Pediatric Ophthalmology Case Study

Study Notes

Patient Information

Emma Watson is a 6-year-old female who presented on March 15, 2024.

Chief Complaint

Emma's mother reported that Emma has had misalignment of her eyes for the past year.
The right eye turns inward intermittently, especially when Emma is tired or focusing on distant objects.
The issue has become more noticeable in the past few months.

History of Present Illness

The eye misalignment was first noticed 12 months ago.
It was initially subtle and intermittent, but the frequency has increased over the last six months.
Emma complains of occasional double vision and difficulty focusing, especially while reading.
She does not report pain or redness.
Emma sometimes tilts her head slightly to the right, which helps her focus.

Past Medical History

Emma was born full-term with no complications.
She has no history of previous eye surgery or trauma.
She reached developmental milestones normally.
There is no significant family history of eye disorders.

Review of Systems

Emma has difficulty seeing clearly in both near and far distances.
She reports no headaches or seizures.
Emma is generally healthy and has no other systemic symptoms.

Physical Examination

Emma appears healthy for her age.
Her visual acuity is 20/40 in the right eye and 20/20 in the left eye.

Ocular Examination

The Hirschberg test shows a noticeable deviation in the right eye, indicating esotropia (inward deviation).
The cover test confirms right esotropia, as the right eye moves outward to take up fixation when the left eye is covered..
Extraocular movements (EOM) are full range in both eyes, with no restrictions observed.
Pupils are equal, round, and reactive to light and accommodation.
Fundoscopy revealed normal findings, with no evidence of retinal abnormalities or optic nerve issues.

Assessment

The diagnosis is right eye intermittent esotropia (squint).
The inward turning of the right eye is confirmed by the Hirschberg and cover tests.
The vision in the affected eye is reduced (amblyopia).

Differential Diagnosis

Concomitant esotropia is the most likely diagnosis, given Emma's age of onset and the absence of neurological signs.
Accommodative esotropia must be considered and will be evaluated further.
Paretic strabismus is unlikely, as there is no limitation in extraocular movements and no history of trauma.

Plan

A cycloplegic refraction test will be conducted to assess for refractive error.
Glasses may help control the esotropia if accommodation is a contributing factor.
Emma will undergo occlusion therapy (patching) of her left eye (dominant eye) for several hours each day to encourage visual development in the right eye.

Follow-Up

Emma will be monitored every 3-4 months to assess improvement in alignment and vision.
Adjustments to glasses or therapy may be needed based on progress.

Surgical Consultation

If the strabismus does not improve with glasses and amblyopia treatment, a referral for possible strabismus surgery (to align the eyes) will be considered.

Patient Education

Emma's mother was educated about the importance of adhering to patching therapy to treat amblyopia and prevent long-term vision loss.
The possibility of needing glasses or surgery, depending on the severity and persistence of the squint, was discussed.
The mother was advised to return to the clinic immediately if Emma develops any new symptoms, such as worsening vision, pain, or significant changes in eye alignment.

Conclusion

Emma is a 6-year-old girl diagnosed with intermittent esotropia and amblyopia of the right eye.
Initial management will focus on correcting any refractive error and treating the amblyopia.
Follow-up will be essential to monitor progress and consider additional interventions if necessary.
Her next appointment is scheduled for June 25, 2024.

Description

This quiz focuses on a pediatric case study involving a 6-year-old girl, Emma Watson, presenting with intermittent eye misalignment. Explore her symptoms, history, and possible diagnosis associated with strabismus and its implications. Test your understanding of pediatric eye disorders.