The Infant Who Keeps Turning His Face Leftwards

Kimberly G. Yen, MD; Ariel Chen

Disclosures

March 14, 2018

Case Diagnosis

The correct diagnosis is homonymous hemianopia. Infants with a homonymous hemianopia can present with an anomalous head position where they turn their face ipsilateral to the visual field defect. It is hypothesized that children adopt this head position because it expands the view of the deficient side of their field. Homonymous hemianopia can be caused by ischemic injury, hemorrhage, tumors, or infections. Patients with suspected homonymous hemianopia should receive further neurologic evaluation.

An anomalous head position can be caused by other ocular conditions.

Patients with nystagmus may present with a compensating face turn or head tilt due to the presence of a null point. Because this patient does not have nystagmus, the head turn would not be due to a null point.

Superior oblique muscle palsy most commonly presents as a contralateral head tilt toward the side of the unaffected eye. Patients with this condition may also present with hypertropia of the affected eye.

Duane syndrome and sixth nerve palsy may present with a face turn; however, patients with these conditions do not present with an inability to see objects on one side of the visual field. Furthermore, this patient had full range of extraocular motility, which makes Duane syndrome and sixth nerve palsy unlikely.

Clinical Course

Owing to the concurrent findings of a left face turn and left homonymous hemianopia, this patient received an MRI of the brain and orbits with and without contrast.

The MRI revealed right-sided cystic encephalomalacia in the left cerebral hemisphere and ex vacuo dilatation of the body and right lateral ventricle. The distribution corresponded with right-middle cerebral artery infarct. The area of the infarct included optic radiations, the white matter tracts extending from the lateral geniculate body of the left thalamus toward the occipital lobe (Figure). It was believed that the infarct likely occurred during the perinatal period.

Figure. MRI revealing right-middle cerebral artery infarct.

At 17 months, the patient continued to have left hemiparesis, left hemianopia, and intermittent left esotropia. He is receiving occupational, speech, and physical therapy. Formal visual field evaluation will be performed when he is older.

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