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Answers: 2007 series -  May 22, 2007 Lecture 32 of 52  NEXT»

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This 18-month-old male has had crossed eyes since birth according to the mother.  There has been no family history of strabismus and the child is otherwise healthy.  Cycloplegic refraction is OU + 1.25.  The deviation is estimated at 60 PD using the Krimsky test (centering the light reflexes with prism).  There is no apparent “A” or “V” pattern.

1.  What is the most likely diagnosis?   

a -- congenital esotropia

The most likely diagnosis is congenital esotropia, but bilateral 6th nerve palsy cannot be ruled out until abduction is evaluated.  This is not likely to be Moebius syndrome either, but the child should be checked for 7th nerve palsy by observing attempts at smiling and checking the anterior 1/3 of the tongue for atrophy.  This is not internuclear ophthalmoplegia, a condition seen in older patients and associated with deficient function of the medial rectus.


2.  If you could do one additional test, it would be:  

d -- checking for abduction using the “doll’s head” test

Carrying out the doll’s head maneuver or the oculo-cephalic reflex is a good way to establish the presence or absence of intact abduction.  While repeat refraction is always something to be considered, it is not likely to result in a change of treatment plan here. From the pictures, the head posture seems to be normal.  The angle can also be re-measured, but with an angle this large it is unlikely that a significantly different angle will be found on repeat measurement.


3.  The most likely next event for this child is: 

c -- appropriate eye muscle surgery

At eighteen months in an otherwise normal child with large angle esotropia, free alternation, and a low hyperopic refractive error, surgery now is the best choice. While alternate patching does not seem practical since the child alternates freely, meaning there is no amblyopia, some believe that keeping one eye patched until the eyes are aligned keeps the “slate clean” contributing to better binocularity after alignment.



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