A 4-year-old child is found to have a visual acuity of 6/6 in the right eye and 6/60 in the left eye. On examination the left eye has a high accommodative esotropia (AC/A ratio > 6:1) with good binocular fusion when wearing full hyperopic correction. The primary treatment is:

• A Immediate surgical recession of the left medial rectus
• B Full hyperopic optical correction in spectacles plus occlusion of the right eye to treat amblyopia ✓
• C Botulinum toxin injection into the medial rectus of the left eye
• D Bifocal lenses without penalization of the fellow eye

Explanation

Fully accommodative esotropia in a hyperopic child should first be managed with full hyperopic correction, which often resolves the esotropia by reducing the accommodative effort. Since significant amblyopia (6/60 in the left eye) is present, patching (occlusion therapy) of the better eye is added concurrently. Surgery is reserved for residual non-accommodative deviation after optical correction and amblyopia treatment. Bifocals alone would not treat the amblyopia.

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.