In a 14‑month‑old infant with congenital unilateral esotropia requiring a +1.50 D correction, what is the appropriate treatment sequence involving full‑time glasses and patching?

Treatment of Unilateral Esotropia with +1.5 D Hyperopia in a 14-Month-Old

Prescribe full-time eyeglasses with the full cycloplegic refractive correction (+1.5 D) immediately, then initiate patching therapy for amblyopia treatment after several weeks of glasses wear, before considering any surgical intervention. 1

Step 1: Immediate Optical Correction (First-Line Treatment)

Begin with full hyperopic correction in eyeglasses as the essential first step. 1, 2

• Prescribe the full +1.5 D correction for the affected eye, as eyeglasses are indicated for ≥+1.00 D of hyperopia in children with esotropia. 1, 3
• The +1.5 D refractive error meets the treatment threshold and creates anisometropia, which is a well-established risk factor for both accommodative esotropia and amblyopia. 1, 3
• Full-time wear is essential—use flexible single-piece frames with head straps or cable temples to ensure compliance in this age group. 1, 3
• Do not under-correct the hyperopia; the goal is to fully neutralize the accommodative stimulus that drives the esotropia. 3

Why Glasses Come First

• Correction of significant refractive errors should be the initial treatment for children with esotropia, before any other intervention. 1, 2
• For accommodative esotropia, realignment by cycloplegia-determined eyeglasses alone is successful in most cases. 1, 2
• Improved alignment after prescribing eyeglasses may take several weeks, so patience is required before assessing response. 1

Step 2: Amblyopia Treatment with Patching

After initiating glasses, begin amblyopia treatment because this 14-month-old with unilateral esotropia is at extremely high risk for amblyopia. 1, 4

Timing of Patching Initiation

• Amblyopia treatment is usually started before surgery because it may alter the angle of strabismus and increase the likelihood of good postoperative binocularity. 1, 2
• Allow 8–18 weeks for the child to adapt to eyeglasses and for refractive correction alone to improve visual acuity before adding patching. 4
• The 14-month age represents a critical window for intervention; treatment success declines as the child ages. 3

Patching Dosage

• For moderate amblyopia (visual acuity 20/40–20/80), prescribe 2 hours daily patching of the non-amblyopic (good) eye. 4
• For severe amblyopia (worse than 20/80), prescribe 6 hours daily patching. 4
• Patching should be combined with at least 1 hour of near-visual activities during the patching period to stimulate the amblyopic eye. 4
• Use direct adhesive patches applied to the skin rather than cloth patches on eyeglass frames, as children can look around cloth patches. 4

Why Patching is Essential

• The unilateral nature of the esotropia places this child at high risk for amblyopia because the brain may suppress the deviated eye's image. 3
• Treatment for amblyopia may improve fusional control and thereby improve postoperative success rates if surgery becomes necessary. 1
• Even in children who begin treatment at ages 3–7 years, substantial visual improvement occurs, but earlier intervention at 14 months offers the best prognosis. 4

Step 3: Monitoring and Reassessment

Schedule follow-up examination 2–3 months after initiating treatment to assess response. 4

• If the esotropia persists despite several weeks of full hyperopic correction, repeat the cycloplegic refraction before considering surgery, as additional hyperopic refractive error may be uncovered. 1
• Monitor for compliance with eyeglass wear; poor motor and sensory outcomes are likely if eyeglass compliance is poor. 1
• Watch for signs of worsening: if the eye turn becomes constant rather than intermittent, or if a head tilt emerges, consider earlier specialist re-evaluation. 4

Step 4: Surgical Consideration (If Needed)

Surgery is reserved for cases where optical correction and amblyopia treatment fail to achieve alignment. 1

• Binocular alignment should be established as soon as possible to maximize binocular potential, prevent or facilitate treatment of amblyopia, and restore normal appearance. 1
• Early surgical correction improves sensory outcomes for infantile esotropia by minimizing the duration of constant esotropia, though there is no evidence that early surgery improves motor outcomes compared with later surgery. 1, 2
• Bilateral medial rectus recessions show higher success rates and lower reoperation rates compared with unilateral surgery for infantile esotropia. 1

Critical Pitfalls to Avoid

• Never initiate patching as the sole initial intervention without first prescribing optical correction; glasses may fully correct accommodative esotropia, making patching unnecessary for alignment (though still needed for amblyopia). 2
• Do not proceed directly to surgery without first attempting optical correction, as this is successful in most cases of accommodative esotropia. 2
• Avoid delaying glasses because the child "seems to see fine"—this allows the amblyogenic stimulus to continue damaging visual development during the critical period. 3
• Do not assume the hyperopia will self-correct with age; while some reduction occurs as the eye grows, the risk of anisometropia-related amblyopia requires active management now. 3

Expected Outcomes

• In children with anisometropic amblyopia, wearing prescribed correction for approximately 18 weeks improves visual acuity by ≥2 lines in ≥66% of cases. 3
• Early correction of hyperopia and astigmatism leads to better development of visual acuity; children corrected before 30 months achieve better outcomes than those corrected later. 5
• The best attainable result of treatment is subnormal binocular vision, which is more likely if infants are aligned by 18 months of age. 6, 7