CASE 142: A CHILD WITH A LAZY EYE
A child presents to you for evaluation of “lazy eye.” The onset has been recent and the problem is intermittent, but the parent is able to offer few other details, such as which eye is affected. The parent wonders whether this is truly an abnormality or whether it could just be a “normal thing.”
SELECT THE ONE BEST ANSWER
1. You assess both red reflexes of the child simultaneously using a direct ophthalmoscope at a distance of several feet in a darkened room. You note that one reflex is darker than the other, diagnose asymmetric red reflexes, and refer the child for ophthalmologic consultation. Potential explanations for the findings on physical examination include all of the following except
(B) unilateral optic nerve hypoplasia
(C) different refractive errors of the 2 eyes
(D) large retinoblastoma involving the macula of 1 eye
(E) all of the above
2. You note that the child has epicanthal folds. The most sensitive method of excluding the presence of true strabismus in the straight ahead position is
(A) cover testing
(B) evaluation of old photos showing the parent’s point of concern
(C) corneal light reflex test
(D) checking to make sure the child can follow a toy into all eccentric positions of gaze
(E) autorefraction (assessing the refractive error of each eye using a handheld automated device)
3. Assuming the child has true esotropia, a common cause would be
(A) uncorrected astigmatism
(B) uncorrected nearsightedness
(C) uncorrected farsightedness
(D) a wide nasal bridge
(E) a wide interpupillary distance (distance between the pupil of each eye)
4. The child has a large-angle constant esotropia and alternates fixation freely between the two eyes (no amblyopia). There is no significant refractive error, so glasses are not prescribed. The child’s ophthalmologist recommends strabismus surgery, sooner rather than later. A prolonged delay in performing surgery may
(A) limit the chance for good visual acuity of each eye
(B) increase the chance of needing glasses in the future
(C) increase the chance of intraoperative complications
(D) limit the chance for good binocular fusion (depth perception) postoperatively
(E) all of the above
5. A parent is concerned because she notes intermittent crossing of her infant’s eyes. You examine the infant. Observation without referral to an ophthalmologist is appropriate if
(A) you believe the child has pseudostrabismus and not true esotropia
(B) you identify an intermittent esotropia in a 6-month-old, which only occasionally is evident
(C) you identify an intermittent esotropia in a 3-week-old, who is visually immature, and the esotropia only occurs occasionally
(D) you identify a constant esotropia in a 1-monthold
(E) A and C
6. A 6-year-old child is newly diagnosed with amblyopia in 1 eye due to a higher refractive error in that eye compared with the fellow sound eye. Despite compliance with eyeglass wear, the vision of the amblyopic eye fails to improve sufficiently. Appropriate supplemental therapy includes
(A) patching of the amblyopic eye
(B) atropine in the sound eye
(C) patching of 1 eye on odd dates and patching of the other eye on even dates
(D) it would not be worthwhile to attempt further therapy, given the age of the child
(E) A and B
7. A child tilts her head to one side nearly constantly. However, you note that when 1 eye is occluded, the torticollis disappears. A common cause of ocular torticollis with a head tilt is
(C) unilateral ptosis
(D) fourth cranial nerve palsy
(E) sixth cranial nerve palsy
8. Which of the following suggests that headaches in a child may have an ophthalmologic basis?
(A) headaches routinely develop in the area of the eyes (eyestrain) after reading for 10 minutes
(B) headaches are preceded by a visual aura
(C) headaches are located in the parietal areas
(D) headaches occur only in the dark
(E) B and D
9. A young child has unilateral ptosis and is commonly noted to manifest chin-up head posturing. Which statement is true?
(A) the parents should encourage their child to hold the head straight
(B) the sound eye probably has a small esotropia
(C) physical therapy will be useful for proper positioning of the head
(D) substantial amblyopia is probably absent from the ptotic eye
(E) A and C
10. A father is anxious because his 5-year-old child has been blinking both eyes frequently and firmly for the past week. The child seems to be unaware of this, and there is no redness, tearing, discharge, itching, pain, photophobia, or blurred vision. The most likely diagnosis is
(C) dry eye
(D) tic disorder
(E) intracranial mass
11. A neonate has an acute purulent conjunctivitis. This is best treated by
(A) systemic antibiotic
(B) topical antibiotic
(C) systemic antiviral
(D) topical antiviral
(E) systemic antifungal
12. A child has a red eye. You instill fluorescein in the eye. Using a cobalt blue light, you note a small lesion with a tree branch pattern (dendrite). The most likely diagnosis is
(A) Neisseria gonorrhoeae (B) fungus
(C) Haemophilus influenzae (D) herpes
13. A child has cellulitis around one eye. Which sign(s) is/are helpful in confirming that this is an orbital process?
(B) limited eye movement
(C) conjunctival injection
(D) presence of discharge
(E) A and B
14. You diagnose a 6-month-old child with nasolacrimal duct obstruction. Which sign is consistent with that diagnosis?
(B) conjunctival injection
(C) maceration of the eyelid skin
(D) A and B
(E) A and C
15. An infant has tearing, photophobia, corneal clouding, and corneal enlargement of one eye. The most likely diagnosis is
(B) blocked tear duct
(E) retinal detachment
16. A child has mild unilateral ptosis and miosis (small pupil) with ipsilateral anhidrosis of the face. An important diagnostic consideration is
(D) Wilms tumor
17. A 6-year-old girl with pauciarticular juvenile idiopathic arthritis should have ophthalmologic screening for
(C) optic neuritis
18. An infant is being followed for retinopathy of prematurity. The presence of which finding will be most important in deciding to proceed with prompt laser therapy?
