Esotropia and Exotropia

Publication Date: December 14, 2022
Last Updated: January 2, 2023


  • Strabismus in children under 4 months of age sometimes resolves without treatment, particularly if the deviation is intermittent, variable, or measures less than 40 prism diopters.
  • Repeat cycloplegic refraction is indicated when esotropia does not respond to an initial prescription for hyperopia or when esotropia recurs after surgery.
  • Acquired esotropia should be evaluated and treated promptly.
  • Young children with intermittent exotropia and good fusional control can be followed without surgery because there is a low rate of deterioration to constant exotropia or reduced stereopsis.
  • Indications for surgery in intermittent exotropia include a progression to constant or nearly constant deviation, reduced stereopsis, and/or a negative effect on social interactions.
  • Unilateral recess-resect and bilateral lateral rectus recessions are both effective initial surgical procedures for the treatment of intermittent exotropia.
  • Convergence insufficiency occurs in children and adults, and symptoms with near viewing can often be improved using vergence exercises.
  • Simultaneous prism and cover testing measures the manifest angle of strabismus, and prism and alternate cover testing measures the total angle of misalignment. Both inform the ophthalmologist’s decisions regarding management and surgical indications.

Recommendation Grading




Esotropia and Exotropia

Authoring Organization

Publication Month/Year

December 14, 2022

Last Updated Month/Year

August 9, 2023

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


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. 

Inclusion Criteria

Male, Female, Adolescent, Child, Infant

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, optometrist, physician, physician assistant


Diagnosis, Treatment, Management

Diseases/Conditions (MeSH)

D013285 - Strabismus


Strabismus, esotropia, Exotropia, crossed eyes

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 Methodology Resources

Data Supplement


Number of Source Documents
Literature Search Start Date
March 1, 2021
Literature Search End Date
May 31, 2022