Pediatric emergency medicine trisk 0597 0597
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subtle reductions in extraocular movement, ophthalmology consultation is most
likely appropriate.
Of note, depending on the patient’s age and clinical circumstance, some
children may not cooperate fully with portions of the examination. If a child will
not follow an examiner’s target but will fix on the examiner, the examiner can ask
the parent to gently move the patient’s head to each side and then up and down.
The examiner can also guide the child by putting one hand on the child’s head (
Fig. 28.2 ), although care must be used to avoid heightening the patient’s anxiety.
As the patient continues to look straight ahead when the head is being turned, the
eyes are moving passively in reference to the head and orbit. When the head is
turned to the left, the eyes move into right gaze to maintain fixation straight ahead
( Fig. 28.2 ). If the head is tilted up, the eyes are moved into relative downgaze.
Essentially, this is the “doll’s eye” maneuver used in the assessment of comatose
patients. If the eyes move symmetrically and fully on passive movement of the
head, this rules out the presence of a neurogenic or restrictive problem with the
same accuracy as if the patient had voluntarily followed a target.
After these ophthalmologic exam maneuvers, computed tomography (CT) scan
of the orbit with both coronal and axial views is the imaging modality of choice
when there is limited extraocular motility in patients in whom orbital fracture is
suspected (see Chapters 107 Facial Trauma and 114 Ocular Trauma ).
The causes of pediatric strabismus are summarized in Tables 28.2 to 28.4 . The
first considerations ( Figs. 28.4 and 28.6 ) are neurogenic palsies and restrictive
strabismus. Myasthenia gravis and thyroid eye disease can mimic virtually any
strabismus with deficiency of extraocular movement and must always be
considered in the differential diagnosis in any pattern of ocular misalignment.
Myasthenia may cause intermittent strabismus and variable ptosis, whereas
thyroid disease causes retraction of the upper lid. The pupils are not involved in
either condition.
ESOTROPIA EMERGENCIES
Figure 28.7 summarizes the approach to a patient with esotropia and exotropia.
Patients with a restrictive or neurogenic esotropia (deficiency of abduction) may
adopt an abnormal head position to place the eyes in the position of best
alignment to avoid double vision. By turning the face in the direction of the
deficiency (e.g., right face turn for right sixth nerve palsy) when looking straight
ahead, the eyes align and appear straight ( Fig. 28.2 ). The patient’s head must be
held in the straight up position to notice that the affected eye is actually crossed.
