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 Course and Discussion

The child was diagnosed with an acute-onset left cranial nerve VI palsy. Neuroimaging and systemic review of symptoms were negative. One month after onset of symptoms, his left esotropia and abduction improved. Four months after onset, he was orthophoric with full abduction, and the head turn was resolved.

Acute-onset esotropia can occur due to sixth nerve palsies, disruption of binocularity, and fusion, such as patching an eye for an eye injury (such as a cornea abrasion) or for amblyopia,[1,2] as well as from neurologic processes such as brain tumors and Arnold-Chiari malformations.[3] High intracranial pressures can also present with cranial nerve VI palsy and inward deviation of the eye.[1]

Children can present with acute-onset esotropia and limitation in abduction secondary to cranial nerve VI palsies after viral infections, immunizations, and impetigo. These etiologies have been termed benign sixth nerve palsies and their clinical prognosis is excellent. These cases tend to recover fully within a couple of months.[1,4,5,6,7,8]

Cases have been reported in which multiple episodes of cranial nerve VI palsies affect the child with no signs or symptoms of an infectious cause.[1] These multiple recurrences, in the absence of any recognizable illness or intracranial process, also have been termed "benign" sixth nerve palsies -- a reminder that not all "benign" sixth nerve palsies in children are due to postinfectious processes.[1] The etiology of isolated benign sixth nerve palsy remains uncertain.


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