Pseudoesotropia

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Background

Pseudoesotropia is a condition in which the alignment of the eyes is straight (also known as orthotropic); however, they appear to be crossed.[1]



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Note the cross-eyed appearance of the right eye in the top image that corrects with elimination of the prominent epicanthal fold.



View Image

In these photos of the same child as in the previous image, note the cross-eyed appearance of the left eye in the top image that corrects with elimina....

Pathophysiology

This condition most commonly occurs in infants when a flat nasal bridge and prominent epicanthal folds tend to obscure the nasal portion of the sclera. This optical illusion causes the patient to have an appearance of eyes deviated nasally, and it is most apparent when the eyes are in side gaze or are focusing up close. A small interpupillary distance (ie, the distance between 2 pupils) also can give the appearance of pseudoesotropia.[2]

Epidemiology

Frequency

United States

Pseudoesotropia is a condition with variable frequency. This condition is one of the most common reasons for infant referrals to ophthalmologists.

Race

Infants or young toddlers of Asian descent with flat nasal bridges often have pseudoesotropia.

Sex

No gender predilection exists in pseudoesotropia.

Age

Pseudoesotropia is more frequent in infants and toddlers where facial structures have not yet fully developed.

History

Parents may notice that their young child's eyes appear to turn in. The deviation is reported to be even more noticeable when the child has a head turn and the eyes are in lateral gaze. Parents may bring pictures showing how the eyes are "turned in" to the ophthalmologist.

Physical

A careful ocular examination (eg, pupillary light reflex) reveals that the eyes are straight.

Using the cover-uncover test, the examiner finds that the patient manifests no deviation.

A flat nasal bridge with wide epicanthus (the part of skin fold that runs from the upper to the lower eyelids) or a small interpupillary distance usually is noted. Since the nasal scleral portion is being covered by the epicanthus, the examiner can demonstrate the orthotropic appearance by pinching slightly the nasal bridge and revealing the nasal sclera.

Causes

A flat nasal bridge with wide epicanthus or a small interpupillary distance obscures the nasal portion of the sclera.

One paper reported 4 cases of pseudoesotropia caused by a negative angle kappa, a nasally dislocated macula in infants with high myopia.

Other Tests

A complete ocular examination is important since a patient may have true strabismus.

The corneal light reflex test, such as shining a flashlight in the patient's eyes from 3 meters away and examining the light reflex on the cornea, can be performed to differentiate pseudoesotropia and true esotropia.

With pseudoesotropia, light reflexes are aligned, while true esotropia has one corneal light reflex offset temporally.

Medical Care

No treatment is required for pseudoesotropia. Parents can be reassured that their child most likely will outgrow the condition. Infants should be observed and reevaluated every 6 months because it is possible that true esotropia, particularly accommodative esotropia, may develop at a later date.

Consultations

Patients with suspected pseudoesotropia should be examined and receive follow-up care by an ophthalmologist since it is possible that true esotropia may develop at a later date.

Further Outpatient Care

Patients should receive follow-up care from an ophthalmologist, with reevaluation every 6 months because true esotropia may develop.

Prognosis

The prognosis is generally good. No treatment usually is required for pseudoesotropia, and most patients outgrow their appearance.

Patient Education

Reassure parents that their child most likely will outgrow this condition.

Author

Kalpana K Jatla, MD, Private Practice, Clarity Eye Center

Disclosure: Nothing to disclose.

Coauthor(s)

Kenneth T Horlander, MD, FCCP, Director, Pulmonary Rehabilitation Program, Physician in Pulmonary Medicine and Critical Care Medicine, Emory Clark-Holder Clinic; Director, Medical and Surgical Intensive Care Unit, Physician in Pulmonary Medicine and Critical Care Medicine, West Georgia Health System

Disclosure: Nothing to disclose.

Robert William Enzenauer, MD, MPH, MBA, MSS, Professor, Department of Ophthalmology, University of Colorado School of Medicine; Chairman, Department of Ophthalmology, Children's Hospital

Disclosure: CLEAR DONOR: Received consulting fee from Clear Donor for consulting; Partner received salary from Clear Donor for employment.

S Anna Kao, MD, Comprehensive Ophthalmologist, Emory Clark Holder Clinic; Staff Physician, Department of Ophthalmology, West Georgia Medical Center

Disclosure: Nothing to disclose.

Specialty Editors

Simon K Law, MD, PharmD, Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Disclosure: Nothing to disclose.

J James Rowsey, MD, Former Director of Corneal Services, St Luke's Cataract and Laser Institute

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Disclosure: Nothing to disclose.

Additional Contributors

Michael J Bartiss, OD, MD, Medical Director, Ophthalmology, Family Eye Care of the Carolinas and Surgery Center of Pinehurst

Disclosure: Nothing to disclose.

References

  1. Catalano RA, Nelson LB. Pediatric Ophthalmology: A Text Atlas. 1994. 25, 94-95.
  2. Damms T, Damms C, Schulz E, et al. [Pseudo-esotropia caused by nasal dislocation of the macula in patients with high infantile myopia]. Ophthalmologe. 1994 Feb. 91(1):77-80. [View Abstract]
  3. Wright K. Pediatric Ophthalmology and Strabismus. 1995. 192.
  4. Silbert AL, Matta NS, Silbert DI. Incidence of strabismus and amblyopia in preverbal children previously diagnosed with pseudoesotropia. Am Orthopt J. 2013. 63:103-6. [View Abstract]

Note the cross-eyed appearance of the right eye in the top image that corrects with elimination of the prominent epicanthal fold.

In these photos of the same child as in the previous image, note the cross-eyed appearance of the left eye in the top image that corrects with elimination of the prominent epicanthal fold. Also, note that corneal light reflex demonstrates straight alignment.

Note the cross-eyed appearance of the right eye in the top image that corrects with elimination of the prominent epicanthal fold.

In these photos of the same child as in the previous image, note the cross-eyed appearance of the left eye in the top image that corrects with elimination of the prominent epicanthal fold. Also, note that corneal light reflex demonstrates straight alignment.