HIGHLIGHTED FINDINGS AND RECOMMENDATIONS FOR CARE

Document Overview

Design and created by Guideline Central in participation with the American Academy of Ophthalmology.

Esotropia and Exotropia

American Academy of Ophthalmology

Publication Date: Dec 14, 2022

Page Last Updated: May 5, 2026

Recommendation Grading

Study Ratings¹
I++	High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of bias
I+	Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
I-	Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
II++	High-quality systematic reviews of case-control or cohort studies High-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is casual
II+	Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is casual
II-	Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not casual
III	Nonanalytic studies (e.g., case reports, case series
Evidence Ratings²
G - Good quality	Further research is very unlikely to change our confidence in the estimate of effect
M - Moderate quality	Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
In - Insufficient quality	Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate Any estimate of effect is very uncertain
Recommendation Ratings³
S - Strong recommendation	Used when the desirable effects on an intervention clearly outweigh the undesirable effects or clearly do not
D - Discretionary recommendation	Used when the trade-offs are less certain—either because of low-quality evidence or because evidence suggests that desirable and undesirable effects are closely balanced

1. To rate individual studies, a scale based on Scottish Intercollegiate Guideline Network (SIGN) is used.
2. The body of evidence quality ratings is defined by Grading of Recommendations Assessment, Development and Evaluation (GRADE). GRADE is a systematic approach to grading the strength of the total body of evidence that is available to support recommendations on a specific clinical management issue.
3. Key recommendations for care are defined by GRADE.

Document Overview

Document Title: Esotropia and Exotropia

Authoring Society: American Academy of Ophthalmology

Document Publication Date: Dec 14, 2022

Page Last Reviewed/Updated: May 5, 2026

Document Type: Guideline

Country of Publication: United States

Full Text Freely Available: Yes

Full Text Guideline: www.aaojournal.org/article/S0161-6420(22)00864-8/fulltext

Source Citation: Sprunger DT, Lambert SR, Hercinovic A, Morse CL, Repka MX, Guyton DL, Hutchinson AK, Cruz OA, Wallace DK; American Academy of Ophthalmology Preferred Practice Pattern Pediatric Ophthalmology/Strabismus Panel. Esotropia and Exotropia Preferred Practice Pattern®. Ophthalmology. 2022 Dec 14:S0161-6420(22)00864-8. doi: 10.1016/j.ophtha.2022.11.002. Epub ahead of print. PMID: 36526451.

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Document Objectives: Identify children at risk for esotropia. Detect esotropia. Detect and treat amblyopia that may cause, or be caused by, esotropia. Educate the patient and/or family caregiver, as appropriate. Inform the patient’s other health providers of the diagnosis and treatment plan. Treat the esotropia to promote and maintain binocular vision (fusion, stereopsis), prevent amblyopia or facilitate its treatment, and restore normal appearance. Maximize quality of life by optimizing binocular alignment and visual acuity. Monitor vision and binocular alignment, and modify therapy as appropriate.

Scope: Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D013285 - Strabismus

Keywords: Exotropia, Strabismus, crossed eyes, esotropia

Inclusion Criteria: Male, Female, Adolescent, Child, Infant

Health Care Settings: Ambulatory, Hospital, Outpatient

Intended Users: Nurse, Nurse Practitioner, Optometrist, Physician, Physician Assistant

Recommendation Development Processes & Methodology

Supplemental Methodology Resource: Data Supplement

Number of Source Documents: 255

Literature Search Start Date: Monday, March 1, 2021

Literature Search End Date: Tuesday, May 31, 2022

Includes peer/external review process?: Yes

Includes public comment process?: No

Methodologist involvement?: Yes

Patient involvement?: No

Includes multi-disciplinary group?: Yes

Includes systematic review?: Yes

Grades quality of strength of evidence?: Yes

Grades quality of strength of recommendation?: Yes

Discloses funding source?: Yes

Discloses conflicts of interest?: Yes

Includes benefits/harms analysis with recommendations?: Yes