RT Book, Section A1 Lueder, Gregg T. SR Print(0) ID 56150225 T1 Chapter 10. Strabismus in an Older Child T2 Pediatric Practice: Ophthalmology YR 2011 FD 2011 PB The McGraw-Hill Companies PP New York, NY SN 9780071633802 LK accesspediatrics.mhmedical.com/content.aspx?aid=56150225 RD 2024/03/28 AB Table Graphic Jump Location|Download (.pdf)|PrintThe Problem“My (older) child’s eyes aren’t straight.”Common CausesAccommodative esotropia (crossing due to farsightedness)ExotropiaRecurrent strabismus following treatment for infantile infantile esotropiaAcute comitant esotropiaOther CausesDuane syndromeCranial nerve palsies (third, fourth, sixth)KEY FINDINGSHistoryAccommodative esotropiaOnset usually about 3 to 5 yearsInitially intermittent, rapid increase over few monthsWorse when viewing at nearAcute comitant esotropiaSudden-onset esotropia, usually ages 3 to 5 yearsNo diplopiaNo other neurological symptomsOften family history strabismusExotropiaUsually intermittentWorse with fatigueWorse when viewing at distanceRecurrent strabismus after treatment for infantile esotropiaHistory of surgery for esotropia when youngerMay be esotropia, exotropia, or vertical strabismusDuane syndromePresent at birth, but often not noted until olderMost commonly appear esotropicWorse in side gazeAffected eye may appear “smaller” (due to narrow lid fissure)Cranial nerve palsyStrabismus dependent on which cranial nerve involvedDiplopiaOther symptoms dependent on etiology of cranial nerve problemExaminationAccommodative esotropiaVariable eye crossing, worse when fixating at nearOtherwise normalAcute comitant esotropiaFull extraocular movementsExamination otherwise normalExotropiaMay not see anything abnormal on examinationEye alignment often normal when viewing object at nearCover test may reveal exotropia when patient fixates at distanceRecurrent strabismus after treatment for infantile esotropiaMay be any type: esotropia, exotropia, or vertical strabismusDuane syndromeHorizontal gaze abnormalityMost commonly limited outward movement of eyeSmall or moderate esotropiaMay appear similar to sixth cranial nerve palsyEyelids narrow when eye turned toward noseCranial nerve palsyThird cranial nerveEye out and downPtosis (droopy eyelid)Dilated pupilFourth cranial nerveAffected eye higherWorse when head tilted to side of palsyEye moves up when turned toward noseSixth cranial nerveLarge-angle esotropiaLimited outward movement of eye