Pediatric emergency medicine trisk 0604 0604
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illnesses, including varicella. As with exotropia of neurogenic origin, it would be
more likely to have other branches of the third cranial nerve involved with other
findings. Another type of vertical eye muscle imbalance, skew deviation, can be
the presenting sign of a midbrain lesion. Ophthalmology consultation can be
helpful in deciding whether MRI is appropriate.
Hypotropia can be caused by an orbital roof fracture with superior hematoma
that pushes the eye down. Alternatively, hypertropia from a deficiency of
downward gaze due to tethering of the superior rectus muscle in an orbital roof
fracture can also occur uncommonly. Orbital roof fracture is an emergent
condition. Neuroradiologic evaluation of the brain and the orbits, including
coronal views, must be obtained to rule out communication between the orbit and
the intracranial cavity. Pulsating proptosis is a particularly ominous sign
indicating direct contact between the intracranial and orbital compartments.
Traumatic hypotropia most commonly results from orbital floor blowout
fractures ( Figs. 28.4 and 28.8 ). Enophthalmos may be observed, and there may
be associated numbness in the distribution of the infraorbital nerve as it
innervates the ipsilateral infraorbital and malar region. Orbital lesions, including
those that may have extended from the intracranial cavity, may push the eyeball
downward and prevent it from looking upward. Thyroid eye disease also can
cause hypotropia due to tightening of the inferior rectus.
In summary, prompt evaluation and treatment by an ophthalmologist is
warranted for all children presenting with acute strabismus as these patients are at
risk for visual loss from amblyopia. Emergent evaluation is needed if the eye
movements are limited by paralysis or restriction of the extraocular muscles.
Suggested Readings and Key References
Abramson DH, Beaverson K, Sangani P, et al. Screening for retinoblastoma:
presenting signs as prognosticators of patient and ocular survival. Pediatrics
2003;112(6 pt 1):1248–1255.
Chapter 8: Pediatrics. In: Bagheri N, Wajda BN, eds. The Wills Eye Manual—
Office and Emergency Room Diagnosis of Eye Disorders . 7th ed. Philadelphia,
PA: Wolters Kluwer; 2017:177–203.
Donahue SP. Clinical practice. Pediatric strabismus. N Engl J Med
2007;356:1040–1047.
Oppenheimer AJ, Monson LA, Buchman SR. Pediatric orbital fractures.
Craniomaxillofac Trauma Reconstr 2013;6(1):9–20.
Ticho BH. Strabismus. Pediatr Clin North Am 2003;50(1):173–188.
