International Journal of Health Sciences and Research Vol.10; Issue: 12; December 2020 Website: www.ijhsr.org Case Report ISSN: 2249-9571

Refractive Accommodative Esotropia: Case Report

Vinitkumar Kamble1, Bhadra Priya1, Satbodh Shrestha2, Arbind Ray3

1Resident, RIO (Ophthalmology), IGIMS Medical College, Patna (Bihar) 2Ophthalmologist, Sagarmatha Choudhary Eye Hospital, (SCEH), Lahan 3Optometry Student, Dr R P Centre AIIMS, New Delhi

Corresponding Author: Vinitkumar Kamble

ABSTRACT

Accommodative esotropia is the popular childhood form of ocular misalignment and has an enthusiastic sequel if management is beginning on time. Here we have single case report reviews a composite presentation of accommodative esotropia and describes the treatment choices.

Keywords: accommodative, abnormal head posture, esotropia, refractive

INTRODUCTION assessed using CSM (central, steady, A 3 -year-old male child, presented maintained) method. to Paediatric eye department at RIO, IGIMS Patient was noticed to have identical Medical College, Patna. The patient’s fixation design with either eye and did not mother was concerned that her son’s eyes resist for occlusion of each eye. Sensory were turning in and he had a no face turn or tests were not performed due to the child is chin elevation. Mother also told that her son non understanding of the Titmus Fly test had never worn glasses or received any type and Worth 4-dot tests. Pupils were equal, of treatment for the eye turn. The patient’s round, reactive and no afferent pupillary medical history was first child, born in the defect was noted. hospital with full term normal vaginal The child had a no head turn. We delivery without complication. Past surgical demonstrated an 80-prism dioptre history was non-significant. Family history intermittent esotropia at distance and near in shows no known strabismus or inherited eye primary gaze position another gaze position condition. He is not currently on any was difficult to determine because of medications. Patient had presented to the uncooperative child. No alphabet pattern paediatric department six months previously squint was found in primary gaze and for a routine eye exam. At that time extraocular movements were full in all gaze. refractive error was documented as being Cycloplegia was accomplished using 1% within normal limits for her age, no cyclopentolate. Post-cycloplegia heterotropia was noted at distance or near, retinoscopy found +3.00 DS OD and +4.00 and a no abnormal head posture was DS OS. Anterior segment was within noticed. normal limit. Examination: A thorough eye exam Dilated fundus exam was within was performed. Due to his age and limited normal limit. Differential diagnosis understanding several standardized tests considered in our case which includes sixth were unable to be performed. cranial nerve palsy, essential infantile Best-corrected visual acuity by esotropia or congenital esotropia, Type I Snellen optotype was unable to be Duane’s retraction syndrome and refractive measured, therefore fixation response was or non-refractive accommodative esotropia.

International Journal of Health Sciences and Research (www.ijhsr.org) 117 Vol.10; Issue: 12; December 2020 Vinitkumar Kamble et.al. Refractive accommodative esotropia: case report.

