QUICK REFERENCE GUIDE

Care of the Patient with Strabismus:

Esotropia and Exotropia
American
Optometric
Association
American
Optometric
Association
American
Optometric
Association

A. DESCRIPTION AND CLASSIFICATION

American Optometric Association
Strabismus
is a manifest deviation of the primary

lines of sight of 1 prism diopter (PD) or more. This

misalignment of the eyes can be classified as to:
Direction (convergent, divergent, or vertical)
Deviation equal or varying with the direction of
gaze (comitant or incomitant)
Frequency (constant or intermittent)
Laterality (unilateral or alternating)
Time of onset (congenital or acquired)
Size (large, small, or intermediate)
Involvement of accommodative system
(accommodative or nonaccommodative)
State of vergence
system
(convergence
American
Optometric
Association
insufficiency or divergence excess, divergence
insufficiency or convergence excess, basic
esotropia or basic exotropia)

B. RISK FACTORS
Family history of strabismus, especially siblings
Uncorrected hyperopia and/or high
accommodative-convergence/accommodation
(AC/A) ratio
Unilateral cataract in infants or young children
Multiple handicaps (e.g., Down's syndrome,
cerebral palsy, and craniofacial dysostosis, such
as Apert-Crouzon syndrome)

C. COMMON SIGNS, SYMPTOMS, AND

COMPLICATIONS
Table l lists the signs, symptoms, and complications
of various forms of esotropia and exotropia.

D. EARLY DETECTION AND PREVENTION

Most types of strabismus cannot be prevented.
However, some forms of accommodative esotropia
may be avoided through the early detection and
correction of significant hyperopia.
Infants and
children
suspected
of having
strabismus
American
Optometric
Association
American
Optometric
Association
American
Optometric
Association
should be
examined
immediately.
The
prognosis
for

achieving normal binocular vision is significantly

improved if treatment is not delayed.

E. EVALUATION
American Optometric Association

The evaluation
of a patient with strabismus may
include, but not be limited to:

1. Patient History

General and eye health history

Probable time and nature of onset of strabismus
Deviating eye and frequency of deviation
Change in size of deviation
Family history of strabismus
Presence
orAmerican
absence
ofOptometric
diplopia Association
andAssociation
other visual
American
Optometric
symptoms

Evidence of neurologic, systemic, or

developmental disorders
Prior treatment and results

NOTE: This Quick Reference Guide should be used in conjunction with the Optometric Clinical Practice Guideline on
Care of the Patient with Strabismus (Reviewed 2004). It provides summary information and is not intended to stand
alone in assisting the clinician in making patient care decisions.

Published by:
American Optometric Association 243 N. Lindbergh Blvd. St. Louis, MO 63141

2. Ocular Examination

3. Patient Education

Patients and/or parents should be provided

information about:

Visual acuity
Ocular motor deviation
Monocular fixation
Extraocular muscle function
Sensorimotor fusion
Accommodation (amplitude, facility and
response)
Refraction (cycloplegic and noncycloplegic)
Ocular health assessment

F.
l.

MANAGEMENT
Basis for Treatment

Treatment of strabismus is directed toward four

goals:
Obtaining normal visual acuity in each eye
Obtaining and/or improving fusion
Eliminating any associated sensory adaptations
Obtaining a favorable functional appearance of
eye alignment
2. Available Treatment Options

Optical correction (full or partial)

Added lens power
Prisms
Active vision therapy

Nature of condition and risks of developing

amblyopia and impaired binocular depth
perception
Importance of timely examination and
management to reduce the risk for loss of vision
and fusion and the development of other related
symptoms
Prognosis and advantages and disadvantages of
various modes of treatment.
4. Prognosis and Followup

The prognosis for treatment of strabismus varies

depending on many factors including the specific
type and nature of the condition, age at onset, and
the presence or absence of fusion and amblyopia.
Patient compliance with the prescribed treatment is
also crucial to success of any treatment plan.
Followup evaluations are needed to assess the
patient's response to therapy and to alter or adjust
treatment as necessary. The schedule of followup
visits (Table 2) depends upon the patient's condition
and associated circumstances. These evaluations
should include but are not limited to:
Patient history
Visual acuity

Pharmacological agents

Characteristics of strabismus at distance and

near

Extraocular muscle surgery

Fusion status

Chemodenervation

Extraocular muscle function

Table 2 provides an overview of the evaluation,

management, and treatment options best suited for
each type of strabismus. Indications for and
specific types of treatment may need to be
individualized for each patient.

Refraction
Tolerance, efficacy, and side effects of therapy.

TABLE 1
Common Signs, Symptoms and Complications
Condition

Signs, Symptoms, and Complications

Accommodative Esotropia

Small to moderate (generally 10-35 PD), often variable, angle of deviation

which occurs more frequently at near

Occurs in children with previously normal binocular vision

Due totally or partly to either uncorrected hyperopia and/or a high AC/A
ratio
May be precipitated by a febrile illness

Average amount of hyperopia is 4.75D for normal AC/A ratios and 2.25D
for high AC/A ratios
May have minimal refractive error and esotropia only at near
May report diplopia or closure of one eye during near work

Acute Esotropia or Exotropia

Develops suddenly at any age in persons with previously normal binocular
vision
May result from underlying disease process
Consecutive Esotropia or Exotropia
Occurs after surgical over-correction of an exodeviation or esodeviation

