Case 1: Why does my eye keep turning in?

Abstract

A five-year-old boy accompanied by his mother presented to the paediatrician’s office with a three-day history of his left eye turning in. He had no emesis, headache or other complaints, except for double vision. The symptoms were preceded by a mild upper respiratory tract infection. His medical history was remarkable for two similar episodes six and 12 months before, both involving his left eye and both following a sinus infection. At that time, a computed tomography scan of his head was performed and was found to be normal except for an incidental finding of an unrelated arachnoid cyst. Subsequent magnetic resonance imaging (MRI), after the second episode, confirmed an otherwise normal brain. He was also evaluated by an ophthalmologist and found to have 20/20 vision. In both previous episodes, the esotropia resolved after two to four weeks. On examination, the boy was alert and interactive. He had normal vital signs, including a blood pressure of 99/62 mmHg. His head circumference was 52 cm (50th percentile for his age). He had no neurocutanoeus lesions. Examination of the head, eyes, ears, nose and throat was only remarkable for left esotropia and an inability to abduct the left eye; otherwise he had full extraocular movements. He had equal and reactive pupils, and a normal fundoscopic examination with no evidence of papilledema. His neurological examination was unremarkable with intact cranial nerves (except for the left sixth cranial nerve), 5 of 5 motor strength, intact proprioception, a negative Romberg’s test, normal reflexes and a normal gait.