Pediatric emergency medicine trisk 0596 0596
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a phoria. Pathology is noted when a previously covered eye shifts back into the
orthotropic (straight-ahead) position.
FIGURE 28.5 Normal Hirschberg light reflex test. Light reflexes fall symmetrically in each
eye.
FIGURE 28.6 A: Left exotropia. Note medial displacement of Hirschberg light reflex in the
left eye. B: Left esotropia. Note lateral displacement of Hirschberg light reflex in the left eye.
Two findings are especially helpful in assessing whether strabismus is
emergent: (1) the presence or absence of double vision and (2) the status of the
eye movements. Although young children may not complain of diplopia, this
symptom often indicates an acute or subacute onset of ocular misalignment.
Nonemergent childhood strabismus is usually not associated with double vision
because the brain becomes adept at suppressing the misaligned, nonfixing eye. If
a child complains of diplopia, ophthalmology consultation is appropriate, even if
no obvious strabismus is apparent.
If the eye movements are completely full and symmetric, a neurogenic palsy or
restrictive phenomenon can be ruled out, and one can be virtually be certain that
the strabismus is not emergent. Problems that cause emergent strabismus do so by
impairing the action of one or more muscles. If there are any questions about