Cranial nerve sixth (CN VI) palsy Therefore, child was tentatively should be ruled out because intermittent, diagnosed with a refractive accommodative alternate pattern of esotropia was present esotropia. Accommodative esotropia is with no abnormal head posture and negative identified by a convergent variance of the forced duction test. This diagnosis is eyes consorted with rousing of the classified with an abduction deficit that can accommodative reflex. (3) This type of sometimes elicit a head turn to compensate strabismus usually presents between 6 for the paretic lateral rectus muscle (1). Other months and 7 years of age; average onset is additional signs of a CN VI palsy include an 2.5 years old. (3) Treatment in our case esotropia that is greater when measured at scenario included the full cycloplegic distance than near and is larger in spectacle prescription for full time wear and magnitude when a patient is gazing into the he was scheduled for a follow up in two field of the paretic muscle. (1) months. In children, a cranial nerve sixth palsy can be triggered by a viral infection, DISCUSSION vaccine administration or trauma. (1) Child Accommodative esotropia is the most common form of all childhood mother reported he was negative for all of (4) these forerunners. Another differential strabismus and can be divided into two diagnosis to consider would be infantile, or types (1) refractive (fully accommodative and partly accommodative) (2) congenital, esotropia. This idiopathic (2) condition presents in an infant by the age of nonrefractive (convergence excess and 3 to 6 months with approximately 1-2 hypo accommodative convergence excess) dioptres of hyperopia. (2) It is associated Refractive accommodative esotropia with a positive family history of strabismus, reveal the same prism dioptre angle of inferior oblique overaction, dissociated squint at both near as well as distance vertical deviation and a large angle of without glasses rectification. The beginning deviation, usually larger than 30 prism of accommodative esotropia mostly starts at (2) the age of two to three, but has been dioptres. (5) In our case report child did exhibit a observed in child of 4 months old . The refractive error of these children averages + larger angle of esotropia, the onset of (3) strabismus is well beyond the age of 6 4.75 dioptres . The mechanism behind months, which we can confirm from her accommodative esotropia consists of three prior eye examination six months before components: under correction of the hyperopia, accommodative convergence, when no strabismus was detected. (3) Duane syndrome (DRS) type I is and insufficient fusional divergence. An characterized by the patient having the uncorrected hyperope is forced to inability to abduct and type III is associated accommodate excessively to produce a clear with poor abduction and adduction of the retinal image. In the presence of same eye. (2) Most commonly Duane accommodation, convergence is stimulated syndrome presents unilaterally and can have requiring the patient’s fusional divergence an associated palpebral fissure narrowing system to react. If the child has a deficient and globe retraction concurrent with fusional divergence working and cannot (2) reimburse for the convergence factor, an attempted or actual adduction . Patients of (2) DRS have no squint in primary position, esodeviation will happened . The treatment for a child is their full cycloplegic but in some cases, AHP of small angle (2,3) found to assist recoup their incapacity to hyperopic spectacle correction. This will abduct or adduct. We ruled out DRS due to reduce the load of accommodation needed the fact that child had no ocular motility to fine their retinal image, which in turn will restrictions in any field of gaze with no keep the exact eye alignment. palpebral fissure narrowing.

International Journal of Health Sciences and Research (www.ijhsr.org) 118 Vol.10; Issue: 12; December 2020 Vinitkumar Kamble et.al. Refractive accommodative esotropia: case report.

If a patient has a residual hyperopic correction which is calculated esodeviation even with their full hyperopic from wet retinoscopy. A large amount of glass correction, the residual deviation is delay in early treatment following esotropia nonaccommodative and is classified as rises the likelihood of nonaccommodative partially accommodative. Partial factor which is called as partially accommodative esotropia commonly occurs accommodative esotropia which is defined because the accommodative treatment by Mulvihill et al (9) in 2000. If there is any needed for an accommodative esotropia was associated amblyopia the treatment should delayed. (2) be started to address this issue. In few patients of esotropia accommodative factor has been removed TREATMENT with the corrective glasses, but after some Patient was given the full period the non-accommodative factor cycloplegic hyperopic correction so that the steadily becomes exposed. These patients’s disparity of refractive and partially treatment may include a surgical accommodative esotropia could be made at management. (3) Hutchinson et al (7) in 2004 her follow up visit. If ocular alignment suggest that roughly 77% of child with through the spectacle prescription is accommodative esotropia have a first or orthophoria the conclusion can be made that second degree relative with same state. First her esotropia is purely refractive degree relatives alone, the prevalence of component. accommodative esotropia is 23%, so it is Berk et al in 2004 explained that if essential to have siblings examined. These the beginning of ocular misalignment is esotropia are commonly associated with after two years of age, then many patients of amblyopia. Generally, in Refractive accommodative esotropia the prognosis has (8) been good due to some form of developing accommodative esotropia the deviation is (5) between 23 and 30 PD which is constant for fusion ability. Amblyopia is a common distance and near. The average amount of associated finding to be monitored for at our hyperopia is +3 up to +10 D. The main aim follow up visit, mainly since her refractive of treating this eye position are to replace error is positive for anisometropia. With normal eye alignment, to keep up good accommodative esotropia, anisometropia visual acuity in each eye and assist good was found to be the only statistically significant risk factor for the development binocular function. Management consists of (5) giving spectacle correction with full of amblyopia.

