Esotropia is an inward deviation of one or both eyes towards the nose, so that the two eyes do not point at the same target. It is the commonest type of strabismus in children and takes several forms, with treatment differing fundamentally between them. One of the most useful things to understand is that an apparent inward turn is not always a real squint. Some infants look cross-eyed because the bridge of the nose is broad or because a fold of skin covers the white of the eye on the nasal side, while examination shows the eyes to be perfectly straight. This distinction cannot be settled by a phone photograph or by common opinion; it needs an eye examination. **Even so, reassurance by guesswork is not acceptable: any squint appearing or persisting beyond the fourth month of life warrants an eye examination, and waiting for it to disappear with age is wrong.** The forms of esotropia include one that appears in the first months of life; one linked to long-sightedness that usually appears in the pre-school years, where full spectacle correction may control it entirely without surgery; an intermittent form that shows up with tiredness or close focusing; and a late-onset form in older children and adults that requires investigation of its cause. Treatment therefore always begins by measuring the refractive error and prescribing full correction, then by treating amblyopia with patching or drops if it is present, and finally by surgery for whatever deviation remains. The limits should be clear. Glasses control only the component driven by long-sightedness and will not straighten a deviation unrelated to it, and eye exercises do not correct a constant esotropia. **Surgery straightens the position of the eye but does not treat a lazy eye; failing to treat amblyopia in time can leave the vision permanently reduced even after the eye has been aligned.** There is also no guarantee of perfect alignment from a single operation, and some patients need a further procedure.
Procedure steps
- 1
Distinguishing true from apparent esotropia
The clinician checks the corneal light reflex and performs cover testing to separate a true squint from an apparent one caused by a skin fold or a broad nasal bridge.
- 2
Refraction with dilated pupils
The refractive error is measured after dilating drops, because undetected long-sightedness is a common cause of esotropia that may respond to glasses alone.
- 3
Measuring the angle and examining the fundus
The angle is measured with prisms at near and distance in different gaze positions, and the fundus and optic nerve are examined to exclude an organic cause behind the deviation.
- 4
Glasses and amblyopia treatment
Full correction is prescribed and amblyopia is treated with patching or drops, with repeat measurements, since part of the deviation may resolve with glasses alone.
- 5
Surgery for the residual deviation
The eye muscles are adjusted for the deviation that glasses did not control, with long-term follow-up because the squint can change through the child's growing years.
Before the procedure
Bring any older photographs showing the child's eyes, since they help establish when the deviation began. Tell the doctor at what age the squint appeared, whether it is constant or comes and goes, whether it increases with tiredness or close focusing, and whether you notice a head tilt or one eye being closed. Mention the pregnancy and birth history including any prematurity, developmental delay, neurological conditions, and any family history of squint, lazy eye or strong glasses. Bring the current glasses, their prescription and all previous examination reports. Expect the doctor to dilate the pupils with drops that leave vision blurred and the eyes light-sensitive for several hours; plan the day around this and do not ask the child to read or focus closely straight afterwards.
After the procedure
If glasses are prescribed, the child should wear them all day rather than only when needed, because in many cases of esotropia the glasses are the treatment itself and not an accessory. Glasses do not weaken the eye or make a child dependent on them; that belief is a myth that delays care and causes harm. If patching is prescribed, keep to the exact number of hours and record them, because missed hours mean an incomplete result. After surgery use the drops on schedule, prevent eye rubbing and swimming until the surgeon allows, and expect redness lasting weeks. Attend every follow-up even if the eye looks straight, since the squint can return or change with growth. **Seek care immediately for severe pain, reduced vision, coloured discharge or increasing eyelid swelling, or for a sudden new squint with headache, vomiting, head tilt or double vision.**
Expected duration
A full assessment usually takes 45 to 90 minutes because of the dilating drops, while surgery commonly takes 30 to 90 minutes.
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