Children who present with acute-onset esodeviation should be investigated for underlying central nervous system disorders, study findings indicate.
By contrast, the same presentation in adults is more likely due to age-related reduction in accommodation, say Erin Herlihy (Seattle Children's Hospital, Washington, USA) and co-authors in JAMA Ophthalmology.
From a retrospective chart review, Herlihy's team examined the clinical and eye movement findings that distinguish abducens palsy from divergence insufficiency.
They analyzed medical records of 15 children (mean age 11 years) and 17 adults (mean age 50 years), all of whom had esotropia greater at distance than at near.
Of the children, 14 (93.3%) had acute or subacute onset of esotropia that coincided temporally with the onset of central nervous system disorder and was the reason for seeking medical evaluation.
Each of the 15 children had an underlying central nervous system disorder that could be associated with increased intracranial pressure. Specifically, five children had a mass lesion (tumor, arachnoid cyst, and encephalocele), three had meningitis, two had spina bifida, two had Guillain-Barré syndrome, one had a transverse sinus thrombosis, and one had Sotos syndrome.
By contrast, each of the 17 adults was initially evaluated by an ophthalmologist because of the insidious onset of horizontal diplopia. Just four patients (23.5%) were ultimately diagnosed with a central nervous system disorder - namely, syringomyelia of the cervical cord, choroid plexus papilloma, basal ganglia stroke, and cerebellar stroke.
On examination, the mean esodeviations at distance and at near were 20 and 7 prism diopters (PD), respectively, in the pediatric group, and 14 and 1 PD, respectively, in adults.
Ocular rotations were normal in both children and adults, and none of the adult patients showed incomitance in lateral gazes. Eye movement recordings in two pediatric patients revealed lateral incomitance suggestive of abducens palsy, although this was not detected clinically.
Herlihy and team write: "The acute onset of an esodeviation greater at distance in a child is frequently associated with an underlying central nervous system disorder.
"The same pattern of strabismus in an otherwise healthy adult is more likely due to age-related reduction in accommodation, increased ratio of accommodative vergence to accommodation, and relative divergence insufficiency."
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