Picture A Picture B Picture C

Picture D Picture E Picture F

International Journal of Health Sciences and Research (www.ijhsr.org) 119 Vol.10; Issue: 12; December 2020 Vinitkumar Kamble et.al. Refractive accommodative esotropia: case report.

Picture A, B, C shows a periodically D, E, F shows photo of ocular alignment alternate esotropia. We did a cycloplegic after wearing glass which is diagnosed as refraction and advice full correction. Picture refractive accommodative esotropia.

Image A Image B Image C

Image D Image E

Second patient a five years old take into consideration the child’s refractive female with alternate convergent squint. We error, binocular status, and accommodative performed a cycloplegic refraction. Image function in diagnosing each individual A, B, C shows a periodically alternate patient so that treatment can be initiated as esotropia. We did a cycloplegic refraction early as possible. with +4.00 D sphere in both eyes. We advise full correction. Image D, E shows Manuscript presented in other meetings orthophoria after wearing glass. or conference: No Financial support: Nil. CONCLUSION Conflict of interest: None. It is important to differentiate between the aetiologies of paralytic and REFERENCES non-paralytic esotropias so that proper 1. Ehlers JP, Shah CP, eds. The Wills Eye th management can be initiated. Manual. 5 Ed. Baltimore: Lippincott Accommodative esotropia has a favourable Williams & Wilkins, 2008. prognosis if treatment is introduced early. 2. American Academy of Ophthalmology. Pediatric Ophthalmology and Strabismus: Management consists full correction of the Basic and Clinical Science Course. San hypermetropia which is diagnosed after Francisco: AAO, 2011-2012. cycloplegic refraction due to the main 3. Nelson LB, Olitsky SE, eds. Harley’s central factor of hyperopia was found in this Pediatric Ophthalmology. 5th Ed. condition. If it is not clear if the aetiology of Philadelphia: Lippincott Williams & the esotropia is non-accommodative, Wilkins, 2005. accommodative, or partial, the initial 4. Mohney BG. Common Forms of Childhood treatment should seek to correct any amount Esotropia. Ophthalmology 2001; 108: 805– of hyperopia found before other treatment 809. options are considered. It is important to

International Journal of Health Sciences and Research (www.ijhsr.org) 120 Vol.10; Issue: 12; December 2020 Vinitkumar Kamble et.al. Refractive accommodative esotropia: case report.

5. Berk AT, Kocak N, Ellidokuz H. Treatment San Francisco: American Academy of Outcomes in Refractive Accommodative Ophthalmology, 2010-2011; 93-95 Esotropia. Journal of AAPOS. 2004;8. 9. Mulvihill A, MacCann A, Flitcroft I, 6. Kanski, JJ. Clinical Ophthalmology: A O’Keefe M. Outcome in refractive Systemic Approach. 6th Ed. Edinburgh: accommodative esotropia. Br J Butterworth Heinemann Elsevier, 2007 Ophthalmology 2000; 84(7): 74 7. Hutcheson KA, Childhood esotropia. Curr Opin Ophthalmol 2004;15(5):444-448 How to cite this article: Kamble V, Bhadra 8. “Refractive Accommodative Esotropia” in Priya, Satbodh Shrestha et.al. Refractive Chapter 7; Esodeviations. Basic and accommodative esotropia: case report. Int J Clinical Science Course; Section 6. Health Sci Res. 2020; 10(12):117-121. Paediatric Ophthalmology and Strabismus.

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International Journal of Health Sciences and Research (www.ijhsr.org) 121 Vol.10; Issue: 12; December 2020