(A) retinal detachment
(C) plus disease
(E) either B or D
19. Referral to what specialist would be most appropriate for an infant with marked bilateral optic nerve hypoplasia?
20. An infant has a small and superficial strawberry hemangioma of the upper eyelid. If the lesion grows in size, which complication is most likely?
(D) retinal detachment
(E) hyphema (bleeding into the anterior chamber of the eye)
21. An infant has bilateral leukocoria. This finding may be caused by
(D) A and C
(E) B and C
22. The most common ophthalmologic finding in neurofibromatosis type 1 is
(B) retinal detachment
(D) Lisch nodules
(E) optic nerve hypoplasia
23. A child with Sturge-Weber syndrome should undergo screening for
(E) dry eye syndrome
24. A 5-year-old child is poked in the eye with a pencil. The finding most likely to signify serious ocular damage is
(A) an irregular (nonround) pupil
(B) large subconjunctival hemorrhage
(C) corneal abrasion
(D) conjunctival injection
(E) excessive tearing
1. (B) This describes the Bruckner test. Asymmetry of the red reflexes is produced by strabismus, anisometropia (different refractive errors of the two eyes), or media abnormality/opacity (cornea, lens, vitreous, retina) in 1 eye or asymmetrically in the 2 eyes. An eye with a small optic nerve would not manifest an abnormal red reflex in the absence of strabismus or another problem.
2. (A) Small-angle strabismus is most sensitively detected by cover testing, watching closely for any refixational movement of the uncovered eye. Corneal light reflex testing and evaluation of photos are relatively insensitive in detecting small-angle strabismus. Testing eye movements in various eccentric positions of gaze offers no information about the presence or absence of strabismus in the straight-ahead position. Refraction gives no direct assessment of ocular alignment (see Figure 142-1).
FIGURE 142-1 Epicanthus tarsalis. (Reproduced, with permission, from Riordan-Eva P, Whitcher JP. Vaughn & Asbury’s General Ophthalmology, 17th ed. McGraw-Hill; 2008: Fig. 4-5.)
3. (C) Farsightedness is a common cause of esotropia. If farsightedness is uncorrected, a child may see clearly but must accommodate excessively to do so. As part of the near reflex triad, accommodation is accompanied by pupillary miosis and convergence of the eyes, which could lead to esotropia.
4. (D) The child already has equal visual acuity in the 2 eyes (no amblyopia). The timing of surgery would have no impact on eyeglass need or surgical complications. The development of binocular fusion postoperatively requires plasticity of the visual system in the brain, and such plasticity diminishes with increasing age.
5. (E) “Crossing” of the eyes can be “normal” in two situations. First, visually immature babies in the first 2 months of life or so commonly manifest occasional esotropia or exotropia; this seems to be a normal phenomenon that disappears quickly after good fixation and following-behavior develops. Second, “crossing” due to pseudostrabismus, which is not true esotropia, occurs normally in children with a wide nasal bridge and/or epicanthal folds. In all other scenarios of true esotropia, prompt referral to an ophthalmologist is appropriate.
6. (B) The case describes anisometropic amblyopia of an eye, which is initially treated with eyeglasses. If the amblyopia is insufficiently responsive, supplemental therapy would include occlusion (patch) or penalization (atropine) of the sound eye. Traditionally, amblyopia has been treated up until 7-9 years of age, but recent research indicates that treatment benefits may be achieved even in older children.
7. (D) The fourth cranial nerve innervates the superior oblique muscle, which is primarily a depressor of the eye. Tilting the head compensates for this vertical strabismus, allowing the child to fuse, have depth perception, and avoid diplopia. Horizontal strabismus would not lead to a head tilt. Ptosis could lead to a chin-up head positioning but not to a head tilt.
8. (A) Convergence insufficiency is a common cause of eyestrain headaches in children, typically becoming symptomatic after 10-20 minutes of reading. A visual aura preceding a headache suggests migraine, a central process.
9. (D) Chin-up head posturing in a child with unilateral ptosis is taken as a positive sign, indicating the child is using the ptotic eye by gazing below the droopy eyelid. Absence of such posturing may indicate that the vision of the ptotic eye is being occluded and suppressed by the droopy eyelid (see Figure 142-2).
FIGURE 142-2 Congenital ptosis of severe degree, left upper lid.
10. (D) Eye blinking is a very common tic. Allergy would be accompanied by redness and itching. Dry eye is unusual in young children in the absence of systemic disease or medications associated with eye dryness; redness and/or the sensation of the presence of a foreign body would also be expected.
