Moran CORE

Accommodative Esotropia

Title: Accommodative Esotropia
Author: Rachael Lux, OD
Date: 06/30/2025
Keywords/Main Subjects: Strabismus, Eye Misalignment, Pediatric Ophthalmology, Esotropia, Pediatric Strabismus, Accommodative Esotropia
Description of Case: Might include definitions, symptoms, patient medical history, examination, tests, labs, prognosis, treatment, etc

Overview:
Accommodative esotropia is a condition in which an eye turns inward due to excessive accommodation in a hyperopic patient.⁶ It is the most common type of esotropia in children. The condition may or may not involve a high AC/A ratio (accommodative convergence (prism diopters)/accommodation (diopters).⁸ A high AC/A means the esotropia will increase when the patient is accommodating on a near target.^6,8 Most commonly this type of esotropia is first corrected with hyperopic single vision spectacles, but a bifocal may be warranted if there is still an inward turning of the eye when the patient is focusing on a near target. Surgery is considered when esotropia is still present in the full cycloplegic refraction.⁴ Surgery is usually pursued after treatment of associated amblyopia.²

Etiology:
Accommodative esotropia accounts for approximately 50% of pediatric esotropias, with an average onset age of 2.5 years. Accommodative esotropia may be refractive, non-refractive, or partially accommodative.^3,4 Pure refractive accommodative esotropia typically measures between 20-40 pd and is eliminated entirely at both distance and near when wearing a fully cycloplegic refraction.³ If treated properly and in a timely manner, 90% of patients will obtain stereopsis 60 seconds of arc or better.^1,6 Non-refractive accommodative esotropia is also known as “convergence excess esotropia” and will present with little to no misalignment at distance but will have an esotropia of 10- 40 pd when the patient is fixated on a near target.⁴ Convergence excess esotropia must be differentiated from a V-pattern esotropia.⁶ Partially accommodative esotropia is when an esotropia decreases by 10pd or more with full hyperopic correction.⁶ A partially accommodative esotropia has the lowest rate of high-grade stereopsis and binocularity because there is residual esotropia.⁸

Evaluation:
Thorough Case History:

• Has the strabismus been present since birth or shortly after? When did it become more noticeable?
  • Review photographs with family to determine onset/variation
• Is the eye always turned inwards or does it sometimes turn outwards?
• Is it always the same eye, or does it alternate?
• Does the eye turn inward more during certain activities?
• Any difficulty grabbing/reaching for objects?
• Any family history of strabismus?
• Any family history of high glasses prescriptions?

Ocular Alignment:

• Perform cover testing at distance and near
• Does the magnitude of esotropia increase at near?
• Does the magnitude of esotropia at near stay the same or improve if the patient is looking through plus-powered lenses?
• Krimsky and/or Hirschberg testing may be helpful when cover testing is not possible

Stereo Testing

• Obtain stereo acuity, if possible

Retinoscopy

• It is beneficial to compare a dry, non-dilated measurement to a cycloplegic retinoscopy
• Significant hyperopic refraction can be expected

Dilated Fundus Exam

• Rule out any ocular pathology that could be affecting vision
• Alignment could be re-assessed after cycloplegia

Management:
The first step in the treatment of an accommodative esotropia is to prescribe the full cycloplegic refraction.⁶ Alignment typically improves significantly once the hyperopia is corrected in cases with entirely refractive accommodative esotropia.⁴ In patients with convergence excess, there may be a residual esotropia at near despite full hyperopic correction. In these cases, a bifocal should be added.⁵ The bifocal segment should be higher than typical to ensure proper utilization of the ADD power when working at near. Depending on the patient’s AC/A, age, arm length/working distance, and day-to-day activities, the bifocal power may range from +1.00 D up to +3.00 D.⁵
If the visual acuity of the esotropic eye begins to plateau at a lower visual acuity measurement than the dominant eye, there is a concern for amblyopia and decreased binocularity.⁴ At this point, patching of the non-strabismic eye may be initiated at 2 hours/day with 1 hour of near work if visual acuity is better than 20/100 and up to 6 hours/day if worse.² Amblyopia can also be treated with atropine penalization or for patients with only small residual esotropia, newer dichoptic therapies such as Luminopia can be utilized. After the patient is fully corrected in distance or bifocal spectacles, if the esotropia is still present, strabismus surgery may be considered.⁴ Prismatic correction may be considered in these patients if the patient and parents are motivated for a non-surgical option, however, this has been shown to have the highest chance of success if the residual esotropia measures less than 15pd.⁸

References:

1. Berk, A.Tülin et al. Treatment outcomes in refractive accommodative esotropia Journal of the American Association for Pediatric Ophthalmology and Strabismus (JAAPOS), Volume 8, Issue 4, 384 – 388
2. Boniquet-Sanchez S, Sabater-Cruz N. Current Management of Amblyopia with New Technologies for Binocular Treatment. Vision (Basel). 2021 Jun 10;5(2):31. doi: 10.3390/vision5020031. PMID: 34200969; PMCID: PMC8293449.
3. Kothari M, Manurung F, Paralkar S. Use of atropine to predict the accommodative component in esotropia with hypermetropia. Indian J Ophthalmol. 2011 Nov-Dec;59(6):487-90. doi: 10.4103/0301-4738.86319. PMID: 22011495; PMCID: PMC3214421.
4. Olitsky, S. E., Chan, E. W. Farzavandi, S. Strabismus: accommodative esotropia. (2016, January 20). American Academy Ophthalmology. https://www.aao.org/education/disease-review/strabismus-accommodative-esotropia
5. Reynolds MM, Diehl NN, Mohney BG. Outcomes in accommodative esotropia with a high AC/A ratio. Eur J Ophthalmol. 2021 Nov;31(6):3342-3348. doi: 10.1177/1120672120977831. Epub 2020 Dec 24. PMID: 33356527; PMCID: PMC10153757.
6. Rutstein, R. P. Update on accommodative esotropia, Optometry – Journal of the American Optometric Association, Volume 79, Issue 8, 2008, Pages 422-431, ISSN 1529-1839, https://doi.org/10.1016/j.optm.2007.11.011.
7. Sharma P, Tibrewal S, Singh PK, Ganesh S. Efficacy of anti-suppression therapy in improving binocular vision in children with small-angle Esotropia. J Optom. 2024 Jul-Sep;17(3):100490. doi: 10.1016/j.optom.2023.100490. Epub 2023 Dec 6. PMID: 38061140; PMCID: PMC10750105.
8. Sreelatha OK, Al-Marshoudi HA, Mameesh M, Al Zuhaibi S, Ganesh A. Accommodative esotropia: An outcome analysis from a tertiary center in Oman. Oman J Ophthalmol. 2022 Nov 2;15(3):274-278. doi: 10.4103/ojo.ojo_80_22. PMID: 36760956; PMCID: PMC9905885.

Faculty Approval by: Marielle Young, MD
Copyright statement: Rachael Lux, ©2025. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/