In such cases an additional hyperopic correction is often prescribed in the form of bifocal lenses, to reduce the degree of accommodation, and hence convergence, being exerted. Many children will gradually learn to control their esotropias, sometimes with the help of orthoptic exercises. However, others will eventually require extra-ocular muscle surgery to resolve their problems. Congenital esotropia
Congenital esotropia, or infantile esotropia, is a specific sub-type of primary concomitant esotropia. It is a constant esotropia of large and consistent size with onset between birth and six months of age. It is not associated with hyperopia, so the exertion of accommodative effort will not significantly affect the angle of deviation. It is, however, associated with other ocular dysfunctions including oblique muscle over-actions, Dissociated Vertical Deviation (DVD), Manifest Latent Nystagmus, and defective abduction, which develops as a consequence of the tendency of those with infantile esotropia to cross fixate. Cross fixation involves the use of the right eye to look to the left and the left eye to look to the right; a visual pattern that will be natural for the person with the large angle esotropia whose eye is already deviated towards the opposing side. The origin of the condition is unknown, and its early onset means that the affected individuals potential for developing binocular vision is limited. The appropriate treatment approach remains a matter of some debate.
Some ophthalmologists favour an early surgical approach as offering the best prospect of binocularity whilst others remain unconvinced that the prospects of achieving this result are good enough to justify the increased complexity and risk associated with operating on those under the age of one year. Incomitant esotropia
Incomitant esotropias are conditions in which the esotropia varies in size with direction of gaze. They can occur in both childhood and adulthood, and arise as a result of neurological, mechanical or myogenic problems. These problems may directly affect the extra-ocular muscles themselves, and may also result from conditions affecting the nerve or blood supply to these muscles or the bony orbital structures surrounding them. Examples of conditions giving rise to an esotropia might include a VIth cranial nerve (or Abducens) palsy, Duanes syndrome or orbital injury. Diagnosis
Classification
Right, left or alternating
Someone with esotropia will squint with either the right or the left eye but never with both eyes simultaneously. In a left esotropia, the left eye squints, and in a right esotropia the right eye squints. In an alternating esotropia, the patient is able to alternate fixation between their right and left eye so that at one moment the right eye fixates and the left eye turns inward, and at the next the left eye fixates and the right turns inward. This alteration between the left and right eye is mostly spontaneous, but may be voluntary in some cases.