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Care of the Patient with

Strabismus:

Esotropia and

Exotro ia

OPTOMETRIC CLINICAL

PRACTICE GUIDELINE OPTOMETRY:THE PRIMARY EYE CARE PROFESSION

Doctors of optometry are independent primary health care providers who

examine, diagnose, treat, and manage diseases and disorders of the visualsystem, the eye, and associated structures as well as diagnose related

systemic conditions.

Optometrists provide more than two-thirds of the primary eye care

services in the United States. They are more widely distributed

geographically than other eye care providers and are readily accessible

for the delivery of eye and vision care services. There are approximately

36,000 full-time equivalent doctors of optometry currently in practice inthe United States. Optometrists practice in more than 6,500 communities

across the United States, serving as the sole primary eye care providers

in more than 3,500 communities.

The mission of the profession of optometry is to fulfill the vision and eye

care needs of the public through clinical care, research, and education, all

of which enhance the quality of life.

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OPTOMETRIC CLINICAL PRACTICE GUIDELINE

CARE OF THE PATIENT WITH STRABISMUS:

ESOTROPIA AND EXOTROPIA

Reference Guide for Clinicians

Prepared by the American Optometric Association Consensus Panel

on Care of the Patient with Strabismus:

Robert P. Rutstein, O.D., Principal Author

Martin S. Cogen, M.D.Susan A. Cotter, O.D.

Kent M. Daum, O.D., Ph.D.

Rochelle L. Mozlin, O.D.

Julie M. Ryan, O.D.

Edited by: Robert P. Rutstein, O.D., M.S.

Reviewed by the AOA Clinical Guidelines Coordinating Committee:

David A. Heath, O.D., Ed.M., ChairDiane T. Adamczyk, O.D.John F. Amos, O.D., M.S.Brian E. Mathie, O.D.Stephen C. Miller, O.D.

Approved by the AOA Board of Trustees, June 28, 1995

Revised 1999; reviewed 2004; revised 2010

American Optometric Association, 2011

243 N. Lindbergh Blvd., St. Louis, MO 63141-7881

Printed in U.S.A.

NOTE: Clinicians should not rely on the Clinical

Guideline alone for patient care and management.

Refer to the listed references and other sources

for a more detailed analysis and discussion of

research and patient care information. The

information in the Guideline is current as of the

date of publication. It will be reviewed periodicallyand revised as needed.

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Strabismus: Esotropia and Exotropia v

2. Available Treatment Options ..................................... 31

a. Optical Correction ............................................ 31

b. Added Lens Power ........................................... 32

c. Prisms .............................................................. 33d. Vision Therapy ................................................ 34

e. Pharmacological Agents .................................. 35

f. Extraocular Muscle Surgery ............................ 36

g. Chemodenervation ........................................... 38

3. Management Strategies for Strabismus ..................... 38

a. Accommodative Esotropia ............................... 38

b. Acute Esotropia and Exotropia ........................ 40

c. Consecutive Esotropia and Exotropia .............. 40

d. Infantile Esotropia and Exotropia .................... 41

e. Intermittent Exotropia ...................................... 42

f. Mechanical Esotropia and Exotropia ............... 44

g. Microtropia ...................................................... 44

h. Sensory Esotropia and Exotropia ..................... 45

4. Patient Education ....................................................... 45

5. Prognosis and Follow-up ........................................... 46

CONCLUSION ..................................................................................... 47

III. REFERENCES......................................................................... 48

IV. APPENDIX ............................................................................... 66

Figure 1: Optometric Management of the Patient

with Strabismus: A Brief Flowchart ............................ 66

Figure 2: Frequency and Composition of Evaluation

and Management Visits for Esotropia and Exotropia ... 67

Figure 3: ICD-10-CM Classification of Esotropia

and Exotropia ............................................................. 69Abbreviations of Commonly Used Terms ................................. 71

Glossary ..................................................................................... 72

vi Strabismus: Esotropia and Exotropia

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Statement of the Problem 7

Table 1

Causes of Acute Esotropia and Exotropia

Neoplasm Head trauma Intracranial aneurysm Hypertension Diabetes mellitus Atherosclerosis Hydrocephalus Multiple sclerosis Meningitis/encephalitis Myasthenia gravis Sinus disease Chiari 1 malformation Ophthalmoplegic migraine Chemotherapy

c. Secondary Esotropia

An esotropia that results from a primary sensory deficit or as a result of

surgical intervention is classified as a secondary esotropia.

