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Pediatric - Cross-Eyed
Question:
May I please solicit some advice?
(first a detailed background and then 2 questions)
On Saturday morning, my daughter (2 years, 9 months)
suddenly woke up...
cross-eyed.
We have been to a doctor and an ophthalmologist, and
will see them again
in a few days, but I would like further input if it
is possible, please.
There are two other issues:
-
At the age of 9 months, she fell from her crib and
fractured her skull. There was slight bleeding
beneath the skull. But all healed on its own.
There was never any fainting, vomiting or any
symptom. She has been fine since. The fracture
was above HER right temple.
-
On Friday night (night before she woke up
cross-eyed), she and I were playing games staring
into each other's eyes (basically, going
deliberately cross-eyed.
The ophthalmologist said that my daughter is
slightly far sighted (unlike me
who is very near sighted), and the far sightedness
is asymmetrical. In such
cases, children try to compensate (hence the
cross-eyed), and that it is
remotely possible that our cross-eye game the night
before might have kicked
it in (but that I should not feel bad, I did not
cause this, and it would
have
happened eventually).
Well the doctor wants us to get glasses for a few
days, and if it all clears
up... likely that was it... if not... a CAT scan.
Now my wife's friend - who has good intent - has
just told me:
1) It should be an MRI not a CAT scan.
2) the analysis above does not hold water... does
not make sense
3) There may be damage to the sixth cranial nerve.
Answer:
Listen
to the ophthalmologist. Tell all doctors her
history (but it seems totally unrelated). It
sounds sounds like Dr. has this diagnosis under
control.
We see 100 children each year like this and
glasses are the proper treatment.
Visit
Signs of Vision Problems for more information.
This seems to be esotropia / crossed eyes and
coincidently happens at this age. This is more
noticeable when child is tired or the focus is
very close.
Glasses are the 'cure' for the problem 95% of the
time. Follow up is mandatory and further
evaluation or testing is mandatory if clinically
indicated or if problems worsen see your
ophthalmologist.
Ask all doctors "what would you do
for your own child"?
Thanks
again for the question, you did the right
thing.....
Mark A. Sibley, MD, FACS
Lasik and Refractive Specialist
Cataract and Laser Specialist
Board Certified Eye
Surgeon
727-895-2020
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Pediatric -
Squinting
Question:
I have a baby
girl she is nine months old, from few weeks I have
observed that whenever she feels sleepy her left
eye gets squint towards the outer side only for
few seconds and then she again becomes normal. I
don't know if this is normal in this age or this
is an issue which has to be taken care of.
Answer:
All
babies eyes are learning to see objects and to
follow the
objects that they are learning to focus on. All
babies eyes will seem to drift or wander at times,
especially when they are tired or distracted.
The natural position of the eyes at those times of
fatigue, etc. may be to drift apart, like you are
describing.
Visit our
Children's Eye Care section for more
information.
It may
be totally normal, BUT please mention it to your
pediatrician.
If it continues or becomes more constant, insist
on having your daughter seen by an eye doctor for
a comprehensive eye exam.
Comprehensive eye exams
Mark A. Sibley, MD, FACS
Lasik and Refractive Specialist
Cataract and Laser Specialist
Board Certified Eye
Surgeon
727-895-2020
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Pediatric - Child Blinks Eyes Frequently
Question:
I don't think anything is really wrong and I will
have him looked at, but I'm looking for a little
insight first. My 3yr old son seems to be
blinking both of his eyes unnaturally frequent.
When he blinks them he squints his face a little.
It almost looks intentional. When I ask him he
says his eyes do not hurt and I think his vision
is fine. Watching television or looking at flash
cards.
I have asked him several times if his eyes hurt
and he says no. and I know it's probably not
related, but he say's and points to a drawing he
made is making him do it.??? It's a complicated
and busy artwork project. He said it makes him
tired? Just 3 year old speak?
Any ideas or direction are greatly appreciated!
