Children with uncorrected hypermetropia, attempt to focus the blurred image by increasing accommodation that will, in turn, causes convergence.

If the amplitude of fusional divergence is enough to compensate for this convergence the child will be orthotropic.

If the amplitude of fusional divergence is equal to the induced convergence, the child will be esophoric.

if the fusional divergence is weak in the presence of normal AC/A ratio, esotropia will develop, this is called Refractive Accommodative Esotropia.

Refractive accommodative esotropia is defined as an esotropia that is corrected at all fixation distances and in all gazes by optical correction of the hypermetropia.

Some children with uncorrected high hypermetropia remain orthotropic because they prefer blurred vision more than the constant attempt to accommodate. Such children may develop deprivation amblyopia in both eyes (ametropic amblyopia)

The prognosis for restoration of normal binocular function in refractive accommodative esotropia is usually excellent if normal binocular functions existed before the onset of the deviation. Full correction of the hypermetropic refractive error, determined by cycloplegic refraction, is usually all that is required initially for rehabilitation.

Children who have never worn glasses may initially complain about blurring of vision with their optical correction. In this instance a brief period of atropinization to relax accommodation may be required before the glasses are tolerated. The cycloplegic refraction is repeated annually, and the glasses are adjusted when necessary.

Although there is a tendency for hypermetropia to decrease as a child gets older, many of them require glasses into adolescence and beyond.

If the glasses only partially reduce the angle of strabismus at near and distance fixation, then the strabismus is not purely refractive-accommodative in nature (partially accommodative esotropia).

The use of LASIK in the treatment of accommodative strabismus in young children is being discussed with increasing frequency. For me in view of the lack of long-term results with this, I'm an opponent to this treatment in the pediatric age group.