Monday, January 24, 2011

Pediatric Optometry Case 7: 5yo/M/M

·         Referred from IIUM eye clinic with diagnose of RE constant Esotropia
·         Mother claim that her son eye is deviated suddenly since 5 month ago
·         He never had any head or eye trauma before
·         He was born through normal delivery born full term
·         Mother doesn’t notice any changes in visual or school performance after the eye deviated

·         Distance (Lea symbol23m)
·        PH
·         Near (Lea symbol@40cm)



Refractive error (dry refraction)
-0.25/-0.25 x 180
Visual Acuity
·         Distance (Lea symbol23m)
·         Near (Lea symbol@40cm)


Patient cannot appreciate
PCT (w/o correction)
·         Distance
·         Near
·         Near (+3.00D)

30-35 BO
18-20 BO
18 - 20 BO
Cycloplegic Refraction (wet refraction)
+1.00/-0.50 x 180             6/6
+0.75/-0.50 x 180                   6/6

·         Patient was tired thus examination cannot be continued
·         TCA 1 week
o   PCT with wet refraction
o   Post cycloplegic refraction
1.)   What is the reason +3.00D test was done? What other test is similar to this test?
2.)    What are the classifications of Esotropia? What type of Esotropia is this patient diagnosed with?

-->specially prepared by Group 1.


  1. 1) +3.00 D test was done to rule out the possibility of accommodative ET. If angle of deviation reduce,ET is associated with high degree of hyperopia.

    2) This patient was diagnosed with non-accommodative RE constant ET at both distrance and near. Distance ET greater than near ET.

  2. Since mother only noted the problem 5 month ago, it is advisable to ask the parents to bring collection of the child's photo to see if this is a sudden onset or not.

  3. 1) besides using +3.00DS , we can patch the affected eye (let say 6 hours) before we proceed with cover test. This is done to suspend the accommodation to see whether the component of accommodation involved or not.

    2)i agree with atikah. he might have non-accommodative RE constant ET at both distrance and near.

  4. @nurlizzz

    a lil correction...Patching...not suspend accommodation..but suspend the fusion..

    Why do think that is not accommodative tropia?

  5. 1)as atikah mentioned, the use of +3D is to rule out the accom ET as it can be used to differentiate near ET from accom ET. 2nd option is by performing CT using accom target.

    2)I think it can be classified as non-accom RE ET basic type since the ET is just notified by the parents 5 months ago which means the onset is after 3 years of age. The diff in deviation at distance and near is also approx. 10 prism diopter. The refractive power is very insignificant to cause such deviation.

    BUT! we still need to look at the deviation as well as the AA with his best correction.

    This is my opinion. TQ.

  6. Good...
    Since it is possible that it is non-accommodative type of Esotropia..
    Let's look back on what are the classification under non-accommodative ET?

  7. salam

    i think u guys should do OMT (for determining incomitant or concomitant strabismus). and did the patient complaint any diplopia??

    1. the reason of +3.00D test is to diminish accommodative component. it is to differentiate whether this is an accommodative or non-accommodative eso. im not sure the other test that is similar to +3.00D.perhaps what Rohaila said is true, do the PCT with near target.

    2. the first diagnosis that i can think of based on findings is non-accommodative esotropia. but then, long- standing of divergence insufficiency is also the other possible diagnosis. this is based on the magnitude which is more at distance than near. acute acquired comitant esotropia is the differential diagnosis because the magnitude for this kind of eso is same for distance and near.

    for classification of eso,

    1. primary
    = constant ( accom and non-accom)
    = intermittent

    2. secondary

    3. consecutive

    correct me if im wrong!

  8. @siti zahirah

    non-accom ET

    1. infantile
    2. blockage-syndrome
    3. normal-sensory

    the most possible diagnosis of this case is normal-sensory ET as this patient's ET started on late onset.

    whaddaya guys think?

  9. salam guys :)

    the used of +3.00DS is to identify either the deviation is caused by accommodation or not. For this patient the accommodation does not involved..hmm..what else other than this? mm..still thinking..

    since the patient has deviation 5 months ago, i can said that it is late onset. so, it is non accommodative constant RE esotropia with normal-sensory late onset..

    others classification under non accomm are infatile esotropia and and nystagmus blockage syndrome..

    correct me if i'm wrong..

  10. @eli aimi

    sori, we forgot to post the OMT & hirschberg result here.

    OMT:SAFE (No diplopia reported by pt.)

    RE: 13 degree to the temporal
    LE: central

  11. hey guys! did you realize that there was a manifest plus power with the wet refraction.

    Can it be there was slight involvemnt of accom for his ET? for the group members, r you sure/comfirm the magnitude of ET using PCT with +3.00DS same as without +3.00DS?

