What Is Esotropia (Misaligned Eyes)?

Home Conditions | Misaligned eyes (esotropia)

By Tom Mangan; reviewed by Valerie Kattouf, OD

What is esotropia?

Esotropia is medical terminology for eyes that cross inward toward the nose. This kind of eye crossing is a form of strabismus, or misalignment in the visual system. Pronounced “ee-so-TROE-pee-ah,” the name arises from the Greek terms “eso” (inward) and “trope” (turn).

The condition is problematic because, for vision to work, the eyes need to line up correctly. When the eyes do not align properly, a person may see two images (called double vision or diplopia). This can create confusion for the brain and discomfort and irritation for the patient.

In younger children, the brain may choose to suppress or turn off an image to avoid the issue of double vision. Esotropia is most common in babies and young children, but it can present at any age.

Presentations of esotropia

Constant, alternating and intermittent esotropia

Infantile and accommodative esotropia may present in different ways:

Constant esotropia – The same eye (or eyes) constantly stay crossed.
Intermittent esotropia – Crossed eyes come and go.
Alternating esotropia – The misalignment switches from one eye to the other.

With constant and intermittent esotropia, the eyes may alternate. There is less risk of complex vision issues with intermittent and alternating strabismus.

Types of esotropia

Esotropia can affect babies, children and adults. The condition may be mild for some and severe for others. It can also occur at different times and for different reasons depending on the person.

Infantile esotropia

Babies are often born with uncoordinated eyes. Eye crossing at birth may resolve on its own within the first three months of life, with no treatment needed. However, any eye turn that persists beyond 3 to 4 months of age must be evaluated by an eye care specialist.

Infantile esotropia refers to the inward crossing of the eyes that presents in the first six months of life. Sometimes called congenital esotropia, the condition can lead to more complex vision issues if it’s not addressed early.

Infants born with esotropia typically have an eye turn that is large in magnitude and presents frequently. When one eye turns inward 100% of the time (constant esotropia), the brain may choose to ignore the image from that eye (the strabismic eye).

In time, this creates the condition of amblyopia (also known as lazy eye), which causes a reduction of vision in the eye with esotropia. Amblyopia does not occur in cases of intermittent or alternating strabismus.

Accommodative esotropia

Sometimes, the act of bringing something into focus can cause the eyes to cross. This is called accommodative esotropia and typically presents between the ages of 2 ½ to 3 ½ years. For example, a child with uncorrected farsightedness may present with intermittent esotropia. It is often seen by parents when a child tries to focus on something up close.

Accommodative esotropia is typically treated by correcting farsightedness with glasses. The glasses prescribed may or may not have bifocal lenses to aid in additional alignment when looking at objects up close. The earlier an accommodative esotropia is diagnosed and treated, the better the outcome.

Signs and symptoms of esotropia

Symptoms can vary in appearance and severity among each individual. Some of the key indicators of the condition include:

Crossing or turning one or both eyes inward
Decreased vision
Problems with depth perception

Contact your eye doctor if you (or your child) display one or more of these characteristics along with any other eye problems. A comprehensive eye exam can help your doctor identify the cause of the condition and determine the best treatment options.

What causes esotropia?

Sometimes, if the eye muscles are not working properly, they can cause an eye misalignment. When that happens, the brain has a hard time making sense of the visual information it’s getting. This can produce double vision, confusion and other problems that need to be addressed by an eye doctor.

Eyes can become misaligned for various reasons, including underlying health issues or trying too hard to focus on an up-close task or object. Esotropia has also been known to run in families.

The type of esotropia a patient develops generally depends on specific factors such as age, the direction and pattern in which the eyes cross, and even how the brain responds to stimuli. This can be determined by an eye doctor.

Other conditions and issues, including cerebral palsy, Down syndrome, strokes or head injury, might also mean a higher risk of developing esotropia.

Esotropia treatment and outcomes

Diagnosing esotropia and deciding on treatment begins with a comprehensive eye exam. During this exam, your eye doctor will likely ask about your family history, as esotropia can sometimes be hereditary.

They will also perform a series of tests to confirm that the eye misalignment is actually esotropia. In one such test, the doctor will cover one eye and observe the movement of the other eye.

Other eye tests determine whether the esotropia responds well to corrective lenses, especially for patients with farsightedness. In most cases, eye doctors will start with the least invasive treatment methods before suggesting procedures such as strabismus surgery.

Eyeglasses

Eyeglasses can help many children who have accommodative esotropia. The doctor will determine whether single-vision or bifocal lenses are the best choices. Children with accommodative esotropia typically respond positively to their corrective glasses and wear them with no resistance.

Keep in mind that eyeglasses at this stage serve a dual purpose: To make things clear and to get the child’s eyes into proper alignment. Over time, their eyes will adapt and change, often requiring new prescriptions. This makes regular eye exams extremely important.

Adults with misaligned eyes pose a different challenge. There may be an underlying disease or condition that causes esotropia. Eyeglasses or prisms might work for some, but other options like vision therapy or surgery may be required.

Vision therapy and more

Vision therapy is a treatment option that trains the visual system to become more efficient and more flexible while working to increase alignment in some strabismic patients. It is not a treatment option for all types of esotropia. Specifically, vision therapy is not an ideal treatment for most accommodative esotropia patients.

Vision therapy is most effective for esotropic patients who have depth perception and intermittent esotropia. A child has to be school-age to have the maturity to successfully complete a vision therapy program.

Wearing an eye patch (occlusion) may help with amblyopia (lazy eye) when it is present due to a constant esotropia. While an eye patch is not a typical treatment for esotropia, it can be beneficial for both children and adults.

Procedures like Botox injections can offer an alternative to the next step, which is surgery. Botox causes paralysis in the eye muscles that can last for a few months or even be permanent. The goal of a Botox injection is to improve eye alignment.

SEE RELATED: Do eye exercises improve vision?

Strabismus surgery

A surgeon may be able to correct some kinds of esotropia if less invasive methods like eyeglasses or vision therapy prove ineffective.

The goal of strabismus surgery is to alter the eye muscles and create an improved alignment of the eyes. A surgeon may operate on both eyes even if the patient has only one eye that turns incorrectly. Strabismus surgery is not overly disruptive. Usually, it’s done on an outpatient basis and doesn’t require a lot of downtime before getting back into everyday activities. A patient choosing strabismus surgery may require multiple surgeries but this is never the goal.

When to see an eye doctor

There’s no time to lose if you or your child’s eyes are out of alignment. An eye care professional needs to check out any symptoms as soon as possible because the longer you wait, the harder esotropia is to treat.

The condition needs to be closely monitored in infants and children. While newborns may have esotropia that goes away naturally, cases in older babies and young children should be addressed quickly to avoid permanent vision changes.

It’s also important to check in regularly with your eye doctor, as crossed eyes could be a sign of another condition, like a tumor or thyroid malfunction, both of which are serious problems.