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Answers: 2008 Series -  January 1, 2008 Lecture 53 of 53  NEXT»

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This 5-year-old boy was presented for examination with a history of having crossed eyes since birth.  Visual acuity is OD 20/40 and OS 20/20.  Refraction is +0.50 in each eye.  The media are clear and the fundus is normal.  Prism and cover measurements are 40 PD esotropia in the primary, increasing to 60 PD in downgaze and decreasing to 30 PD in up gaze.

1.  This boy has the following:   

a -- V pattern esotropia

This is a V pattern esotropia because there is more than 15 PD decrease in the ET in up gaze compared to down gaze.  It is important to control accommodation when taking these measurements because the ET can increase with accommodation that is more likely to take place when looking down.


2.  What is a likely cause for this?  

b -- bilaterally lax superior oblique tendons

One cause for this condition that is becoming better understood is congenital laxity of the superior oblique tendons.  Whether this is a primary laxity or is due to bilateral congenital superior oblique palsy is argued.  In either case the treatment is the same.  The condition can be confirmed by finding a lax tendon doing the superior oblique traction test.  This is a test that must be done with anesthesia.  Treatment can be either bilateral superior oblique tuck (not too big, just make the traction test normal and equal) or bilateral inferior oblique weakening.


3.  What workup would help you in planning for treatment of this condition? 

e -- all of the above

All of these tests are useful.  The superior oblique traction test will reveal lax tendons.  Lateral version will show inferior oblique over action if it is present.  Coronal CT of the orbit will show the pulley position.  In this case, if a pulley heterotopia was the cause, with the pulleys, the lateral rectus pulleys would be displaced inferiorly and the medials superiorly.  The Bielschowsky head tilt test could show a right hyper on right tilt and a left hyper on left tilt if a bilateral superior oblique palsy were present.



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