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Esotropia is a type of strabismus or eye misalignment. In esotropia, the eyes are "crossed"; that is, while one eye looks straight ahead, the other eye is turned in toward the nose. This inward deviation of the eyes can begin in infancy or later in childhood.
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Pseudoesotropia refers to the appearance of crossed eyes in a child whose eyes are actually perfectly aligned in relation to each other. This is common in infants and younger children who have a broad, flat bridge of the nose which allows the skin on the inner part of the eyelids to extend over and cover the inner part of the eye. The sclera (the white part of the eye) closest to the nose becomes partially covered, especially when the child looks toward either side, and a crossed eye appearance is simulated. As the face matures and the nasal bones grow, the skin is pulled forward and away from the eye, thereby eliminating the crossed eye appearance.
Child with pseudoesotropia due to wide bridge of the nose. The eyes are perfectly straight as evidenced by the central location of the camera flash in the pupil of each eye.
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Congenital or infantile esotropia is a type of strabismus which occurs in the first six months of life. This esotropia can be present at birth but often develops a few months later. In the first weeks to months of life, it is common for the eyes to intermittently become misaligned. If a misalignment of the eyes persists after the first few months, an eye examination is necessary.
One to two percent of children have congenital esotropia. Though the cause is unknown, it is thought that the problem is in the brain's inability to coordinate the movement of the eyes, which are themselves most commonly completely normal. These children will often alternate their vision between the two eyes by sometimes crossing one, and at other times the other. Some children will constantly cross the same eye. This is often an indication that amblyopia, or decreased vision, is developing in one eye.
Treatment of congenital esotropia usually requires eye muscle surgery. Before surgery is performed, other factors must be considered. If amblyopia has developed in one eye, this poor vision must be treated right away. This is accomplished by patching the better eye to force the brain to use the eye with poorer vision. Though this will not correct the eye crossing, it will equalize the vision which improves the prognosis for a successful outcome from surgery. The presence of farsightedness must also be detected prior to an operation. Though this is an uncommon cause of esotropia in this young age group, glasses must be tried when there is significant farsightedness present as glasses, alone, may diminish the eye crossing. (See Accommodative Esotropia)
This six month old child with esotropia measured to be significantly farsighted. With the appropriate glasses in place, the eye crossing resolved.
Children do not outgrow congenital esotropia. Surgical correction is usually recommended between six and fourteen months of age. The reasons for correction go beyond the obvious drastic improvement in the child's appearance. When the eyes are misaligned in childhood, binocular vision, or the ability of the brain to use the two eyes together, does not develop. Early alignment of the eyes allows for the development of brain to eye communication which results in enhanced depth perception, fine motor skills, and the best opportunity to maintain good eye alignment throughout life. Even after successful surgery, close follow-up is necessary to detect associated eye problems. Vertical misalignments of the eye, especially when looking to the side, recurrent eye crossing and amblyopia may occur several months or years later.
Despite successful surgical correction of congenital esotropia, this child developed a vertical imbalance of the eyes on both right and left gaze. -
Esotropia can occur after infancy and not be responsive to farsighted glasses, thereby not falling into the categories of congenital or accommodative esotropia which are described elsewhere on this web site. Acquired esotropia can have multiple causes. Most common are children who have been farsighted for awhile and have not had glasses, or children who were initially responsive to glasses but later developed an additional eye crossing even with the proper glasses. All children with acquired eye crossing require a prompt evaluation by a pediatric ophthalmologist. Eye muscle surgery can correct such deviations and restoration of binocular vision is often possible.