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What is Esotropia?

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Girl with esotropia

Esotropia is a type of strabismus in which eyes do not line up properly. A less medical term that you could possibly hear is ”crossed eyes”. The muscles that normally control the eyes are not synchronized as they should be. In this eye disorder, one or both eyes point inward. It can affect only one eye (monocular) or both eyes (binocular). The prevalence of strabismus is estimated at 1%–3% of the population.

Types of Esotropia

By Age

Esotropia can be classified by age. If so, the distinction is between congenital (infantile) and acquired. 

Infantile esotropia happens in the first year of life. The exact cause is unknown. We know that some youngsters have trouble utilizing both eyes simultaneously, but with early surgery, these children can learn to use both eyes simultaneously. If one eye turns in more frequently than the other, the eye that crosses more frequently is at a higher risk of developing amblyopia.

Acquired esotropia refers to those who develop crossed eyes later in life. Individuals suffering from this type of esotropia typically experience double vision. Normally, individuals detect condition really quickly as everyday tasks become difficult.

Infantile esotropia happens in the first year of life.
Infantile esotropia

By Frequency of Occurrence

Esotropia can also be classified based on how often it occurs. If eyes are directing inward all the time, this is a constant esotropia. Most occurrences are constant.

If it happens from time to time, the condition is called intermittent esotropia. For example, accommodative esotropia can be intermittent. However, without treatment, intermittent will most likely progress to constant.

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By Eye Focusing

Accommodation is a term that describes the focusing effort. Accommodative esotropia, also known as refractive esotropia, is eye crossing caused by the eyes’ focusing efforts to see clearly. If glasses can fully fix the condition, this is a fully accommodative esotropia. If not, it is characterized as partially accommodative.

A non-accommodative esotropia occurs when there is no change in the angle of strabismus when wearing glasses. This condition is not related to refractive issues, but to other central nervous systems.

Causes of Esotropia

It’s important to note that the exact cause of esotropia can vary from person to person, and sometimes the cause remains unknown. However, there are several potential causes of esotropia, and they can be classified into different categories:

1. Accommodative Esotropia: This type of esotropia is common in infants and young children. It occurs when there is a significant difference in the refractive power between the two eyes, leading to one eye becoming misaligned to avoid double vision. It is often associated with farsightedness (hyperopia).

2. Infantile Esotropia: This type of esotropia is typically present from birth or develops within the first six months of life. The exact cause is not always clear, but it may result from abnormal development of the eye muscles or their control mechanisms.

3. Refractive Esotropia: Similar to accommodative esotropia, this type is caused by a significant difference in the refractive power of the eyes, but it can persist beyond childhood. It may be associated with untreated or inadequately corrected nearsightedness (myopia), farsightedness (hyperopia), or astigmatism.

4. Strabismic Esotropia: This type occurs due to a misalignment of the eye muscles, which can be caused by various factors, including:

Nerve or Muscle Problems: Conditions that affect the nerves controlling the eye muscles or the muscles themselves can lead to esotropia.
Brain Disorders: Some neurological conditions or brain injuries can interfere with the normal coordination of eye movements, causing one or both eyes to turn inward.
Eye Injuries or Diseases: Trauma to the eye or certain eye conditions, such as cataracts or retinopathy, can lead to misalignment.

5. Consecutive Esotropia: This type can occur after corrective eye surgery for other forms of strabismus or eye conditions. The misalignment may develop as a result of the surgical intervention.

6. Visual System Abnormalities: Certain visual system disorders or anomalies may cause esotropia. For example, problems with binocular vision or abnormal visual development during early childhood can contribute to the condition.

Risks Associated with Esotropia

Risk factors for the development of esotropia include family history, meaning it can be inherited. However, if someone in your family has esotropia, it does not mean that you or your children will have it too.

Risk factors for the development of esotropia include family history, meaning esotropia can be inherited.

Esotropia can be a sign of a variety of different disorders, including a condition within one or both eyes, issue with your brain (stroke), neurological disorders, systemic conditions (diabetes), eye injury, and thyroid disease.

Symptoms of Esotropia

The most obvious and visible symptom is the eyes that turn inward towards the nose. In other words, the eyes that don’t move in synchrony.

Squinting and excessive blinking can also signalize esotropia.

Other symptoms include low vision, blurry vision, double vision, decreased visual field and problems with depth perception, tilting the head, covering one eye.

Individuals with esotropia are often farsighted, which means they can see objects farther away more clearly than things closer to them.

