Erin P. Herlihy

Esotropia greater at distance: children vs adults.

IMPORTANCE Esotropia greater at distance than at near can be related to abducens palsy or to divergence insufficiency. Mild abduction weakness can be difficult to detect, blurring the distinction between these 2 conditions. OBJECTIVES To examine the clinical and eye movement findings that distinguish abducens palsy from divergence insufficiency and to account for these findings based on current knowledge of vergence neurophysiology and saccadic adaptation. DESIGN Retrospective medical record review. SETTING A pediatric referral center. PARTICIPANTS The medical records of 32 patients with esotropia greater at distance seen during a 17-year period from August 1989 to July 2006 were reviewed. MAIN OUTCOME MEASURES Details regarding age, medical history, oculomotor and neurological examinations, and result of any neuroimaging studies were recorded. Eye movements were recorded in 2 subjects using binocular video-oculography. RESULTS Fifteen children and 17 adults were identified; 93.3% of the children had an underlying central nervous system disorder that coincided with the onset of their esodeviation, and 23.5% of the adult patients had an underlying central nervous system disorder. Eye movement recordings in 2 pediatric patients revealed lateral incomitance suggestive of abducens palsy not detected by clinical examination. CONCLUSIONS AND RELEVANCE The acute onset of an esodeviation greater at distance in a child is frequently associated with an underlying central nervous system disorder. Several features suggest that the children, unlike the adults, likely had a subtle abducens paresis rather than divergence insufficiency. This was confirmed by formal eye movement studies in 2 children in whom lateral incomitance was not detected clinically. 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.

Primary myoepithelioma of the orbit in an infant.

Myoepitheliomas are rare tumors with various growth patterns and cellular variants. Primary myoepithelioma is rare in the orbit, with most previously reported cases involving the lacrimal gland region of adult patients. The authors report the case of a primary orbital soft tissue myoepithelioma in a 3-month-old boy. Diagnostic criteria and management considerations of this unusual tumor presenting in a young child are discussed.

Strabismus surgery in a patient with a Boston K-pro keratoprosthesis

We report the case of a 33-year-old woman with sensory exotropia who developed diplopia following implantation of a Boston K-pro keratoprosthesis. She underwent uneventful, successful strabismus surgery with recovery of stereopsis. To the best of our knowledge, surgical treatment of diplopia related to sensory exotropia in a K-pro patient has not been previously reported.

Chronic keratoconjunctivitis with dermatitis as a presenting sign of child abuse

A 13-month-old girl presented with chronic keratoconjunctivitis with dermatitis. She was initially diagnosed with corneal abrasion and mild preseptal cellulitis and was treated with topical and oral antibiotics. After failing to respond to standard therapy, she was eventually identified as a victim of abuse. We discuss key findings that could have provoked earlier recognition.