Acute-Onset Esotropia in a 2-Year-Old Boy

Frank E. Valentin, MD; Kimberly G. Yen, MDSeries Editor: David K. Coats, MD


April 12, 2007

Clinical Presentation

A 2-year-old Hispanic boy was referred for evaluation of an acute-onset esotropia (Figure 1). That morning, his mother had noticed that the child's left eye was turned inward, a condition that was not previously noticed. He was also closing the left eye occasionally. There was no active ear infection and no history of viral illness, head trauma, or other neurologic symptoms. The child was healthy with the exception of several episodes of otitis media in the past with no sequelae.

Left esotropia in primary position

Image published with permission.

Examination revealed fix-and-follow vision in each eye with no fixation preference. Motility evaluation demonstrated a left esotropia of 30 prism diopters. There was moderate limitation of abduction of the left eye, and the child preferred a left face turn of about 30° (Figure 2). There was no afferent pupillary defect, and examination of the anterior and posterior segment, including the optic nerves, was normal. His cycloplegic refraction was +1.50 diopters in each eye.

Limitation of abduction of left eye

Image published with permission.

Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the brain and orbits were unremarkable (Figures 3A and 3B).

Normal MRI of brain and orbits

Normal MRI of brain and orbits

Acute-onset esotropia in a child can be caused by:

  1. Brain tumor

  2. Viral infection

  3. Decompensated esophoria

  4. Increased intracranial pressure

  5. Benign cranial nerve VI palsy

  6. All of the above

View the correct answer.


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