Answer:
While it is possible that your child is simply
discovering the joys of controlling his eyes for
the first time, it is perhaps equally likely that
he may have discovered his focus improves during
the act of squinting. This could indicate a
problem with astigmatism (a blurring of the light
beams they enter the eye) anisometropia
(inequality of focus between the two eyes), or
early signs of nearsightedness.
I have seen similar cases where the only problem
was "middle child syndrome." Older siblings and
younger siblings are perceived by the middle child
to get "all the attention" and the middle child
discovers that he can definitely boost his share
of parental attention by doing safe but strange
things like blinking the eyes too much.
A professional evaluation would likely be the best
way of assuring that any legitimate problem is
discovered and treated and that any "attention
syndromes" are noted as such.
I hope this is helpful to you, and thanks for your
question.
Florida Eye Center
727-895-2020
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Pediatric Anisocoria Question
Question:
My son Leighton is 17 months and has had different
size pupils in low light. Should I be concerned?
Thanks for your help on this.
Unequal
pupils is called anisocoria.
Approximately 10 percent of people have
different-sized pupils (anisocoria). Your child
should be examined by a pediatric ophthalmologist.
There are simple medical tests to rule out certain
causes of anisocoria.
Children's Eye Care
These tests could be done by the Ophthalmologist
and usually involve the use of drops in the
office.
The ophthalmologist should carefully evaluate the
vision and motility. The most important
consideration is to determine if amblyopia is
present.
Signs of Vision
Problems
Amblyopia ( Lazy Eye)
in children with anisocoria may be increased.
There may also be a possibility of strabismus
(crossed eyes), emphasizing the need for careful
motility examination in these patients . Children's
Eye Exam
Assessing for amblyopia
in an infant can be difficult. Children with good
vision in only one eye may function and behave
just as well as a child who has perfect binocular
visual acuity. Therefore, vision should be
assessed in each eye independently.
The presence of
anisometropia is a possible cause of amblyopia.
correction. Early cycloplegic refraction must be
performed in patients to detect any anisometropia
and spectacles prescribed as necessary. In
general, a difference of 1.25 to 1.50 D of
astigmatism is considered amblyogenic.
Sometimes the abnormality is not the larger pupil
but the smaller one. Without knowing the exact
cause, I can't say whether it is normal or not.
Even if there is a problem, it could eventually
become normal.
One possible cause
could be Horner's Syndrome.
Horner's syndrome is a
triad of features resulting from interruption of the
sympathetic pathway from the hypothalamus to the
orbit, as follows:
Horner's syndrome is
associated with several other syndromes:
Congenital Horner's
syndrome may be associated with congenital heterochromia of the iris
Horners
Syndrome
Question: How is Horners syndrome detected?
What is the treatment for Horner's syndrome? What
is the cause?
Answer: Horners
Syndrome is caused by damage or interruption of
the sympathetic nerve to the eye. This causes a
small, regular pupil; ptosis (drooping) of the eye
lid on the same side; and occasionally loss of
sweat formation on the forehead of the affected
eye. The pupil will still react to light stimulus
and will accommodate to distant vision. The pupil
of Horners Syndrome will not enlarge in the dark.
Treatment for Horners Syndrome focuses on finding
the cause of the interruption of the sympathetic
nerve to that area of the eye. This is usually in
the neck, but can be in the brain.
Other possible
causes of Anisocoria
Anisocoria is a cause of
concern for any clinician since some of the
associated conditions are sight- or even life-
threatening. The first step towards a correct
diagnosis is to determine if the pupillary
response in each eye is normal.
Physiologic anisocoria:
the majority of patients with anisocoria have a
physiologic difference in the size of the two
pupils. The patient usually has no symptoms and
may not be aware of the difference. Response to
light and near testing is usually normal and
difference in size of the two pupils is usually
less than 2mm.
Horner’s syndrome: can
be congenital or acquired (trauma, surgery,
migraine, stroke, lung tumors, and demyelinating
diseases). Ptosis, miosis, and facial anhydrosis
are noted in Horner’s syndrome; the congenital
disease is also associated with iris heterochromia.
