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Accommodative Esotropia

What is accommodative esotropia?

Accommodative esotropia or refractive esotropia is eye crossing that is caused (partially or wholly) by focusing efforts of the eyes as they try to see clearly. Patients with refractive esotropia are typically farsighted (hyperopic). This means that the eyes must work harder to see clearly, particularly when the object of regard is up close. This focusing effort is called accommodation. The closer an object is to the eye, the greater the amount of accommodation that is required. A side effect of the accommodative effort is convergence or crossing of the eyes. In general, the more farsighted a person is, the greater the amount of effort they must exert and the more likely they are to cross their eyes. However, not all farsighted people will cross - some are more or less sensitive than others to the extra work required to see clearly. Therefore, while two individuals may have the same eye prescription strength, one may cross and the other may have perfectly straight eyes.

How is accommodative esotropia treated?

Initial treatment for accommodative esotropia usually involves the prescription and full-time wearing of eyeglasses or contact lenses to correct the patient’s refractive error (hyperopia) [See figure 1]. By letting the eyeglasses do the work, the eyes can relax their focusing or accommodative effort. In turn, this will reduce the convergence or crossing stimulus and the eyes will straighten as they relax.

Fig. 1 Initial treatment for accommodative esotropia usually involves the prescription and full-time wearing of eyeglasses or contact lenses to correct the patient’s refractive error (hyperopia).

What happens after my child starts wearing glasses?

It is normal for the eyes to continue crossing without the glasses and in fact the crossing may be even more noticeable than it was before your child started wearing glasses. The important matter is whether or not the eyes are sufficiently straight and controlled with the glasses on. Your pediatric ophthalmologist is the best person to judge this and will give you feedback at your follow-up examinations. These follow-up examinations are important not only to monitor the eye crossing, but also to monitor for other associated problems such as amblyopia (vision loss that may affect one or both eyes in young children).

What role does surgery play in accommodative esotropia?

Surgery is only indicated if the eyeglasses fail to straighten the eyes adequately while the glasses are on. In this case, eye muscle surgery (strabismus surgery) may be recommended to further help improve the alignment of the eyes. In general, surgery for refractive esotropia does not eliminate the need for glasses but rather fixes the amount of crossing that is “left-over” when the glasses are on. The eyes will likely continue to cross when the eyeglasses are off and surgery does not replace the need for eyeglasses.

Why do some children with accommodative esotropia require bifocals?

In some cases, children will have particularly excessive amounts of eye crossing (esotropia) when looking at objects up close, such as while reading. This may occur even when wearing the correct glasses to correct their farsightedness (hyperopia) and they may have perfectly straight eyes when looking at objects further away. These children may benefit from making the lower, reading area of the eyeglasses “extra strong” in the form of a bifocal lens.