11. (A) Ophthalmia neonatorum with copious purulence is highly suggestive of gonococcal infection, which is treated by systemic antibiotics. Topical antibiotics are often additionally given but are not adequate for sole therapy (see Figure 142-3).
FIGURE 142-3 Neonatal conjunctivitis (ophthalmia neonatorum). Copious purulent drainage in a newborn with neonatal gonococcal conjunctivitis. (Reproduced, with permission, from Knoop KJ, Stack LB, Storrow AS, et al. Atlas of Emergency Medicine, 3rd ed. New York: McGraw-Hill; 2010:26. Photo contributor: Department of Ophthalmology, Naval Medical Center, Portsmouth, Virginia.)
12. (D) A corneal dendrite is highly specific for herpes infection, either simplex or zoster (see Figure 142-4).
FIGURE 142-4 A magnified view via slit-lamp biomicroscopy shows classic terminal bulbs pathognomonic for ocular HSV infection. (Reproduced, with permission, from Knoop KJ, Stack LB, Storrow AS, et al. Atlas of Emergency Medicine, 3rd ed. New York: McGraw-Hill; 2010:47. Photo contributor: Department of Ophthalmology, Naval Medical Center, Portsmouth, Virginia.)
13. (B) Ptosis, conjunctival injection, and discharge would be common in both periorbital and orbital cellulitis. Limited eye movement, proptosis, pupil abnormality, and/or vision loss suggest an orbital process.
14. (E) Conjunctival redness suggests ocular surface involvement, such as is seen with conjunctivitis, not tear duct obstruction. Redness and maceration of the eyelid skin, however, are common in tear duct obstruction due to prolonged skin contact with water and mucus. Infection in the tear sac is common with tear duct obstruction, and digital pressure on the tear sac may cause discharge to express from the puncta.
15. (D) The only symptom here characteristic of tear duct obstruction is tearing. Cataract and retinal detachment would produce none of these symptoms. Metabolic disease could produce all of these symptoms except corneal enlargement; additionally, the eye involvement would be bilateral. The symptoms are classic for early-onset glaucoma, which can be unilateral or bilateral.
16. (A) The case describes Horner syndrome (see Figure 142-5). In an infant, important associations are brachial plexus injury and neuroblastoma arising in the neck/upper chest area.
FIGURE 142-5 Congenital Horner syndrome. Ptosis, miosis, and heterochromia. Lighter colored iris is on the affected left side. (Reproduced, with permission, from Hay Jr WW, Levin MJ, Sondheimer JM, et al. Current Diagnosis & Treatment: Pediatrics, 19th ed. New York: McGraw-Hill; 2009: 430.)
17. (D) Uveitis (iritis) sometimes develops in juvenile idiopathic arthritis and is often a “silent disease,” with no early complaints of redness, photophobia, floaters, or blurred vision.
18. (C) The decision to treat an infant for retinopathy of prematurity is most commonly reached when the infant develops engorgement and tortuosity of the retinal blood vessels surrounding the optic nerve. Retinal detachment is generally considered a late finding, and laser treatment is ideally performed before its development. Glaucoma and cataract are not features of this disease, except when they occur as complications of cryo or laser therapy.
19. (D) Optic nerve hypoplasia is sometimes associated with midline central nervous system defects, such as absence of the septum pellucidum. In septo-optic dysplasia (de Morsier syndrome), pituitary abnormalities may be present.
20. (C) Hemangioma of the eyelid may lead to amblyopia due to occlusion of the visual axis by the tumorous eyelid or deformation of the eyeball (induced astigmatism) by the mass.
21. (E) A swollen optic nerve would not alter the red reflex; a cataract or a retinal tumor would.
22. (D) Lisch nodules are dome shaped, usually tan hamartomatous lesions of the iris surface. They are extremely common in neurofibromatosis type 1, their presence increases with age, and they are nearly universally seen in this disease by adulthood.
23. (C) Glaucoma is a classic ocular complication of Sturge-Weber syndrome, and children with SturgeWeber syndrome should be screened for its development (see Figure 142-6).
FIGURE 142-6 A girl with a large trigeminal (V1/V2) port wine stain. A. Appearance at age 3 years; neither glaucoma nor hypertrophy have yet developed; magnetic resonance imaging did not show Sturge-Weber syndrome. B. At age 5 years, after six pulsed dye laser and one alexandrite laser treatment to the affected face, labia, and oral mucosa under general anesthesia. The lesion is nearly gone. (Reproduced, with permission, from Wolff K, Goldsmith LA, Katz SI, et al. Fitzpatrick’s Dermatology in General Medicine, 7th ed. New York: McGraw-Hill; 2008: Fig. 173-4A,B.)
24. (A) A nonround pupil suggests the possibility that the eye was penetrated by the pencil, leading to iris and intraocular damage. Eye redness and corneal abrasion would be less serious concerns.
Wright K. Pediatric Ophthalmology for Primary Care. Elk Grove Village, IL: American Academy of Pediatrics; 2008.