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The Problem
“My (older) child’s eyes aren’t straight.”
Common Causes
Accommodative esotropia (crossing due to farsightedness)
Exotropia
Recurrent strabismus following treatment for infantile infantile esotropia
Acute comitant esotropia
Other Causes
Duane syndrome
Cranial nerve palsies (third, fourth, sixth)
KEY FINDINGS
History
Accommodative esotropia
Onset usually about 3 to 5 years
Initially intermittent, rapid increase over few months
Worse when viewing at near
Acute comitant esotropia
Sudden-onset esotropia, usually ages 3 to 5 years
No diplopia
No other neurological symptoms
Often family history strabismus
Exotropia
Usually intermittent
Worse with fatigue
Worse when viewing at distance
Recurrent strabismus after treatment for infantile esotropia
History of surgery for esotropia when younger
May be esotropia, exotropia, or vertical strabismus
Duane syndrome
Present at birth, but often not noted until older
Most commonly appear esotropic
Worse in side gaze
Affected eye may appear “smaller” (due to narrow lid fissure)
Cranial nerve palsy
Strabismus dependent on which cranial nerve involved
Diplopia
Other symptoms dependent on etiology of cranial nerve problem
Examination
Accommodative esotropia
Variable eye crossing, worse when fixating at near
Otherwise normal
Acute comitant esotropia
Full extraocular movements
Examination otherwise normal
Exotropia
May not see anything abnormal on examination
Eye alignment often normal when viewing object at near
Cover test may reveal exotropia when patient fixates at distance
Recurrent strabismus after treatment for infantile esotropia
May be any type: esotropia, exotropia, or vertical strabismus
Duane syndrome
Horizontal gaze abnormality
Most commonly limited outward movement of eye
Small or moderate esotropia
May appear similar to sixth cranial nerve palsy
Eyelids narrow when eye turned toward nose
Cranial nerve palsy
Third cranial nerve
Eye out and down
Ptosis (droopy eyelid)
Dilated pupil
Fourth cranial nerve
Affected eye higher
Worse when head tilted to side of palsy
Eye moves up when turned toward nose
Sixth cranial nerve
Large-angle esotropia
Limited outward movement of eye
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Children with strabismus should be referred to an ophthalmologist. If an acute cranial nerve palsy is suspected, referral to a pediatric neurologist and brain imaging may be indicated.

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What Shouldn’t Be Missed

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Third, fourth, and sixth cranial nerve palsies may initially present with strabismus. Although some causes of these palsies are benign or self-limited, they may be due to central nervous system infections, tumors, or other serious diseases.

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  • 1. Accommodative esotropia. Accommodative esotropia is a form of eye crossing due to farsightedness. The majority of children in the first several years of life are farsighted. Few young children need to wear glasses, however, because the lens is able to change its shape to focus (accommodation), as if the children have a built-in pair of glasses. When children are more farsighted than normal, the effort to focus is greater, and this effort may induce esotropia. The esotropia usually resolves when the farsightedness is corrected with spectacles. Bifocal glasses are sometimes used if the eye crossing is worse when viewing ...

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