Treatment of Monocular Absolute and Esotropia Absolute Low
The primary treatment for monocular absolute and esotropia absolute low involves surgical correction, with the specific approach depending on the angle of deviation and patient characteristics. 1
Diagnostic Evaluation
- Before initiating treatment, a comprehensive strabismus evaluation should be performed to confirm the diagnosis and establish baseline status 1
- Assessment should include:
Treatment Algorithm
1. Correction of Refractive Errors
- Correct any significant hyperopia with eyeglasses, generally prescribing for +1.00 D or more in a child with esotropia 1
- Full cycloplegic correction is typically recommended initially 1
- For patients with accommodative esotropia, eyeglasses or contact lenses alone may restore alignment in most cases 1
2. Surgical Management
For non-accommodative or partially accommodative esotropia:
For large-angle esotropia:
- Bilateral approach: Bilateral medial rectus recession when the distance deviation exceeds the near deviation 1
- Unilateral approach: Recession-resection procedure (lateral rectus recession and medial rectus resection) when the near deviation is greater than the distance deviation 1
- Supramaximal recession and resection may be considered for very large angles (≥65 prism diopters) 2
For monocular esotropia with poor vision in one eye:
Surgical considerations:
- Recent evidence shows no significant difference in outcomes between bilateral medial rectus recession and unilateral recess-resect procedures 1
- Three or four horizontal muscle surgery may provide better results (64.5% success) than two-muscle surgery (37.3% success) for large-angle congenital esotropia 4
3. Post-Surgical Management
- Monitor for immediate post-surgical esotropia, which may cause diplopia but is often temporary 1
- If consecutive esotropia persists for several weeks, temporary membrane prisms with gradually reduced power may be helpful 1
- When prism therapy is unsuccessful, additional surgery may be required 1
- Pain management typically involves non-narcotic analgesics 1
- Many surgeons use a combination antibiotic-corticosteroid preparation for the first week after surgery 1
Follow-up Care
- Regular follow-up is essential as patients remain at high risk for developing amblyopia, losing binocular vision, or experiencing recurrence 1
- Children who are well-aligned without amblyopia should be followed every 6-12 months 1
- As the child matures, follow-up frequency can be reduced 1
- Assess for hyperopia at least annually, or more frequently if visual acuity decreases or esotropia increases 1
Special Considerations
- Early surgical correction may improve sensory outcomes for infantile esotropia by minimizing the duration of constant esotropia 1
- Untreated early-onset esotropia may have a lower incidence of amblyopia (15%) compared to conventionally treated cases (80%), though this must be balanced against other benefits of treatment 5
- Amblyopia treatment should generally precede surgery as it may alter the angle of strabismus and increase the likelihood of good postoperative binocularity 1
- Patients with the monofixation syndrome (small-angle constant esotropia with overlying variable esophoria) require careful management, as patching for amblyopia may cause breakdown to a large esotropia 6
Potential Complications
- Parents should be advised about risks of postoperative complications, especially orbital cellulitis and slipped or lost muscle 1
- Recurrence of esotropia or consecutive exotropia may occur and require additional intervention 1
- Long-term results after bilateral lateral rectus recession show recurrence is common despite good initial alignment 1