A Girl With Acute-Onset Esotropia

Karen Alvarez, DO; Kimberly G. Yen, MD


June 17, 2010


Acquired onset comitant esotropia generally occurs during infancy or early childhood. In a case of acute-onset esotropia, a paretic cause should be ruled out through careful evaluation, as well as other abnormalities, such as papilledema. In general, comitant esotropias are traditionally believed to be benign. However, acute-onset comitant esotropia has been demonstrated to be a harbinger of neurologic disease and central nervous system illness.[1]

Although rare, acute-onset comitant esotropia has been shown to occur in cases of Arnold-Chiari malformation, hydrocephalus, and central nervous system tumors even before other presenting signs, such as downbeat nystagmus (in the case of Arnold-Chiari malformation) or papilledema (in the case of hydrocephalus).[1,2] The esotropia may resolve after treatment of the underlying condition, but some patients will need strabismus surgery.[1]

A presenting symptom of acute-onset comitant esotropia or nystagmus of any type should prompt a careful neurologic work-up.[1] Furthermore, the inability to re-establish ocular motor fusion after surgery in these cases should also prompt the physician to further investigate for a neurologic cause.[1]


Acquired acute-onset comitant esotropia can be a harbinger of neurologic disease. Neuroimaging studies should be considered in the absence of expected findings (eg, hypermetropia suggestive of accommodative esotropia) or fusion potential or in the presence of atypical features or neurologic signs.


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