Acta Scientific Ophthalmology (ISSN: 2582-3191)
Volume 5 Issue 12 December 2022
Case Report
Why Plus not Minus - A Case Report on Refractive Accommodative Esotropia
Raisul Azam1*, Eram Khan2 and Yusra Shuaib3
Received: November 23, 2022
1
Faculty, Laxmi College of Optometry, Panvel, India
Published: November 25, 2022
2
Assistant Professor, Chandigarh University, Chandigarh, India
© All rights are reserved by Raisul Azam., et
3
PG Student, Jamia Hamdard, New Delhi, India
al.
*Corresponding Author: Raisul Azam, Faculty, Laxmi College of Optometry, Panvel,
India.
DOI: 10.31080/ASOP.2022.05.0600
Abstract
Accommodative Esotropia is the type of deviation of eyes or squint which is basically due to accommodation reflex. There are
various types of accommodative depending upon different parameter’s such as refractive error, amount and type of squint, age, AC/A
ratio and utmost important refraction and vision with follow ups. Considering these factors practitioner can get to the right diagnosis
and can start the right treatment having good improvement in vision as well as decrease in the ocular deviations. In Refractive
accommodative esotropia giving full cycloplegic treatment is one of the best treatments for better improvements in vision. Follow up
of patient can also lead us to the correct diagnosis in early case we can get confused between refractive accommodative esotropia and
infantile esotropia, one with a follow ups can lead us if the deviation or the amount of squint decreases or gets ortho with spectacles
we can diagnose the case with Refractive accommodative esotropia and if the deviation remains with glasses and without glasses
we can diagnose it with infantile esotropia, in which surgery is the only treatment options for that. So a correct and diagnosis and a
correct treatment can give a good results.
Keywords: Accommodation; Accommodative Esotropia; Refractive Accommodative Esotropia
Introduction • In older children, it might be related to diplopia, but it later
The term “accommodative esotropia” refers to an eye vanishes as a suppression.
convergence deviation brought on by the accommodation reflex.
Refractive accommodative Esotropia
More than half of all childhood esotropias are caused by it [1].
Uncorrected hyperopia, accommodative convergence, and
It can be classified into 3 forms: (1) refractive, (2) non-refractive, inadequate fusional divergence are the three elements that make
and (3) partially accommodative or decompensated. up the mechanism. Uncorrected high hyperopia causes greater
convergence because of which the accommodative effort to create
All three versions share the following traits: a clean retinal image. Esotropia develops if the patient’s fusional
• Onset typically occurs between 6 months and 7 years of age, divergence is weak and easily corrected. If fusional divergence
with a 2.5-year average. amplitudes are small or if sensory variables affect motor fusion,
• Initially intermittent, then with time becoming consistent poor fusional divergence may result. Despite having lower degrees
of hyperopia, patients with substantial anisometropia run the risk
• Usually brought on by trauma or sickness
of developing refractive accommodative esotropia [2].
• Commonly connected to amblyopia
Citation: Raisul Azam., et al. “Why Plus not Minus - A Case Report on Refractive Accommodative Esotropia". Acta Scientific Ophthalmology 5.12 (2022):
44-47.
Why Plus not Minus - A Case Report on Refractive Accommodative Esotropia
45
frequently blame the increased esodeviation on the introduction of
spectacles. This is due to the youngster becoming acclimated to a
much reduced accommodative effort after beginning full-time use
of glasses. However, once the glasses are taken off, the youngster
will have to exert more accommodative effort than they did before
the prescription for glasses, which will result in a larger angle.
Case History
A two-year-old male child came to our pediatric and squint
clinic of Laxmi Eye Institute on Jan 15th, 2022, with a chief complain
of inward movement of the left eye noticed in the last 3 month and
were informed by his parents. The birth history was normal. It was
Figure 1: Pathophysiology of Refractive Accommodative
a full-term Cesarean delivery and the birth weight at the time of
Esotropia.
birth was 3000 Gram. There was a history of immediate cry. And the
developmental milestone was also normal. On ocular Examination,
In most cases, acquired intermittent or persistent esotropia
unaided vision was “follow and fixate to light “in both eyes and on
precedes the development of refractive accommodative esotropia.
dry retinoscopy we got +5.00 D Spherical in both eyes and in Wet
Although children between the ages of 2 and 3 are most affected,
Retinoscopy we got +7.00 D spherical. On subjective refraction we
refractive accommodative esotropia can occasionally affect infants
gave the full cycloplegic refraction on first visit. It is shown Table 1.
as young as 1 year old. The child’s eyes are sometimes straight,
In torch light examination everything was within normal limits as
according to the parents, but when they are sleepy or trying to
shown in Table 2.0.
focus up close, one or both child’s eyes may cross inward. Younger
children may first exhibit increased rubbing or squinting of the Vision and refraction
eyes. Children who are older may express asthenopia symptoms
including headaches or diplopia. The average cycloplegic refractive Vision and Refraction Right eye Left eye
error in refractive accommodative esotropia is +4.75 D, the most Unaided FFL FFL
effective cycloplegic is cyclopentolate, however in patients with Dry retinoscopy +5.00DSPH +5.00DSPH
dark irides, atropine, which has a longer acting cycloplegic action,
Cyclo retinoscopy +7.OODSPH +7.OODSPH
may be needed. But ranges between + 1.5 and +7.0 D [3].
