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What is esotropia?

Esotropia is a form of strabismus (eye movement problem) where one or both of the eyes turn inwards toward the nose [See figure 1]. It may come and go or it may be there all the time. Esotropia may show up when focusing close up or far away, or both. The crossing may occur mostly with one eye or may switch back and forth between eyes. Esotropia may show up at any age and is the opposite of exotropia (outward eye turn towards the ear).

Fig. 1: Photo showing esotropia, in-turning of one or both eyes. In this photo the right eye of the child on the left side of the photo is turned in toward the nose.

IS ESOTROPIA EVER ‘NORMAL’?

Esotropia in infants less than 20 weeks (about 4-5 months) old is common and generally goes away on its own, especially when the eye movement problem is small and comes and goes (intermittent). However, constant eye crossing at ANY age is worrisome and that child should be seen by a pediatric ophthalmologist. Concerns about eye crossing should be shared with your pediatrician Any eye crossing (constant or intermittent) beyond 4 months of age should be checked out.

WHAT ARE THE DIFFERENT TYPES OF ESOTROPIA?

Esotropia can come in different forms. Some forms of esotropia start very young (congenital/infantile) while others start later in life (acquired). Some forms of esotropia come and go (intermittent) while others have an eye turn that is present all the time(constant). Some forms get better with glasses (accommodative) while others do not (nonaccommodative). For more specific information, see infantile esotropia and accommodative esotropia. Esotropia can also be caused by other problems. Poor vision can cause eye crossing. Different brain problems (hydrocephalus, stroke, etc.) can cause an eye to turn inward. A number of other medical problems can also cause esotropia (examples:  thyroid eye disease, Duane syndrome).

WHAT PROBLEMS CAN ESOTROPIA CAUSE with vision?

The effect of esotropia on vision depends on the how often the eye crossing happens, how bad the eye crossing is and the age of the person with crossing. Eye crossing makes it hard for the eyes to work together. Older children and adults with a new esotropia often have diplopia (double vision) and/or a problem with peripheral vision (side vision). Children can lose stereopsis (3-D vision) and binocularity (ability to use both eyes together at the same time) in addition to blurry vision or weak vision in the crossing eye (amblyopia).

DOES ESOTROPIA RUN IN FAMILIES?

Eye movement problems or misalignment of the eyes (Strabismus) can run in families. However, affected family members do not always have the same type and/or severity of strabismus. Many times, strabismus happens for people without a  family history.

ARE THERE CONDITIONS THAT INCREASE THE CHANCES OF GETTING ESOTROPIA?

Prematurity, a family history, high hyperopia (far sightedness) and different brain and genetic problems increase the risk of eye movement problems. Also, some other medical problems can have eye movement issues (like hyperthyroidism and diabetes).

DO CHILDREN EVER LOOK CROSS-EYED BUT ACTUALLY HAVE STRAIGHT EYES?

Sometimes children may appear to have esotropia without signs of true crossing on an eye exam. This is usually due to the shape of the eyelids and/or bridge of the eyes [See figure 2].  This problem is called pseudostrabismus. Any child though to have eye movement problems should have a full exam by a pediatric ophthalmologist. Some children can have both pseudostrabismus and an actual eye movement problem. Therefore, pseudostrabismus by itself does not rule out the possibility of true eye crossing.

Fig. 2: Pseudostrabismus is the appearance of, but not truly misaligned eyes. The photo shows a baby with a wide bridge of the nose which makes it look like the eyes are crossed even when they are straight.

HOW DOES A PEDIATRIC OPHTHALMOLOGIST LOOK FOR POSSIBLE ESOTROPIA?

After taking a careful history, the ophthalmologist will check vision and make sure the vision is good and the same in both eyes. Eye movements will be checked and measured for problems. The general health of the eye, as well as  whether or not the eyes need glasses to focus (for example: farsightedness, nearsightedness, astigmatism) is  checked.  Signs of brain problems or tumors, are also ruled out.

WHAT TREATMENTS ARE THERE FOR ESOTROPIA?

Treatment of esotropia is based on specific goals:

• getting the eyes to be as straight as possible
• getting the most binocular vision or use of both eyes together at the same time
• Improving double vision 
• Treatment of amblyopia (weak vision)

Treatments used to make the eyes straight include glasses (sometimes with prism or bifocal), patching, strabismus surgery (eye muscle surgery), and botulinum toxin/Botox (less commonly) or a combination of the above.