Sensory esotropia. A convergent strabismus resulting from visualdeprivation or trauma in one eye that limits sensory fusion is

classified as a sensory esotropia. It may result from any number of

8 Strabismus: Esotropia and Exotropia

conditions that limit visual acuity in one eye (e.g., uncorrected

anisometropia, unilateral cataract, corneal opacity, optic atrophy,

macular disease). It occurs most frequently in persons under 5

years of age.18

Approximately 4 percent of those with esotropiahave sensory esotropia.19

Consecutive esotropia. A convergent strabismus that occurs aftersurgical overcorrection of an exotropia, consecutive esotropia is

frequently associated with other oculomotor anomalies (e.g.,

vertical or cyclotorsional deviations). It may result in amblyopia

and loss of normal binocular vision in young children and diplopia

in adults.

d. Microesotropia

When the angle of esotropia is less than 10 PD,it is classified as

microesotropia. This condition often occurs beginning in a child under 3

years of age, and, in some cases, may escape diagnosis by conventional

methods. The esotropia is constant and usually unilateral. The terms

"microtropia," "microsquint," "minitropia," "monofixation syndrome,"

and "small-angle deviation" have been used to describe microesotropia.

2. Exotropia

Exotropia, or divergent strabismus, can be subclassified on the basis of

its comparative magnitude at distance and near or its frequency.20

In basic-type exotropia, the angle of deviation is within 10 PD at distance

and near.

In the convergence-insufficiency type, the angle of deviation at near

exceeds the angle of deviation at distance by at least 10 PD.

Divergence-excess type exotropia occurs when the angle of deviation at

distance exceeds the angle of deviation at near by at least 10 PD.

Although exotropias may be constant or intermittent, most are

intermittent. Children with intermittent exotropia often have the

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Statement of the Problem 17

Table

Clinical Conditions

Condition

Deviation

in Primary

Position Motility Refraction Diplopia

Decompensatedheterophoria

10-20 PD atdistance andnear

Normal Similar to non-strabismic

population

Yes; at distanceand near

Late-onsetaccommodativeesotropia

10-35 PD;may be largerat near

Normal Causative(2-6 D)hyperopia

Yes; usuallymore at near

Abducens nerveor lateral rectus

palsy

20-40 PD;larger atdistance

Abnormal;restrictedabduction inone or botheyes

Similar tononstrabismic

population

Yes; usuallymore at distance

Divergenceparalysis/insufficiency

8-30 PD atdistance;4-18 PD atnear

Normal Similar tononstrabismic

population

Yes; only atdistance

Acute acquiredcomitantesotropia

15-75 PD atdistance andnear

Normal Similar tononstrabismic

population

Yes


2

Presenting as Acute Esotropia

Fusion

Systemic/

Neurologic

Disease Comment

Yes No History of pre-existing esophoriathat has become manifest; can be

provoked by prolonged occlusion orfebrile disease.

Yes No Can be prevented by correctinghigh hyperopic refractive errorduring childhood.

Yes, may

have touse headturn

Frequent Abducens nerve or lateral rectus

palsy should always be suspectedwith acute-onset esotropia.

Yes Sometimes Evidence suggests this strabismusmay be caused by anatomicalchanges in the extraocular muscleswith aging.

Most ofthe time Sometimes Patients with related disease mayalso have poor fusion and otherabnormal ophthalmic findings, suchas nystagmus.

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C l i 47 48 St bi E t i d E t i

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Conclusion 47

CONCLUSION

The optometrist should emphasize the examination, diagnosis, timely andappropriate treatment and management, and careful follow-up of patients

with strabismus. Proper care can result in reduction of personal sufferingfor those involved, as well as a substantial cost savings for persons with

strabismus and their families.


III. REFERENCES

1. Robaei D, Rose KA, Kifley A, et al. Factors associated withchildhood strabismus: findings from a population-based study.

