Acute Comitant Esotropia

    • Recent-onset diplopia and comitant esotropia when fixating a distant target
    • Full ocular versions and ductions
    • Common causes: accommodative esotropia, breakdown of latent esophoria, spasm of the near reflex, high myopia
    • Uncommon (but serious) causes: increased intracranial pressure, subarachnoid hemorrhage, acute thalamic or brainstem lesion, meningoencephalitis
    • Core neuro-ophthalmic features
      • Diplopia
      • Full ocular versions and ductions
      • Comitant esotropia when fixating a distant target
      • Eyes are often aligned when fixating a near target
    • Possible accompanying neuro-ophthalmic features
      • Episodic convergence, miosis, and accommodation, which are components of the synkinetic near response, as part of “spasm of the near reflex”
      • Intermittent back-and-forth conjugate saccadic movements (“volitional flutter”)
      • Papilledema
    • Possible other accompanying features
      • Hyperopic refractive error
      • Headache
      • Ear pain
      • Reduced consciousness
      • Impaired cognition
      • Ataxia
      • Extremity weakness and numbness
    • Possible imaging features
      • Ventriculomegaly
      • Cerebellar, thalamic, or midbrain lesion
      • Meningitis
      • Subarachnoid hemorrhage
      • Dural venous sinus thrombosis
    • Lumbar puncture may show an elevated opening pressure or abnormal constituents suggesting meningitis or subarachnoid hemorrhage
    • Bilateral sixth nerve palsies, which should be accompanied by incomitant esotropia
    • Look for sedative medications that could have caused a decompensated esophoria
    • Look for signs of spasm of the near reflex
      • Convergence movements that interrupt ocular versions
      • Episodic miosis and pseudomyopia
    • Look for an uncorrected hyperopic refractive error
    • Tip: accommodative esotropia rarely has its onset after age 3 and rarely includes diplopia
    • Look for high myopia
    • Tip: the esotropia of high myopia may have a subacute onset
    • Exclude signs of an underlying brain lesion
    • Order brain MRI if you cannot attribute the esotropia to sedative medication, accommodative esotropia, spasm of the near reflex, or high myopia
    • Order lumbar puncture if MRI is normal and there are features to suggest a neurologic illness
    • Most cases without other neurologic features will be caused by decompensated esophoria, accommodative esotropia, or spasm of the near reflex, but…
    • Tip: distinguishing between decompensated esophoria and spasm of near reflex may be difficult
    • Accommodative esotropia can be corrected with the appropriate hyperopic glasses prescription
    • Diplopia of decompensated esophoria is easily palliated with base-out prism
    • Eye muscle surgery is indicated only if
      • Esotropia has not resolved after at least 9 months
      • Esotropia is large
      • Patient does not want to wear glasses with prism
    • Trap: eye muscle surgery for spasm of the near reflex carries a risk of consecutive exotropia (See Spasm of Near Reflex )

    Brainstem Ocular Motor Disorders

    Internuclear Ophthalmoplegia Skew Deviation Dorsal Midbrain Syndrome Thalamic or Tegmental Midbrain Syndrome Unilateral Pontine Syndrome Bilateral Pontine Syndrome Dorsolateral Medullary (Wallenberg) Syndrome Ototoxic Vestibulo-ocular Dysfunction Syndrome Acute Upgaze Deviation Acute Downgaze Deviation Acute Comitant Esotropia Omnidirectional Slow Saccades Omnidirectional Saccadic Pursuit