Acceptance +7.00DSPH +7.OODSPH
Treatment Table 1: Vision and Refraction.
The mainstay of treatment is spectacle correction in refractive
Torch light examination
accommodative esotropia. The full hyperopic correction based
on the cycloplegic refraction is initially prescribed. This is true
Torch light examination
for both refractive variants of accommodative esotropia with
Right eye Left eye
juvenile and infantile onsets [4]. There is some urgency in starting
Anterior
treatment because delaying it could lead to fusion ability loss, Within normal limit Within normal limit
segment
amblyopia development, and stereopsis loss [5]. There are two
IOP Dig n Dig n
significant parental counselling points: It is necessary to wear
Lens Clear Clear
glasses all the time. When children use glasses just occasionally,
their accommodation is never totally relaxed, and their vision Posterior
Within normal limit Within normal limit
segment
becomes hazy if they return to wearing their hyperopic glasses
Cup Disc Ratio 0.2: 1 0.2: 1
on a regular basis. Esotropia will worsen when the youngster
is not wearing glasses following the start of sight correction. Table 2: Torch Light Examination.
Appropriate counselling is crucial prior to therapy because parents
Citation: Raisul Azam., et al. “Why Plus not Minus - A Case Report on Refractive Accommodative Esotropia". Acta Scientific Ophthalmology 5.12 (2022):
44-47.
Why Plus not Minus - A Case Report on Refractive Accommodative Esotropia
46
On squint workup we got that facial symmetry was there as it is for hypermetropia of +1.50 D. They also emphasize the need for a
one of factor for pseudo-Strabismus and the ocular alignment, we subsequent cycloplegic refraction when esotropia is not controlled
got 20-degree left esotropia on Hirshberg corneal reflex test. The by the wearer’s present glasses [7]. According to previous research,
ocular motility was full in all direction. On Modified krimsky test hypermetropia does, on average, start to decline around age 7, but
we got 40 PD of deviation. only little. In this study, the typical infant had hypermetropia of 4.28
D at birth, which rose to 4.93 D at age 7. This child would be over
The plan of management for first visit was to give full optical 11 years old before hypermetropia had once again reached 4.28 D,
correction (Cycloplegic refraction). with a mean annual decline of.17 D after age 7. It seems unlikely
that the hypermetropia would continue to reduce in this typical
The differential diagnosis is Refractive accommodative
youngster in a way that would allow the accommodative esotropia
Esotropia and Infantile Esotropia.
to resolve [8]. These findings suggest that under correcting for
Follow Up 5 months hypermetropia does not result in a quicker reduction. The degree of
hypermetropia present at the time of diagnosis is the most crucial
On follow up the subject was the sub was comfortable with
factor in predicting the resolution of accommodative esotropia.
glasses and there was inward deviation without glass. And we
advised new glasses in view of scratches over glass.
Conclusion
Patient was ortho with glass. As the patient was ortho with glass In patients with congenital esotropia we should rule out
and without glass there was esotropia seen, as our differential whether it is infantile esotropia or accommodative esotropia.
diagnosis say it can be either Refractive accommodative Esotropia We should do all the pre optometric workup to find the right
or Infantile Esotropia. In infantile esotropia the deviation will not diagnosis and can give the possible outcome with the treatment. In
decrease after wearing glass and In infantile esotropia the deviation Accommodative esotropia also we will have to find out which of the
as mostly greater than 40 prism diopter and the refractive error type it is refractive, non-refractive, and partially accommodative
will also be less than +2.5 D in this age group, and if esotropia or decompensated. For this we should have a dilated cycloplegic
reduces with subjective correction and the refractive error is more refraction and calculate AC/A ratio. In non-refractive type we
than +2.5 D then we can conclude that it is a case of Refractive have AC/A ratio high. Then we can give the best treatment so
accommodative Esotropia. that the best visual outcome can come in congenital patients.
Then we suggest giving full refractive correction in refractive
Results and Discussion accommodative esotropia.
The main mistake in treating childhood esotropia is inadequate
Conflict of Interest
management, which can cloud the diagnosis and result in poor
care [6]. When it comes to the initial prescription for glasses or There is no financial interest, or any conflict of interest exists.
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Citation: Raisul Azam., et al. “Why Plus not Minus - A Case Report on Refractive Accommodative Esotropia". Acta Scientific Ophthalmology 5.12 (2022):
44-47.
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Citation: Raisul Azam., et al. “Why Plus not Minus - A Case Report on Refractive Accommodative Esotropia". Acta Scientific Ophthalmology 5.12 (2022):
44-47.