Diagnosing Esotropia

Esotropia is diagnosed through a comprehensive eye examination conducted by an ophthalmologist or an optometrist. The diagnostic process typically involves the following steps:

1. Medical History: The eye care professional will begin by taking a detailed medical history of the patient, including any family history of eye conditions, previous eye problems, or any other relevant medical conditions.

2. Visual Acuity Test: A visual acuity test is performed to assess how well the patient can see at various distances. This test involves reading letters or symbols from an eye chart.

3. Cover Test: The cover test is used to detect the presence and magnitude of the eye misalignment. During this test, the eye care professional will have the patient focus on an object while covering one eye and then uncovering it to observe any movement in the other eye.

4. Ocular Motility Exam: This exam evaluates the range of motion and alignment of the eyes. The patient will be asked to follow a target (e.g., a moving pen or light) with their eyes while the examiner observes how the eyes move.

5. Refraction Test: A refraction test determines if the patient has any refractive errors, such as nearsightedness, farsightedness, or astigmatism, which could contribute to the esotropia.

6. Dilation of Pupils: The eye care professional may use eye drops to dilate the pupils, allowing a better view of the internal structures of the eyes.

Dilation of the pupils is one of the tests used to diagnose esotropia.

7. Retinal Examination: With the pupils dilated, the doctor can examine the back of the eyes, including the retina, optic nerve, and blood vessels.

8. Special Tests: In some cases, additional tests may be performed, such as a cover-uncover test, alternating cover test, or prism cover test, to further assess the degree and characteristics of the esotropia.

Esotropia Treatment

Severity and duration of the condition determines treatment options. Treatment plan will also differ depending on whether the misalignment affects one or both eyes.

1. Glasses or contact lenses aim to correct refractive error. In most cases, corrective lenses will quickly resolve the over-focusing issue. Some people, however, may still have esotropia while performing specific tasks.

2. Prisms lenses alter the way light enters the eye. Therefore, lenses lessen the effort required by the misaligned eye when focusing on an item, hence improving the condition.

3. Vision therapy. For instance, your doctor may advise you to wear an eye patch over the unaffected eye. This pushes you to use your misaligned eye, which strengthens it and aids in vision improvement. It may also advise you to use vision therapy software, such as AmblyoPlay, which offers monocular and binocular mode. The latter teaches the brain and the eyes how to work together simultaneously.

Vision therapy or orthoptic treatment is one of the treatment options for esotropia.
AmblyoPlay Vision Therapy

4. Surgery
In severe cases, surgery may be an option. This therapy strategy, however, is mostly used for infants. The goal of surgery is to straighten the eyes by correcting the length of the muscles around the eyes.

Latest Research on Esotropia

Acute Acquired Concomitant Esotropia From Excessive Application of Near Vision During the COVID-19 Lockdown

Vagge, Giannaccare, Scarinci, et al (2021) investigated a peculiar case of acute acquired concomitant esotropia, a type of inward eye misalignment, occurring during the COVID-19 lockdown. The study highlights a possible association between increased near vision activities (such as prolonged screen time and reading) due to the lockdown measures and the onset of the condition. The researchers aim to raise awareness of this potential eye health issue and its connection to changes in visual habits during pandemic restrictions.

Clinical Characteristics and Aetiology of Acute Acquired Comitant Esotropia

This research study, conducted by Meng et al. in 2022, explores the clinical characteristics and potential causes of acute acquired comitant esotropia (AACE). The researchers investigate the presentation and underlying factors contributing to this type of inward eye misalignment.

Timing of surgery in essential infantile esotropia – What more do we know since the turn of the century?

Bhate et al. posted a study in 2022, discovering what is the best time for surgery in infantile esotropia, highlighting the advantages and disadvantages of early and late surgery.

AdvantagesDisadvantages
Early surgeryBetter stereopsis and binocular vision.Accurate estimation of the angle of deviation is challenging.
Reduced incidence and severity of postoperative DVD and inferior oblique overaction.Possibility of development of accommodative esotropia as sequelae.
Improved psychosocial and parental bonding.
Minimizes delay in sensorimotor and gross motor development.
Late surgeryBetter accuracy in estimating the angle of deviation.Increased incidence and severity of DVD necessitating additional surgery.
Possibility of correction of vertical misalignment if any at same surgical sittingPoorer fine and gross stereopsis and binocular vision.
Possibility of treating amblyopia successfully.
(Bhate et al., 2022)

Connection of Esotropia to Other Vision Problems

Esotropia can be connected to various other vision problems due to the complex interplay of visual pathways and ocular muscle coordination. One common association is with amblyopia, commonly known as “lazy eye,” where the brain suppresses input from the deviating eye to avoid double vision, leading to reduced visual acuity in that eye.

