What is the treatment for acute esotropia?

Treatment of Acute Esotropia

If acute esotropia presents with neurological signs or symptoms, immediate evaluation and neuroimaging should be performed to exclude intracranial pathology, as studies report underlying neurological disease in up to 10% of cases. 1, 2

Initial Diagnostic Approach

The treatment algorithm depends critically on identifying the underlying etiology:

• Perform cycloplegic refraction immediately to identify significant hyperopia (≥+1.00 D), as this determines whether the esotropia has an accommodative component 3
• Assess for neurological symptoms including headache, cerebellar imbalance, weakness, or nystagmus, which mandate urgent neuroimaging 1, 2
• Measure the angle of deviation at distance and near using prism and alternate cover test to classify the type of esotropia 3
• Evaluate for amblyopia which must be treated before surgical intervention 3

Treatment Based on Etiology

Accommodative Component Present

For patients with accommodative esotropia, prescribe full cycloplegic correction for hyperopia ≥+1.00 D, as eyeglasses or contact lenses alone restore alignment in most cases (high-quality evidence). 3

• Corrective lenses may eliminate the esotropia completely in fully accommodative cases 1
• Partially accommodative esotropia shows improvement but not complete resolution with hyperopic correction 1
• For high AC/A ratio with persistent near esotropia despite distance correction, bifocals or miotics may be considered as supplementary agents 4

Common pitfall: Miotics (phospholine iodide, DFP) are almost never better than glasses alone and carry risk of iris cysts in children; they should only be used as supplementary agents, not primary treatment 4

Nonaccommodative Esotropia Without Neurological Pathology

When no significant refractive error exists or correction provides no improvement, and neurological evaluation is normal:

Surgical intervention is the definitive treatment, with bilateral medial rectus recession recommended when distance deviation exceeds near deviation, achieving 64.5% success rate for three or four horizontal muscle surgery. 3

• Recession-resection procedure is recommended when near deviation is greater than distance deviation 3
• Good motor and sensory outcomes with restoration of binocularity can be achieved in adults with acute acquired comitant esotropia of undetermined etiology 5
• In children, strabismus surgery successfully restores binocular function with resolution of diplopia 2

Alternative Non-Surgical Options

For patients declining surgery or as temporizing measures:

• Prism correction can restore binocular function and has been used successfully in adult cases 5
• Botulinum toxin injection into the medial rectus muscle is an option, though it induces only temporary weakness and requires careful technique to avoid complications including ptosis, vertical deviations, and globe perforation 6, 7, 5

Special consideration: In cases associated with accommodative spasm (spasm of near reflex), cycloplegic medications may resolve the condition but require a longer course of treatment (up to 1 year) for successful resolution and stability 8

Post-Treatment Management

• Monitor post-void residual if botulinum toxin used (not applicable for strabismus, but critical safety information from FDA labeling) 7
• Pain management typically involves non-narcotic analgesics, with many surgeons using combination antibiotic-corticosteroid preparations for the first week after surgery 3
• Assess for recurrence or consecutive exotropia, which may occur and require additional intervention (37.3% success rate for two-muscle surgery on revision) 3
• Follow-up every 6-12 months in well-aligned children without amblyopia, as patients remain at high risk for developing amblyopia or losing binocular vision 3
• Reassess for hyperopia annually or more frequently if visual acuity decreases or esotropia increases 3

Critical Red Flags

Neuroimaging is mandatory when:

• Onset is unclear or truly acute with witnessed sudden change 1, 2
• Any neurological signs or symptoms are present 1
• Headache, cerebellar signs, weakness, or nystagmus accompany the esotropia 2

Important caveat: Acute esotropia in adults is particularly common in myopic individuals and may occur without neurological pathology, but this is a diagnosis of exclusion requiring normal neurological evaluation 1, 5