A 4-year-old girl has an esotropia measuring 20 prism dioptres at distance and 35 prism dioptres at near. Cycloplegic refraction shows +4.50 DS in each eye. After full correction with single-vision spectacles, the deviation at near persists at 15 prism dioptres while distance deviation resolves. The most appropriate next step is:

• A Reduce the hypermetropic correction by 1.00 D to encourage fusion
• B Perform bilateral medial rectus recession
• C Prescribe atropine 1 percent daily to the fixating eye
• D Prescribe bifocal spectacles with a +2.50 D near addition ✓

Explanation

This is accommodative esotropia with a high AC/D ratio: convergence excess at near despite full distance correction. The standard management is a bifocal addition, classically a flat-top segment fitted low enough for the child to use at near, which relaxes accommodative effort and removes the near deviation. Surgery is reserved for non-accommodative or partially accommodative residual tropia. Reducing the hypermetropic correction worsens accommodative convergence.

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.