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Esotropia: Understanding and Treatment of Crossed Eyes

Esotropia = inward deviation of one/both eyes (convergent strabismus). Most common pediatric strabismus (2–3%).

Classification

  • Infantile (congenital): Onset <6 mo, large angle, cross-fixation, latent nystagmus.
  • Accommodative: Onset 2–4 yrs, hyperopia-driven; improves with glasses.
  • Partially accommodative: Residual deviation with full hyperopic correction.
  • Acquired non-accommodative: Neurologic, mechanical, sensory deprivation.

Risk Factors

Family history, prematurity, low birth weight, hydrocephalus, cerebral palsy, cranial nerve VI palsy, Duane syndrome, high hyperopia.

Symptoms

  • Crossed eyes, diplopia (older children/adults), head turn/tilt, eye strain, headache, amblyopia risk.

Treatment

  • Refractive correction: Full cycloplegic refraction; glasses for hyperopia.
  • Amblyopia therapy: Patching/atropine if asymmetry.
  • Vision therapy: Convergence exercises (limited evidence for esotropia).
  • Surgery: Medial rectus recession ± lateral rectus resection. Timing: infantile → 6–12 mo; accommodative → if residual deviation after glasses.

Prognosis

Excellent with early intervention. Binocular vision potential highest if aligned <6–8 yrs.

Key Takeaway

Esotropia is inward eye turn; hyperopic correction often resolves accommodative type. Surgery aligns eyes; early treatment prevents amblyopia and preserves stereopsis.

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