Ophthalmology 2006; 113:1146-53.

2. Tomilla V, Tarkkanen A. Incidence of loss of vision in the healthyeye in amblyopia. Br J Ophthalmol 1981; 65:575-7.

3. van Leeuwen R, Eijkemins MJ, Vingerling JR, et al. Risk ofbilateral visual impairment in individuals with amblyopia: the

Rotterdam study. Br J Ophthalmol 2007; 91:1450-1.

4. Jones RK, Lee DN. Why two eyes are better than one. J ExpPsychol Hum Percept Perform 1981; 7:30-40.

5. Sheedy JE, Bailey IL, Buri M, Bass E. Binocular vs. monoculartask performance. Am J Optom Physiol Opt 1986; 63:839-46.

6. Weissberg E, Suckow M, Thorn F. Minimal angle horizontalstrabismus detectable by lay observers. Optom Vis Sci 2004;

81:506-9.

7. Akay AP, Cakaloz B, Berk AT, Pasa E. Psychosocial aspects ofmothers of children with strabismus. J AAPOS 2005; 9:268-73.

8. Prosser PC. Infantile development: strabismic and normalchildren compared. Ophthalmic Optician 1979; 19:681-3.

9. Tonge BJ, Lipton GL, Crawford G. Psychological and educationalcorrelates of strabismus in school children. Aust N Z J Psychiatry1984; 18:71-7.

10. Dobson V, Sebris SL. Longitudinal study of acuity and stereopsisin infants with or at risk for esotropia. Invest Ophthalmol Vis Sci

1989; 30:1146-58.

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References 63 64 Strabismus: Esotropia and Exotropia

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159. Rosner J, Rosner J. Vision therapy in a primary care practice.New York: Professional Press Books, Fairchild Publications,

1988: 52-5.

160. Repka MX, Beck RW, Holmes JM, et al.; Pediatric Eye DiseaseInvestigator Group. A randomized trial of patching regimens for

treatment of moderate amblyopia in children. Arch Ophthalmol

2003; 121:603-11.

161. Donahue SP. Clinical practice. Pediatric strabismus. N Engl JMed 2007; 356:1040-7.

162.

Scheiman MM, Wick B. Optometric management of infantileesotropia. Probl Optom 1990; 2:459-79.

163. Williams F, Beneish R, Polomeno RC, Little JM. Congenitalexotropia. Am Orthopt J 1984; 34:92-4.

164. Cooper J, Medow N. Intermittent exotropia. Basic and divergenceexcess type. Binoc Vis 1993; 8:185-216.

165. Coffey B, Wick B, Cotter S, et al. Treatment options inintermittent exotropia: a critical appraisal. Optom Vis Sci 1992;

69:386-404.

166. Asjes-Tydeman WL, Groenewoud H, van der Wilt GJ. Timing ofsurgery for exotropia in children. Strabismus 2007; 15:95-101.

167. Ekdawi NS, Nusz KJ, Diehl NN, Mohney BG. Postoperativeoutcomes in children with intermittent exotropia from apopulation-based cohort. J AAPOS 2009; 13:4-7.

168. Hiles DA, Davies GT, Costenbader FD. Long-term observationson unoperated intermittent exotropia. Arch Ophthalmol 1968;

80:436-42.

169. Wick B. Visual therapy for small angle esotropia. Am J OptomPhysiol Opt 1974; 51:490-6.

170. Pratt-Johnson JA, Tillson G. Intractable diplopia after visionrestoration in unilateral cataract. Am J Ophthalmol 1989; 107:23-

6.

References 65 66 Strabismus: Esotropia and Exotropia

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Figure 1

Optometric Management of the Patient With Strabismus:

A Brief Flowchart

Patient history and examination

Assessment and diagnosis

Correct refractive error, if significant

Assess binocular vision status with prescription

No

strabismus

Strabismus remains

Intermittent Constant

Amblyopia No

amblyopiaAmblyopia No

amblyopia

Amblyopia No

amblyopia

Treatamblyopia Monitor

Treat

amblyopiaAdded lenses,prisms,occlusion,

orthoptics/vision therapy.

For largedeviations,surgery may be

needed.