Complications include amblyopia, suppression, and anomalous

correspondence
Esotropia may be associated with decompensated heterophoria, late-onset
accommodative esotropia, abducens nerve palsy, divergence
paralysis/divergence insufficiency, or acute acquired comitant esotropia
Exotropia is usually associated with decompensated exophoria or acquired
ocularmotor nerve palsy
Consecutive esotropia, usually constant and unilateral, is frequently
associated with other oculomotor anomalies (e.g., vertical or cyclo
deviations)
Spontaneous consecutive exotropia may be related to a sensory deficit, weak
binocular function, or excessive hyperopic refractive error (>4.50D)

Begins in neurologically normal children during the first six months of life

Complications include amblyopia, loss of stereopsis, and reduced potential

for normal binocular vision
Infantile esotropia may be associated with a large-angle, constant esotropia
(generally 40-60PD), low hyperopia, amblyopia, and ocular motility
disorders

May be associated with other neurological syndromes or defects

Limited potential for normal binocular vision and good stereopsis

Infantile or Early-acquired Esotropia or Exotropia

Infantile exotropia usually exhibits a large, constant deviation (generally 3080PD) with associated ocular motility disorders

Intermittent Exotropia
Occurs at any age in persons with previously normal binocular vision

Rarely amblyopiogenic because of alternating fixation pattern, but provides

limited potential for normal binocular vision and good stereopsis
Variable periods of strabismus and of normal binocular alignment with good
stereopsis (>60 seconds of arc when fusing)
Significant deviation at one or more fixation distances, becoming more
apparent when patient is fatigued, or after prolonged dissociation
Minimal or no amblyopia
Reduced positive fusional vergence amplitudes and facility
Reports of discomfort during or following prolonged visual activity, closing
one eye in bright sunlight
Diplopia or suppression

Mechanical Esotropia or Exotropia

Associated accommodative dysfunction

Minimal esotropia or exotropia in primary position

Occurs at any age in persons with previously normal binocular vision

Increased deviation in right or left gaze

Caused by a mechanical restriction or a physical obstruction of the

extraocular muscles or adjacent structures

Restricted horizontal versions and ductions

Microtropia
Occurs in children under 3 years of age
Results from a primary sensory deficit or treatment of a larger angle
esotropia or exotropia
May occur idiopathically or secondary to anisometropia
Sensory Esotropia or Exotropia
Esotropia occurs most frequently in persons <5 years of age; exotropia
predominates in persons >5 years of age
Results from a unilateral decrease in vision that limits or disrupts sensory
fusion (e.g., uncorrected anisometropia, unilateral cataract, trauma)

Frequent compensatory head turns

Absence of amblyopia
Constant and usually unilateral esotropia or exotropia of <10PD
May exhibit amblyopia, eccentric fixation, anomalous correspondence,
deficient stereopsis, and anisometropia

Constant unilateral esotropia or exotropia

High degrees of anisometropia
Vertical deviations associated with overaction of oblique muscles
Complications include amblyopia, loss of stereopsis, and limited potential
for normal binocular vision

TABLE 2*
Frequency and Composition of Evaluation and Management Visits for Esotropia and
Exotropia
Type of Patient

Frequency of
Evaluation**

Treatment Options

Management Plan

Accommodative
esotropia

<6 years: every 4-6 mo

6-10 years: every 6-12 mo
>11 years: every 12 mo

Optical correction
Vision therapy

Provide refractive correction; treat any

amblyopia; use added plus at near if needed
to facilitate fusion; prescribe vision therapy
to develop/enhance normal sensory and
motor fusion.

Acute esotropia and

exotropia

Every 3-12 months

Prisms
Vision therapy
Surgery

Use prisms to eliminate diplopia and reestablish binocular vision; prescribe vision
therapy; in stable deviations over 20-25 PD,
consult with ophthalmologist regarding
extraocular muscle surgery.

Consecutive esotropia
and exotropia

Variable, depending on
etiology

Optical correction
Prisms
Vision therapy
Surgery

Provide refractive correction; prescribe prism

and/or vision therapy to prevent amblyopia,
eliminate diplopia, and establish normal
sensory fusion, if applicable.

Infantile or earlyacquired esotropia or

exotropia

<2 years: every 3 mo

2-5 years: every 4-6 mo
6-10 years: every 12 mo
>11 years: every 12-24 mo

Optical correction
Prisms
Vision therapy
Surgery

Provide refractive correction; treat any

amblyopia; use prism to establish normal
sensory fusion, if applicable; consult with
ophthalmologist regarding extraocular muscle
surgery.

Intermittent exotropia

<5 years: every 4-6 mo

5-10 years: every 6-12 mo
>11 years: every 12-24 mo

Optical correction
Prisms
Vision therapy
Surgery

Provide refractive correction; use added

minus lens power or base-in prism if needed
to facilitate fusion; prescribe vision therapy;
if deviation persists or increases, consult with
ophthalmologist regarding extraocular muscle
surgery.

Mechanical esotropia or
exotropia

Variable, depending on
etiology

Prisms
Surgery

No therapy if strabismus is not present in the

primary position of gaze and no diplopia.
Consider prisms and/or surgery to treat head
turn.

Microtopia

Every 3-12 months

Optical correction
Prisms
Vision therapy

Provide refractive correction; treat any

amblyopia; prescribe vision therapy and/or
prism to establish bifoveal fusion, if
applicable.

Sensory esotropia or
exotropia

Every 3-12 months

Optical correction
Prisms
Vision therapy
Surgery

Consult with ophthalmologist regarding

treatment of any underlying ophthalmic
disease; provide refractive correction; treat
any amblyopia; prescribe vision therapy
and/or prism, if applicable; if deviation
persists or increases, consult with
ophthalmologist regarding extraocular muscle
surgery.

Adapted from Figure 2 in the Optometric Clinical Practice Guideline on Care of the Patient with Strabismus: Esotropia and Exotropia

** Vision therapy would require additional visits.