Additionally, individuals with esotropia may experience difficulties with binocular vision and depth perception, impacting their ability to perceive the world in three dimensions.

Accommodative problems, such as difficulties focusing on nearby objects (nearsightedness) or distant objects (farsightedness), can also be linked to esotropia, as the eyes may overcompensate for refractive errors by crossing inward.

What if I do not Treat Esotropia?

If left untreated, esotropia can lead to eye issues such as binocular vision issues, double vision, loss of three-dimensional vision, and even vision loss in one or both eyes.

Therefore, it is important to minimize the risks over which we have influence, detect possible symptoms, and visit an optometrist or ophthalmologist.

Read about the Experiences of Individuals with Esotropia and AmblyoPlay

Treating Esotropia with AmblyoPlay.
Torrington, CT

Erick: Optometrist whose son has intermittent esotropia

As an optometrist with a background in pediatrics and vision therapy, I can honestly say that this product has been an excellent option for my son who deals with intermittent esotropia during the covid19 pandemic. It is an excellent adjunct to in-office therapy for anyone looking for some additional therapy for their kids at home.

Treating Esotropia with AmblyoPlay.
Woodstock, GA

Stephanie’s son using AmblyoPlay to help treat esotropia

Our son was diagnosed with strabismus esotropia when he was two years old and received surgery to correct it within the year. It wasn’t until he was ten and we started seeing a new optometrist that vision therapy was recommended.

His depth perception was terrible, he would get headaches doing schoolwork, he couldn’t catch a ball, and he had to sit very close to the TV when playing video games.

We started with an evaluation for a baseline and then tried 6 months of therapy in the office plus daily homework on a program that he found boring and tedious (cost: $1700). He repeated the evaluation and had made definite progress, but we were not in a place to fork over another $1700, plus weekly trips to the therapist’s office, and our son was pretty burned out on the homework through them.

At this point, we found AmblyoPlay and decided to give it a shot for six months since it was a fraction of the price and looked much more engaging. He retook his evaluation at the office and has improved tremendously!

His scores went from 17 (baseline) to 31 (after six months and $1700) to 50 (after six months of AmblyoPlay for 5-6 days/week). He still has some work to do, but we are so pleased with the results and his symptoms are getting better functionally as well. He also loves the games and variety, so it keeps him motivated. Great program at a great price!

Frequently Asked Questions and Tips for Parents

What is esotropia?

Esotropia is a type of strabismus in which eyes do not line up properly. A less medical term that you could possibly hear is ”crossed eyes”. The muscles that normally control the eyes are not synchronized as they should be. In this eye disorder, one or both eyes point inward.

Can esotropia be corrected in children?

Yes, esotropia can often be corrected in children, especially when detected and treated early. The treatment approach depends on the underlying cause and severity of the condition.

How do I know whether my child has esotropia or not?

Detecting esotropia in a child may require some observation and awareness of potential signs.

How to support a child with esotropia?

Follow the instructions the doctor gave you for treating your child’s esotropia. Make sure your kid receives a lot of support and love during the treatment. Remind them of the importance of the treatment approaches used to treat their vision. Furthermore, inform the child’s teachers about the treatment. In that way, they can help support your child.

How to communicate effectively with eye doctors?

To communicate effectively with eye doctors, come prepared with a list of specific symptoms or concerns, and provide relevant medical history. Be clear in describing issues and ask questions if needed. Request explanations for tests or procedures, and be honest about any difficulties in following instructions or treatments. Take notes during the appointment and express any concerns you may have, ensuring a two-way conversation to address your eye health effectively.


Sources:
https://aapos.org/glossary/infantile-esotropia
https://www.verywellhealth.com/esotropia-crossing-of-the-eyes-3421583
https://my.clevelandclinic.org/health/diseases/23145-esotropia
https://www.healthline.com/health/esotropia#treatment

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Why Do We Suggest a Minimum Time of 6 Months for Success?

Based on the data from over 15,000 patients using AmblyoPlay, improvements start within 4 months, while optimal results take anywhere between 6-18 months on average. The duration of required training depends on the patient’s age, the severity of the problem, accompanying diseases, and adherence to the training program.