For more scientific information about esotropia see: https://eyewiki.org/Esotropia

Updated 03/2023

#Conditions

Print Version


What is esotropia?

Esotropia is a form of strabismus (eye misalignment) characterized by an inwards turn of one or both eyes [See figure 1]. It may be intermittent or constant and may occur with near fixation, distance fixation, or both. The crossing may occur mostly with one eye or may alternate between eyes. Esotropia may occur at any age and is the opposite of exotropia (outward eye turn). Fig. 1: Esotropia is in-turning of one or both eyes.

Fig. 1: Esotropia is in-turning of one or both eyes.

Is esotropia ever ‘normal’?

Esotropia in infants less than 20 weeks old frequently resolves on its own, especially when the misalignment is intermittent and small in degree. However, constant eye crossing at ANY age should be evaluated promptly by a pediatric ophthalmologist. Any eye crossing (constant or intermittent) beyond 4 months of age should be evaluated.

What are the different types of esotropia?

Esotropia can be classified by age of onset (congenital/infantile vs. acquired); by frequency (intermittent vs. constant); or by whether it can be treated with glasses (accommodative vs. nonaccommodative). For more specific information, see infantile esotropia and accommodative esotropia. Esotropia can also be due to other conditions. Poor vision can cause eye crossing. Various neurological conditions (hydrocephalus, stroke, etc.) can cause an eye to turn inward. A number of medical conditions can cause esotropia (thyroid eye disease, Duane syndrome, etc.).

What problems can esotropia cause?

The effect of esotropia on the visual system depends on the frequency/severity of eye crossing and age. Eye crossing affects the ability of the eyes to work together. Older children and adults with a new onset esotropia often experience diplopia (double vision) and/or a decreased field of vision.  Children can lose stereopsis (3-D vision) and binocularity (simultaneous use of the eyes) in addition to loss of vision in the crossing eye (e.g. amblyopia).

Does esotropia run in families?

Eye muscle problems or misalignment of the eyes (Strabismus) can run in families. However, affected family members do not necessarily share the same type and/or severity of strabismus. A family history of strabismus is an indication to be seen by a pediatric ophthalmologist. Are there conditions that increase the risk of esotropia?

Prematurity, a positive family history, and various neurological and genetic disorders increase the risk of eye misalignment. Also, some systemic disorders cause ocular misalignment (hyperthyroidism, diabetes, etc.).

Are there conditions that increase the risk of esotropia?

Prematurity, a positive family history, and various neurological and genetic disorders increase the risk of eye misalignment. Also, some systemic disorders cause ocular misalignment (hyperthyroidism, diabetes, etc.).

Do children ever look crossed eyed but actually have straight eyes?

Occasionally children may appear to have esotropia without evidence of true crossing.  This is usually due to the shape of the eyelids and/or nasal bridge [See figure 2].  These children have pseudostrabismus. Any child suspected of having ocular misalignment should have a thorough examination by a pediatric ophthalmologist. Some children can have both pseudostrabismus and an actual eye misalignment. Therefore, pseudostrabismus by itself does not eliminate the possibility of true eye crossing. Fig. 2: Pseudostrabismus is the appearance of, but not truly misaligned eyes.

Fig. 2: Pseudostrabismus is the appearance of, but not truly misaligned eyes.

How does a Pediatric Ophthalmologist evaluate a child with suspected esotropia?

After taking a careful history, the physician assesses the visual acuity in a manner appropriate for age. A key component is to determine whether the acuity is equal in each eye or if one eye is stronger than the other. Ocular misalignment, if detected, is quantified. The general health of the eye, as well as the refractive state of the eye (ie. farsightedness, nearsightedness, astigmatism) is assessed.  More occult causes of esotropia, such as an eye tumor or neurologic origin, are also ruled out.

What are the treatment options for esotropia?

Management of esotropia is based on a number of factors. The overriding principles are:

• Re-establishment of ocular alignment
• Maximization of binocular vision
• Relief of diplopia
• Treatment of associated amblyopia

Treatment modalities used to realign the eyes include spectacles (sometimes with prism or bifocal), patching, strabismus surgery (eye muscle surgery), and botulinum toxin (less frequently utilized).

Updated 10/2019

#Conditions