Where the degree of hyperopia is large, the child  may not be able to produce clear vision no matter how much extra-accommodation is exerted and thus no incentive exists for the over-accommodation and convergence that can give rise to the onset of esotropia. However, where the degree of error is small enough to allow the child to generate clear vision by over-accommodation, but large enough to disrupt their binocular control, esotropia will result. Only about 20% of children with hyperopia greater than +3.5 diopters develop strabismus.Where the esotropia is solely a consequence of uncorrected hyperopic refractive error, providing the child with the correct glasses and ensuring that these are worn all the time, is often enough to control the deviation. In such cases, known as fully accommodative esotropias, the esotropia will only be seen when the child removes their glasses. Many adults with childhood esotropias of this type make use of contact lenses to control their squint. Some undergo refractive surgery for this purpose. A second type of accommodative esotropia also exists, known as convergence excess esotropia. In this condition the child exerts excessive accommodative convergence relative to their accommodation. Thus, in such cases, even when all underlying hyperopic refractive errors have been corrected, the child will continue to squint when looking at very small objects or reading small print. Even though they are exerting a normal amount of accommodative or focusing effort, the amount of convergence associated with this effort is excessive, thus giving rise to esotropia.
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.