Response to light and near testing is usually
intact although anisocoria is greater in dim
light. Instillation of 1-% hydroxyamphetamine is
used to determine the location of the lesion.
Iritis: can be
traumatic, idiopathic, or associated with systemic
disease. Patients usually complain of pain,
photophobia, and red eye. Cells and flare are
noted in the anterior chamber and ciliary
injection is usually present; posterior synechiae
can also develop.
Argyll-Robertson pupil:
is a light-near dissociative response most
commonly associated with neurosyphilis. It is
usually bilateral and patients do not experience
symptoms directly related to it. Pupils are
assymetrical, irregular, and react poorly to light
but constrict normally to a near stimulus.
Pharmacologic miosis:
most commonly secondary to unilateral instillation
of a miotic drop for the treatment of glaucoma.
Pupil will react poorly to light and pharmacologic
dilatation.
Traumatic pupillary rupture:
patient usually has no symptoms; there is a
history of trauma and the slit–lamp exam reveals
iris atrophy, sphincter rupture, or synechiae in
the affected eye.
Adie’s tonic pupil: more
common in females and usually patient is
asymptomatic. Most cases are idiopathic but
associations are present with viral infections,
neuropathies, or trauma. Pupil is fixed and
dilated with poor response to light and near.
Depressed deep tendon reflexes are also associated
with this condition.
Acute angle-closure
glaucoma: patients with ACG usually complain
of eye pain, blurred vision, haloes, and nausea.
Exam reveals an edematous cornea, IOP is elevated,
pupil is fixed mid-dilated, and gonioscopy reveals
a closed angle.
Pharmacologic mydriasis:
common culprits include the use of mydriatic
agents, scopolamine patches for motion sickness,
and contact with belladona plants.
Third nerve palsy: sudden ptosis, diplopia,
and pain are some of the symptoms of CN III palsy.
Pupil is fixed-dilated, and extraocular motility
will be restricted.
MANAGEMENT
In general, the treatment for Horner's syndrome
depends upon the cause. In many cases there is no
treatment that improves or reverses the condition.
Treatment in acquired cases is directed toward
eradicating the disease that is producing the
syndrome. Recognizing the signs and symptoms is
tantamount to early diagnosis and expedient
referrals to specialists.
Horner's syndrome has no predilection for age,
race, gender or geographic location. Horner's
syndrome of congenital origin is typically around
the age of two years with heterochromia and
absence of a horizontal eyelid fold or crease in
the ptotic eye. Iris pigmentation (which is under
sympathetic control during development) is
completed by the age of two, making heterochromia
an uncommon finding in Horner's syndromes acquired
later in life. Old photographs can aid the
clinician in distinguishing congenital Horner's by
documenting heterochromia present at, or near,
birth.
CLINICAL PEARLS
-
The time frame for testing is
important because cocaine has the ability to
inhibit the uptake of Pholedrine and Paradrine
into the presynaptic vesicle, reducing accuracy.
There must be at least 48 hours between the
tests.
-
Some of the older literature
suggests employing Phenylephrine 1% solution for
localization. This technique is rarely employed
because patients with either preganglionic or
postganglionic lesions become hypersensitive to
the drug making results inaccurate.
-
There is a "dilation lag" in
Horner's syndrome where the involved pupil will
dilate slowly in dim illumination. That is, the
degree of anisocoria diminishes as the patient
sits in a dark room.
-
Post-ganglionic Horner's
syndromes tend to occur from more benign causes
and are typically vascular in origin.
-
If hemianalgesia and/or
hemiparesis appear with Horner's syndrome, then
the lesion is within the spinal cord or brain.
-
Isolated Horner's syndrome
typically is vascular in nature.
I hope
this information was helpful. Please save and
discuss this with your baby's doctors.
Mark A. Sibley, MD, FACS
Lasik and Refractive Specialist
Cataract and Laser Specialist
Board Certified Eye
Surgeon
727-895-2020
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