What is the most appropriate initial management for a 6-month-old infant with esotropia (inward turning of the eye) and a present red reflex?

Urgent Ophthalmology Referral is Required

This 6-month-old infant with esotropia (inward eye deviation) requires urgent referral to a pediatric ophthalmologist, not CT imaging or reassurance. 1, 2

Why Urgent Referral is the Correct Answer

Critical Time-Sensitive Factors

• Infantile esotropia appearing before 6 months of age demands urgent specialist evaluation to preserve binocular vision and prevent irreversible amblyopia 1
• The rapidly developing visual system in infants means delayed treatment is disadvantageous for achieving binocular realignment 1
• Children with infantile esotropia remain at high risk for developing amblyopia and losing binocular vision, making early detection and treatment critical 1, 3

Why CT is Inappropriate

• CT imaging has no role in the initial management of uncomplicated infantile esotropia 1
• The initial management should involve comprehensive ophthalmological examination, including cycloplegic refraction to assess for refractive errors, not neuroimaging 1
• The presence of a normal red reflex bilaterally rules out structural abnormalities like cataracts or retinoblastoma that might warrant imaging 3

Why Reassurance is Dangerous

• While some intermittent eye misalignment during the first 3 months is normal, constant esotropia at 6 months is pathological and requires intervention 1
• Reassurance would delay critical treatment during the sensitive period for visual development 1
• Untreated infantile esotropia carries a 14-16% risk of amblyopia development, with higher risk when anisometropia is present 4

What the Ophthalmologist Will Do

Comprehensive Evaluation Components

• Assessment of deviation magnitude using cover-uncover test, Hirschberg light reflex, or prism testing 1
• Determination of whether the esotropia is constant or intermittent, which influences treatment urgency 1
• Cycloplegic refraction to identify significant hyperopia (≥+1.00 D) that may be driving the esotropia 5, 2
• Amblyopia screening and visual acuity assessment 1

Treatment Algorithm After Referral

First-line treatment: Optical correction with eyeglasses if significant hyperopia (≥+1.00 D) is present, as this is the initial treatment for children with esotropia 5, 2

For accommodative esotropia: Realignment by cycloplegia-determined eyeglasses alone is successful in most cases 5, 2

Surgical intervention: Recommended if the deviation is constant, large, or fails to respond to optical correction 1

• Early surgical correction (before age 2 years) improves sensory outcomes by minimizing the duration of constant esotropia 1, 2
• However, there is no evidence that early surgery improves motor outcomes compared to later surgery 5

Amblyopia treatment: Usually started before surgery because it may alter the angle of strabismus and increase the likelihood of good postoperative binocularity 5, 2

Common Pitfalls to Avoid

• Never delay referral waiting to see if the esotropia resolves spontaneously at this age—the window for optimal visual development is closing 1
• Do not order neuroimaging as the first step unless there are concerning neurological signs beyond isolated esotropia 1
• Avoid initiating patching without specialist evaluation, as the underlying cause (potentially accommodative esotropia) must be identified first 2
• Do not assume alternating fixation means no amblyopia risk—proper assessment requires specialist examination 4

Answer: B - Urgent referral for ophthalmology 1, 2, 3