A Girl With Acute-Onset Esotropia

Karen Alvarez, DO; Kimberly G. Yen, MD


June 17, 2010

Clinical Presentation

A 4-year-old girl presented to the emergency department (ED) with a 2-month history of headaches and "bumping into things." She was taken to the ED by her mother at the urgency of her pediatrician. Her mother stated that the headache had slowly increased in severity over the past 2 months. The headache was more intense at night and at school, with no associated nausea. The patient's mother felt that her daughter was bumping into things more frequently and described her movements as similar to those of a "drunken sailor." She also noticed that her daughter's eyes began crossing fairly suddenly since the onset of the headaches. Family history was significant for esotropia, including the girl's sibling who had accommodative esotropia.

On examination, the child had central, steady, and maintained vision in each eye. Abduction was normal without nystagmus, and she had comitant esotropia of 35 prism diopters. The pupils in both eyes were equal, round, and reactive to light with no afferent pupillary defect. Portable slit lamp examination showed a normal cornea, anterior chamber, iris, and lens in both eyes. The fundus examination was normal and showed a cup-to-disc ratio of 0.25 for both eyes.

Question 1. What should be the next step?

A. Cycloplegic refraction
B. Magnetic resonance imaging of the brain
C. Observation
D. Surgery to correct strabismus
E. Computed tomography of the brain

View the correct Answer.

Question 2. What is the most likely diagnosis?

A. Brain tumor
B. Viral encephalopathy
C. Accommodative esotropia
D. Myasthenia gravis
E. Syphilis

View the correct Answer.


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