Late onset esotropia and diplopia in childhood: differential diagnosis and advices for paediatricians

Key words: Diplopia, Esotropia, Strabismus, Accommodation

The acute acquired concomitant esotropia is for the paediatricians a clinical manifestation of difficult interpretation and management, as generally underlies benign conditions, but it may be the manifestation of a CNS diseases. “Acute acquired concomitant esotropia” (acute acquired comitant esotropia, AACE) is defined as acute onset of a convergent strabismus and diplopia associated with no or minimal refraction defects, in which the angle between the two visual axes is preserved in all directions of gaze. The onset usually occurs after the third year of life and includes forms whose etiologies range from the intracranial hypertension to the functional forms. The forms of AACE are essentially three: type I (the most common), which follows the iatrogenic break of binocular vision; type II or functional type, which includes the esotropie associated with a concomitant high angle of deviation, with little or no hyperopia and binocular vision potentially normal in the absence of accommodative component and CNS diseases; type III, which includes the forms secondary to intracranial hypertension, Arnold-Chiari syndrome and expansive posterior fossa disease. In the differential diagnosis ophthalmological causes (eg, decompensated esoforie or accommodation defects) and no ophthalmological causes (CNS diseases and ocular myasthenia) should be considered, so it is necessary to identify patients who require neuroimaging.