Help! My Baby s Eyes Are Crossed (or Something!)

Transcription

1 Help! My Baby s Eyes Are Crossed (or Something!) Madhuri Chilakapati, MD Ophthalmology Chief Complaint My baby has a lazy eye The eyes move funny The eyes don t move together The eyes get stuck The eyes are out of sync One eye moves and the other one doesn t The eyes move all over the place There s just something wrong with the eyes! 1

2 Goals Review differential diagnosis of ocular misalignment in infancy Recognize signs of potential misalignment in an infant that looks normal Understand treatment options Provide even better support for our patients Pseudostrabismus Diagnosis of exclusion Still present after 4-6 months Intermittent and often improving Corneal light and cover testing are normal Reassurance Observation 2

3 Infantile Esotropia Constant Family history Cross Fixate and Alternate Full abduction Latent nystagmus, vertical deviations Amblyopia: patch Surgery after age 6 months, before 24 months Infantile Exotropia Less than age 1 High association with neurological conditions and craniofacial syndromes Alternate fixation common Association with nystagmus and vertical strabismus Amblyopia: patch Strabismus: alternate patch Correct refractive errors Surgery after 6 months 3

4 Congenital 4 th Nerve Palsy Presentation Torticollis: head tilt away from affected side Facial asymmetry Hypertropia often unmasks with age (or on eye exam) Unilateral vs bilateral Vertical diplopia, reading difficulty Etiology: unclear-possible dysgenesis of CN IV nucleus or nerve Observation Amblyopia: patching Surgery: significant head tilt or misalignment Third Nerve Palsy Ptosis with misalignment, limited movement Possible pupillary dilation Etiology: Congenital 40-50%, Trauma, Inflammatory, Neoplastic Imaging: pupil involvement, trauma, acute Amblyopia: Patching Ptosis: observation, eyelid surgery Strabismus: observation, muscle surgery 4

5 Sixth Nerve Palsy Only one eye crosses Congenital: esotropia present at birth, agenesis of nerve or nucleus, no other signs or conditions Other etiologies: increased ICP, microvascular, infectious, trauma Rule out underlying conditions Amblyopia: patch Esotropia: surgery if congenital or no resolution Duane Syndrome Face turn Small strabismus in primary position Unilateral or bilateral deficit in abduction, adduction, or both Narrowing or widening of eyelids with movement Etiology: hypoplasia CNVI nucleus with abnormal innervation of lateral rectus by CNIII Typically nonprogressive Amblyopia: patching Misalignment/face turn: surgery 5

6 Duane Syndrome Brown Syndrome Chin up head position or face turn Possible hypotropia in primary Limited elevation in adduction Etiology: Congenital or acquired Amblyopia: Patching Abnormal head position or hypotropia: surgery 6

7 Marcus Gunn Jaw Winking Ptosis, abnormal eyelid movement with sucking, chewing, jaw movement Etiology: Trigeminal oculomotor synkinesis between the muscles of mastication and the levator muscle Adaptation by control with subtle jaw position changes Ptosis: patch and/or surgery Jaw wink-denervation and sling Amblyopia # cause of preventable vision loss 1in children 7

8 Management Amblyopia Patching: distract child, break up time, socks, elbow splints Pharmacologic penalization Surgery Optimal after amblyopia treated For misalignment in primary position or significant abnormal face turn Take Home Points Parent concerns can be vague Detection of ocular misalignment during infancy is important for amblyopia prevention Look for abnormal head position, reluctance to look in certain direction, abnormalities with EOMs Referral is urgent with acute onset strabismus to rule out 6 th nerve or 3 rd nerve palsy : amblyopia management, surgery 8