Clinical Findings and Management of Opiate Withdrawal Related Acute Onset Esotropia: A Case Report

Acute onset comitant esotropia (AOCE) is a rare ophthalmic complication associated with opiate withdrawal. As the prevalence of opioid use disorder remains high, it is critical for clinicians to recognize this condition as a differential diagnosis for acute diplopia in adults, especially after ruling out emergent neurological pathologies. This case report details the clinical presentation, diagnostic workup, and management of AOCE secondary to acute heroin withdrawal in a 34-year-old male. The patient reported the sudden onset of constant, horizontal diplopia three days after stopping heroin use. An initial outside consultation three weeks after onset measured a 25 prism diopter (PD) esotropia. Upon presentation to our clinic, his deviation had reduced, and a comprehensive workup, including magnetic resonance imaging (MRI) and angiography (MRA), was performed to rule out intracranial pathology. All were found to be unremarkable. The patient’s symptoms were managed with a temporary 12 PD base-out Fresnel prism, and his esotropia and diplopia spontaneously and completely resolved over the following three weeks. Opiate withdrawal-induced AOCE is theorized to result from a reversible disuse atrophy of the motor fusion system. Chronic opiate-induced miosis decreases accommodative demand; acute withdrawal causes a relative parasympatholytic state (mydriasis), increasing accommodative demand that the atrophied motor fusion system cannot meet with appropriate divergence, resulting in esotropia. This patient’s history of uncorrected hyperopia and convergence excess likely predisposed him to this condition. This case highlights that acute esotropia following opiate withdrawal is a transient condition where a thorough history is paramount, allowing for conservative management and avoiding unnecessary procedures.