Ophthalmology Update - Cleveland Clinic

Case Study: Five-Month-Old Boy Presents with
Incomitant Esotropia
By Evelyn Fu, M.D., and Elias I. Traboulsi, M.D.
a 5-month-old boy with no significant ocular history
presented to cleveland clinic cole eye institute with
esotropia of the right eye for 1 month. no other visual
symptoms were noted. his medical history revealed
a recent episode of otitis media treated with antibiotic
eardrops. he was born at full term via vaginal
delivery without perinatal complications. review
of systems is significant for episodic nonprojectile
vomiting with increasing frequency that began one
week prior to presentation. Family history is positive
for hypertension and aortic dissection in paternal
great-grandfather and grandfather.
On examination, the boy appears well nourished and
developed. he fixes and follows well with both eyes.
there is a moderate esotropia of the right eye in primary
gaze that increases on right gaze and decreases
on left gaze. the degree of esotropia is equal at
distance and near. there is severe limitation in
abduction of the right eye beyond midline. globe
retraction is not noted in adduction. the pupils are
equal, round and reactive to light without an afferent
defect. slit-lamp examination and dilated ophthalmoscopy
are normal in both eyes. the remaining
medical and neurological examination is normal.
Differential Diagnosis
incomitant esotropia describes an inward deviation
of the eye that varies in different fields of gaze. it results
from a variety of etiologies including sixth-nerve
palsy, type i duane syndrome, divergence insufficiency
and orbital blowout fracture with restriction of the
lateral rectus muscle. patients with type i duane syndrome
have poor abduction with globe retraction in
adduction. divergence insufficiency is characterized
by esotropia that is greater at distance than at near.
Further, the deviation does not change with vertical or
horizontal gaze. Our patient’s symptoms and signs
are most consistent with an isolated sixth-nerve palsy.
Diagnosis
the most common causes of sixth-nerve palsy in
children are trauma and intracranial lesions. 1, 2 in
the absence of trauma, a full neurological evaluation
including neuroimaging is recommended. On head
ct, a 2.6-cm hyperdense mass was noted in the right
middle fossa with remodeling of the adjacent
FIGURE 1
FIGURE 2
sphenoid body and greater wing (Figure 1). cta and
mri demonstrated characteristics of a giant thrombosed
aneurysm of the cavernous internal carotid
artery, without compression of the optic nerve or
chiasm (Figure 2). the diagnosis was a giant intracavernous
carotid artery aneurysm (iccaa).
Discussion
iccaas are extremely rare in the pediatric population.
3, 4 information regarding the natural history,
pathogenesis, radiographic features, treatment and
prognosis are derived from large case series of adult
patients. 5, 6, 7 symptoms from iccaa can be divided
Continued on page 26
i n v e s t i g a t i O n s
Figure 1: CT image of
a 5-month-old boy with
incomitant esotropia.
Figure 2: MR image of
a 5-month-old boy with
incomitant esotropia.
c O l e e y e i n s t i t U t e c l e v e l a n d c l i n i c . O r g / e y e //