  12. @bahjah

    hai bahjah, belum tido lagi? hehe

  13. @bahjah

    hai bahjah, belum tido lagi? hehe

  14. @azuwan
    double ewww...

    actually i'm a bit confused when i first look at the timetable..on the LE, with PH the vision become worst, how come?? then i realized it is actually for near vision..someone should fix that...

    it obvious that no accommodation involve in this case since the PCT with +3.00 did not show any different with PCT without +3.00 at near...that's answer question no.1 right??
    then for question no.2, it would be non-accomodative RE ET...

    is it possible for us to prescribe prism to this patient?? what is his AC/A ratio?? or with rx it is enough to overcome the deviation??

  15. gud morning!!!

    Q1- the purpose of using +3.oo test is: to look out whether the deviation is accommodative or non-accomodative..since the deviation with +3.00 does not improve, so it is non-accommodative ET

    Q2- diagnosis: RE non-accommodative constant ET at distance and near. Distance ET > near ET

  16. hi everyone...

    ~ most of u understand the purpose of +3.00 test...gooood... :)

    ~ for the diagnosis, i can see rohaila, eli n che nur got some ideas...nice try guys...

    ~ others : lets revise the eso classification... :)

  17. @azuwananswering ur question bout manifest plus power with the wet refraction :

    if it is involve accommodation, the degree of deviation will reduce after we paralyze his accommodation...but the degree of eso deviation still same before and after we put cycloplegic and, it is non-accomodative type...

    sir, plez enlighten me if i'm wrong... :)

  18. in my opinion, this child is having non accommodative esotropia under classification of neuro sensory late onset..

    it is based on:
    recently his eye is deviated inward - thus, it is late onset..

    the +3.00DS test shows no changes in the deviation..thus, it falls into non accommodative constant esotropia classification.

  19. So what is the expected management procedure for this patient? Did you guys prescribe Rx? since the degree of wet Rx is not significant would you still prescribe? Would it be a good idea to prescribe reading spectacle. As for the vergence assesment PFV & NFP how can we measure them?

    I think it would be necessary to refer pt to ophthalmologist but at what stage?

  20. Informative blog..I love the case discussions part..may I share my view too?

  21. salam'alaik..gud morning everybody..

    regarding this patient, may i know what are the other tests done during the follow up visit yesterday(wednesday) and also the result of each tests done...

    and just response to ATIKAH's answer, the best treatment for constant tropia case is surgery..erk, it's that true abg2 n kakak2?huhu

  22. @Kak long, erm, if the patient undergone cyclo refraction, and the power is not significant, it is also give hint to us that the eso is due to non-accommodative factor..erk, just heard from somewhere...sorry if i'm wrong

  23. hey guys, im just asking whether 'your PCT with +3.00Ds was accutare or not'. If that so, thanks.

    agree will you regarding the use of +3.00DS to differentiate between accommodative ET or non-accom one.

    Non-accom RE constant ET. Dist > near

    the proper management is to prescribe full wet Rx. Monitor his performance yearly.

    Atikah, even though the Rx is less significant but the VA on RE was improved. He will benefit the plus prescription later.

    Yes, we can suggest patient for strabismus surgery. One orthoptist in Hospital Selayang used to refer this kind of patient for surgery, at age of 5yo as well.

    Patient is 5yo, in preschool already. Cosmetically and physically important for him to have 'straight eyes'in front of friends. I would be happy if having squinting eye at school..hehe.. What do you think of this?

  24. salam to kakak2..n BROs..
    hehee..this case was came out in ORTHOPTICS midsem exam last week..
    i'm a bit late nampaknyer..huhuu..not a bit..very late..

    so..what is the final Diagnosis??
    In exam..this patient is classified as NORMOSENSORY LATE ONSET :CONSTANT NON ACCOM ET..

    Mood : Frustrating~~~

  25. yepp the diagnosis is...normalsensorial late onset onset constant non accom ET......

    kakak2 n abg2 jwb correctly..huuu
    so what the management was given since adik2 3rd not have opportunity to workout this case with 4rd yr on that day.

    1st thing 1st, we treat it and after that if the deviation still there, baru we refer for surgery?

    is it prism help much?

  26. NOR ARIFAH BY ZAKARIAFebruary 6, 2011 at 6:48 PM


    kak bajah, i want to ask...hehe...

    patient has the esotropia---but why the hirshberg test show the deviation RE have 13 degree to temporal.

    why eaa?

    (soalan midterm yg mengharu kn..uuuu)....

  27. nor arifah zakariaFebruary 6, 2011 at 7:06 PM

    ok3..kak bahjah...hehe...

    cornea reflex mmg should be shifted in direction of opposite with eye deviation..

    huhu...betoi3...confusion solved...(gelak)

  28. nor arifah zakariaFebruary 6, 2011 at 7:07 PM

    ok3..kak bahjah...hehe...

    cornea reflex mmg should be shifted in direction of opposite with eye deviation..

    huhu...betoi3...confusion solved...(gelak)

  29. nor arifah zakariaFebruary 6, 2011 at 7:23 PM

    @hidayah > nurul atikah> > azuwan>

    those u guys answer totally correct, we all (3rd year) have been discused with bro muzy..(since it's our mid sem exam Q)..

    i just wanted to asked acute acquired concomintant esotropia is also known as normo-sensorial late onset esotropia? or it is different classification of ET...

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