologic
 May be related to infectious or immunologic processes
 Management
 Patching
 Press-on prisms to correct diplopia
 Correction of a significant hyperopic refractive error
 Botulinum toxin injection of the ipsilateral medial rectus muscle
 Surgery may be indicated If the deviation does not resolve after 6 months of
Other Forms of Incomitant Esotropia
 Medial rectus muscle restriction may result from thyroid eye disease,
medial orbital wall fracture, excessive medial rectus muscle resection,
congenital fibrosis of the extraocular muscles.
 Duane retraction syndrome and Möbius syndrome  may develop
secondary restriction of the medial rectus
 High myopia  displacement of the posterior globe between the lateral
and superior rectus muscles

 Manifest or latent divergent strabismus

 In Asians, exodeviations are more common than esodeviations
 Risk factors for exotropia include :
1. Maternal smoking during pregnancy,
2. Premature birth,
3. Family history of strabismus,
4. Uncorrected refractive errors.

 The term pseudoexotropia refers to an

appearance of exodeviation when in fact
the eyes are properly aligned.

 Pseudoexotropia is much less common

than pseudoesotropia
 exodeviation controlled by fusion under normal viewing
 detected when binocular vision is interrupted, as during an
alternate cover test.
 asymptomatic if the angle of strabismus is small and fusional
convergence amplitudes are adequate.
 Prolonged, detailed visual work may bring about
 Breakdown of an exophoria to an exotropia may occur
transiently during a serious illness or after ingestion of
sedatives or alcohol.
 Treatment is usually not necessary unless an exophoria
progresses to intermittent exotropia or it causes asthenopic
1. Intermittent Exotropia
 Usually occurs before age 5 years.
 May develop during the first year of life, in which case it
must be differentiated from :
(a) The intermittent strabismus that is common in the first 1-2
months of life and that spontaneously resolve
(b) Constant infantile exotropia
 The exotropia  during illness, daydreaming, or drowsiness
on awakening, Fatigue
 Exposure to bright light often causes a reflex closure of 1 eye
 The clinical evaluation. During the
examination, an assessment is made of the
patient’s control of the exodeviation, which
can be categorized as follows:

Good Control • Manifest only after cover testing

• Patient resumes fusion rapidly
without blinking or refixating

Fair Control • Exotropia manifests after fusion is

disrupted by cover testing
• Patient resumes fusion only after
blinking or refixating
Poor Control • Exotropia manifests spontaneously
• Remain manifest for an extended time
The most common form of intermittent
exotropia. Patients initially have larger
deviations at distance than at near fixation,
Pseudodivergence excess but this difference becomes minimal after
exotropia monocular occlusion or with +3.00 D lenses
at near

Present when the exodeviation is

Basic exotropia approximately the same at distance and near

True divergence excess Present when the exodeviation is

approximately the same at distance and near
exotropia fixation

Convergence weakness Present when the exodeviation is greater at

exotropia near than at distance.
Nonsurgical management :
Correction of refractive errors  Corrective lense
Occlusion therapy  Patching
Active orthoptic treatments  Antisupressan Agen
Prisms  Base in

Surgical treatment
Pseudodivergence excess exotropia  symmetric recession of
both lateral rectus muscle
Basic intermittent exotropia  combined lateral rectus m.
Recession and medial rectus m. Resection
Smaller exodeviations  unilateral lateral rectus m. recession
Convergence Weakness
 There are 2 main types of convergence weakness exotropia:
 convergence insufficiency (CI), in which there is usually no
distance deviation
 convergence weakness associated with exotropia at both
distance and near fixation, but greater at near.
Constant Exotropia

 Constant exotropia is encountered most often in older patients with

sensory exotropia or patients with long-standing intermittent exotropia
that has decompensated.
Infantile exotropia is much less common
Infantile than infantile esotropia. It presents before
Exotropia age 6 months with a large-angle constant
Any condition that severely reduces vision in 1
eye—for example, anisometropia, corneal or lens
Sensory Exotropia opacities, optic atrophy or hypoplasia, retinal
lesions, or amblyopia—can cause sensory

Much more commonly, consecutive exotropia

Consecutive develops after previous surgery for esotropia
Exotropia (postsurgical exotropia), usually developing
within a few months or years after the initial
Other Form of Exotropia