Treat

amblyopia

Fusion

potentialNo fusion

potential

Added lenses,

prisms,occlusion,

orthoptics/visiontherapy.

For largedeviations,surgery may be

needed.

Favorable

cosmesis

No

treatment

Unfavorable

cosmesis

Surgery,

prisms

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Appendix 69 70 Strabismus: Esotropia and Exotropia

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Figure 3

ICD-10-CM Classification of Esotropia and Exotropia

Strabismus and other disorders of binocular eye movements 378

Excludes: nystagmus and other irregular eye movements (379.50-379.59)

Esotropia 378.0

Convergent concomitant strabismus

Excludes: intermittent esotropia (378.20-378.22)

Exotropia, unspecified 378.00

Monocular esotropia 378.01

Monocular esotropia with A pattern 378.02

Monocular esotropia with V pattern 378.03

Monocular esotropia with other noncomitancies 378.04

Monocular esotropia with X or Y pattern

Alternating esotropia 378.05

Alternating esotropia with A pattern 378.06

Alternating esotropia with V pattern 378.07

Alternating esotropia with other noncomitancies 378.08

Alternating esotropia with X or Y pattern

Exotropia 378.1

Divergent concomitant strabismus

Excludes: intermittent exotropia (378.20, 378.23-378.24)

Exotropia, unspecified 378.10

Monocular exotropia 378.11

Monocular exotropia with A pattern 378.12

Monocular exotropia with V pattern 378.13

Monocular exotropia with other noncomitancies 378.14Monocular exotropia with X or Y pattern

Alternating exotropia 378.15

Alternating exotropia with A pattern 378.16

Alternating exotropia with V pattern 378.17

Alternating exotropia with other noncomitancies 378.18

Alternating exotropia with X or Y pattern

Intermittent heterotropia 378.2

Excludes: vertical heterotropia (intermittent) (378.31)

Intermittent heterotropia, unspecified 378.20

Intermittent:

esotropia NOS

exotropia NOS

Intermittent esotropia, monocular 378.21

Intermittent esotropia, alternating 378.22

Intermittent exotropia, monocular 378.23

Intermittent exotropia, alternating 378.24

Other and unspecified heterotropia 378.3

Heterotropia, unspecified 378.30

Monofixation syndrome 378.34

Microtropia

Accommodative component in esotropia 378.35

Mechanical strabismus 378.6

Mechanical strabismus, unspecified 378.60

Appendix 71 72 Strabismus: Esotropia and Exotropia

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Abbreviations of Commonly Used TermsAC/A Accommodative convergence/accommodation

D Diopter

OKN Optokinetic nystagmus

PD Prism diopter

q.d. Daily

Glossary

Accommodative convergence/accommodation (AC/A) ratio The amountof convergence of the eyes due to a unit of accommodative response, which is

the response AC/A ratio. Clinically, the stimulus AC/A ratio is used when theaccommodative response is not objectively measured.

Alternating strabismus The ability of a strabismic individual to hold

fixation with either eye while both eyes are open.

Amblyopia Reduction in best-corrected visual acuity in the absence of any

obvious structural anomalies or ocular disease. It is usually unilateral (as in

unilateral strabismus or with significant anisometropia) or occasionallybilateral (as with high refractive error of both eyes).

Anisometropia A condition of unequal refractive state for the two eyes, one

eye requiring a different lens correction from the other.

Anomalous retinal correspondence Correspondence of subjective

directionalization of the fovea of the fixating eye with an extrafoveal area of

the strabismic eye, occurring in strabismic individuals whose onset is in early

childhood. The condition is usually clinically abbreviated as ARC (foranomalous retinal correspondence) since testing involves retinal locations;

another abbreviation, however is AC with the rationale being that directional

correspondence takes place in the cortex rather than in the eyes.

Comitant The normal condition in which the magnitude of deviation of the

visual axes (heterophoria or strabismus) remains essentially the same in all

positions of gaze and, in cases of strabismus, with either eye fixating.

Comitantis used clinically, but concomitantis the etiologically correct term.

Diplopia A condition in which a single object is perceived as two rather than

one.

Ductions Ability of the eyes to show a full range of motion under monocular

(one-eye) viewing conditions.

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