Ophthalmology

Aldwin Ong (MD070061) July 9, 2010

Patient Encounter Write-Up

Patients Name: WMB Sex: Male

Age: 6 (DOB: 03/01/04) Residence: Brgy Bonilad Nagcarlan, Laguna

nd
July 9, 2010, 9:00 am; Eye Center, 2 Floor , The Medical City

Chief Complaint
Persistent Esotropia

SALIENT FEATURES

General Data

6 years old
Male
Social class is moderate.
Started going to school; often teased by classmates about eyes.
Mother as source of history; Good reliability

History of Present Illness

Problem List:
CC and concerns regarding problem: Esotropia of four years duration; unresolved despite corrective measures
About 4 years PTC, patient was noted to start getting cross-eyed, no head tilt. Patient personally claims not to have had double vision
then. Patients mother recalls that patient accidentally fell sideways from a height between 1-2 feet early that same year, no bruises, no
lesions noted. Patient was not noted to have had fever or any other significant events prior. Persistence of esotropia prompted mother to
bring patient for consultation with a pediatric ophthalmologist, who prescribed corrective lenses to the patient. Patient has since adjusted
the lens correction at least 3 times prior to present consult.
1 month PTC, patient was started on eye patch therapy, eye patch alternated between right and left eyes every 4 hours, when at home;
continued use of corrective lenses in school.
Persistence of condition and discomfort with it in school prompted patient and mother to request for an alternative treatment, hence present
consult/referral for surgical correction.

Past Ocular History

Glasses. Last refracted June of 2009; last refraction from OD +250, OS +300 (Prism), corrected to OD +300, OS +350 (Prism)
Trauma. As recalled by the mother, a minor fall sideways from a height of 1-2 feet.
Otherwise unremarkable past ocular history.

Past Medical History

No hospitalizations
Completed vaccinations
Normal course of gestation; mother claims to have had no diseases or complication during pregnancy, labor and delivery of patient.
Otherwise unremarkable past medical history.

Family History

Fathers side:
Direct aunt (sister of father) has esotropia
Grandmother has esotropia

Review of Systems

(-) Photophobia
(-) Headache
(-) Dizziness
Otherwise unremarkable ROS

Pertinent Ocular Findings

Visual Acuity (Snellen Chart)

EYE OD OS OU
SC 20/20 2 20/20 - 1 20/20
SC w/ PH 20/20 20/20
CC 20/20 20/20 20/20
CC w/ PH 20/20 20/20
 Gross Examination

Eyebrows/Lids/Lashes
OU: (-) brow scales; (-) swelling, lashes not matted, (-) discharge; pink palpebral conjunctivae
Normal appearing epicanthus
Sclerae, Cornea
OU: Anicteric, non-hyperemic sclerae; clear cornea bilaterally
OD: Corneal light reflex medial compared to the left
OS: Corneal light reflex lateralized towards left limbic edge
Anterior Chamber
OU: Clear anterior chamber bilaterally
Iris, Pupils
OU: 3-4 mm, briskly reactive to light, (-) RAPD
Extraocular Muscles

OD: Full range of motions

OS: Full range of motions
OU: Eye on the side of the stimulus is unable to fully lateralize or gaze towards the same side.
Stereoscopic Vision
Stereoscopic vision intact using pen-tip apposition test
Titmus fly stereotest not done
Confrontation Test
OU: No visual cuts
Digital and Applanation Tonometry
OU: soft-firm by digital tonometry, 8 mmHg bilaterally by applanation tonometry
Funduscopy
OU: (+) ROR; clear media, distinct disc border; C:D ratio 0.3, OU; A:V ratio 2:3, OU; foveal reflex not observed; (-) hemorrhage, (-)
exudate
Slit-lamp
OU: Clear cornea, deep anterior chamber, round and even pupil, intact and clear capsule and lens

Psycho-socio-economic & religious Context

Born and raised as a Catholic.

Lives in Laguna, ophthalmologic equipment for observation and correction of pediatric ophthalmologic condition not complete in province;
has to travel to Quezon City for observation and management
Started to go to school (Grade 1) in Laguna, however, continually gets teased by his classmates about his thick, weird appearing
spectacles, his eyes and his vision; hence hesitation to continue attending classes.
Mother is sole breadwinner; father not known by patient. No siblings.

Stakeholder Interest in Issue Role Level of Influence

Patient - personal health: alignment of both eyes Change agent Medium
- loss of productivity from missing classes due to
embarrassment
Patient's mother - sole breadwinner Ally High
- childs health and continued education
- taking time off work to bring patient to Quezon City
for treatment

Pre-intervention work-up (minimum)

Hirschberg corneal light reflex test To assess degree of eye bilateral eye alignment or misalignment
Alternating cover-uncover test for both eyes To rule out or confirm ambyopia of either eye
Titmus fly test or another stereotest To assess stereoscopic vision
Neurologic examination / EOMs to rule out cranial nerve palsy (i.e. CN III, IV and VI)
Visual acuity (with prism) To assure that vision for either or both eyes have not degenerated from use or misuse; for eventual prescription
 of corrective lenses
Dilation and Indirect fundoscopy to have a better view of the retina and observe for possible vascular or retinal congenital or
developmental abnormalities

Clinical Impression/Diagnosis & Differential Diagnosis/es

Alternating esotropia

r/o refractive esotropia

The primary impression of alternating esotropia is well supported by the non-apparent dominance of either eye on physical examination. Both eyes
were also fully functional on visual acuity examination. Furthermore, upon use of cover-uncover test, both eyes showed equal esotropic tendencies,
where both eyes were noted to alternate fixation between right and left eye, such that at one moment the right eye fixates and the left eye turns
inward, and the next moment, the left eye fixates and the right eye turns inward. This is highly characteristic of an alternating esotropia.

On the other hand, esotropia due to refractive error may also be considered since high refractive errors may also result in pediatric patient from
hyperopia, such that their tendency to over-accommodate results in squinting and esotropia. In other words, where the degree of hyperopia is large,
the patient may not be able to produce clear vision no matter how much extra accommodation is exerted, so that their eye instead tends to converge,
resulting in the esoptropia. However, this is currently being ruled out since visual acuity for both eyes are almost perfect. On the other hand, where in
such cases as this, the degree of error is small enough to allow the child to possibly generate a clear vision by over-accomodation, there is still
chance that binocular control is still disrupted, resulting thus in esotropia.

Management

Out-hospital management
OU: Attempt to continue alternating eye patching every four hours at home; continued use of corrective lenses (Prism therapy)
With continued non-resolution of esotropia using non-surgical therapeutics, and disruptive effects of aesthetic appearance of strabismus
leads to the non-productivity of the patient, surgical correction may be warranted.

Prevention

Any pediatric patient with signs of strabismus should be brought in for evaluation and diagnosis as early as possible, in order for corrective measures
to be taken. Delay in such a consult may result in a poorer overall prognosis for the patients binocular vision and/or total angle deviation of both or
either eye, and hence aesthetic appearance of the strabismus.

Sources:

[AOA] American optometric Association. 1999. Care of the patient with strabismus: esotropia and exotropia.

Valbuena, MN. May 2006. Self-intructional materials in ophthalmology. BeaconPress Inc. University of the Philippines, Manila.