Accommodative Esotropia:  A Mom’s Perspective

Your active toddler can pick up speck of dust from the carpet and point out an airplane 5 miles above his head.  And then one morning as he puts a handful of Cheerios into his mouth, you notice that one eye crosses.  Initially you pretend that you didn’t see it, but after waking from his morning nap, both eyes are crossing.  As a normal and concerned mom, you first panic and then call your mother for her advice.  She recommends that you schedule an appointment with his pediatrician, and surprise!  There is a cancellation for the next day. 

The pediatrician’s examination reveals an outwardly healthy toddler, with the exception of the crossed eyes, or “esotropia”, where first one eye, and then the other turns in.  He recommends an appointment with a pediatric ophthalmologist, an eye doctor who specializes in children’s eye care.  The office staff schedules an appointment for 3 weeks in the future.   You wonder how you will live through the next 21 days; 504 hours; 30,240 minutes…

The pediatric ophthalmologist confirms the presence of the esotropia.  He tests the vision by quickly applying an adhesive eye patch to each of your toddler’s eyes, observing how he eagerly responds to a cartoon movie playing on the television screen at the end of the examination room, and follows a finger puppet dancing just beyond his grasp.  The doctor assures you that the vision is the same in each eye.  At the same time, he estimates the amount that the eyes are crossing.  Your toddler has been very peaceful and compliant during the examination and you are thrilled with his good behavior.  All of that changes instantly when several drops are used to dilate the eyes.  The happy toddler transforms into the wailing toddler; the two of you are brought to the waiting room where for the next 30 minutes the two of you wait for the drops to work, and you try to calm your previously peaceful toddler.

Once the eyes have dilated, you both return to the examination room.  The room is now dark.  The pediatric ophthalmologist shines an intense light back and forth in front of your toddler’s eyes with an instrument called a retinoscope, quickly changing small lenses that he grabs from a case while making odd noises to attract the toddler’s attention to the light.  This is called “refraction”, a test to find out whether your toddler needs glasses.  Unlike moths that are drawn to the porch light, your toddler is very unhappy with this bright light!  Dracula’s fear of sunlight pales in comparison!  The pediatric ophthalmologist is experienced and persistent:  the frequent lens changes and wavering light find that your toddler is very farsighted.  Before you can question what this means, the pediatric ophthalmologist screws on a headpiece similar to a miner’s light, technically called an indirect ophthalmoscope.  It projects a light more intense than that of the retinoscope.   With a large lens that provides a view of the back of the eye, he shines the light through your toddler’s dilated pupils to quickly make certain that the back of each eye is normal in appearance.  These tests are performed in less than 5 minutes, but it seems much longer.

The room lights are turned back on, causing everyone to blink.  Your toddler is exhausted from the previous testing and promptly falls asleep.  The quiet is overwhelming.  Now that peace has returned to the examination room, the pediatric ophthalmologist begins to explain his findings.  The high degree of farsightedness, or hyperopia, has caused the eyes to cross.  Children have a lot of focusing power, or accommodation, but your toddler’s ability to see clearly depends on additional focusing to overcome the unusually high degree of farsightedness, or hyperopia.  Therefore, the eyes cross, a condition called “accommodative esotropia”. 

The treatment is simple:  glasses to correct for the hyperopia and eliminate the excessive focusing burden, to be worn during all waking hours.  The glasses should allow him to use his eyes together again, restore his depth perception and maintain good vision in each eye.  The pediatric ophthalmologist warns that the esotropia will recur as soon as the glasses are removed, a “normal situation”.  He also tells you that your toddler will have to wear glasses for many years.  Surgery is not a treatment option at this time:  the crossing is caused by the farsightedness, which the glasses will correct.  He recommends the name of an optical shop that is particularly well-equipped to fit children’s glasses—“the frame must be small enough for his face.”  You are handed a piece of paper written with +6.00 right eye and +6.00 left eye.

The pediatric ophthalmologist asks if you have questions.  At the moment, you are just relieved to have an answer as to why your toddler’s eyes are crossing.  Questions will spring to mind later when you have had a chance to digest the experience.  He walks the 2 of you to the check-out area, and tells you bring the toddler for a follow-up examination in 2 months.  You briefly wonder how in the world you will keep a pair of glasses on an active toddler, but that worry can wait until tomorrow.

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