Reese is a 2-year-old who comes to the clinic because her parents have noted her left eye deviates nasally more than the right. Her parents have noted Reese

Instructor question

Hello Class,

As you review your peers' responses this week, please share alterative approaches to care with the class. How would you approach this case differently? Thoughts? Please share with us. 🙂

Kathy

Case Scenario 2: 2-year-old Reese

Case Scenario 2: Reese is a 2-year-old who comes to the clinic because her parents have noted her left eye deviates nasally more than the right. Her parents have noted Reese squints and tilts her head often and seems to have decreased visual acuity from her left eye. They are concerned about her vision.

1)What relevant questions would you want to know about Reese?

Onset:

When did you first notice the eye deviation?

Has the deviation been present since early infancy?

Was Reese born full-term or premature?

Were there any complications during pregnancy or birth?

Did she have any past or present head trauma or accidents?

Location:

Which eye is primarily affected?

Does the deviation occur in both eyes or only in the left eye?

Duration:

Is the deviation always present or intermittent?

When is the deviation most noticeable? (e.g., with fatigue or in certain gaze positions)

Has the deviation worsened over time, or has it been always the same?

Characteristics:

Besides squinting and head tilting, have there been changes in her behavior or ability to interact visually with the environment?

Does she tilt her head in a specific direction frequently?

Does she tilt her head more toward the right or left?

Does she have difficulty tracking objects?

Does she show signs of possible double vision (e.g., closing one eye, misjudging objects)?

Has she ever complained of double vision (if verbal)?

Aggravating Factors:

Does the deviation worsen with fatigue, activity, or focusing on near objects?

Are there other symptoms like headaches, eye strain (asthenopia), or abnormal head posture?

Relieving Factors:

Does anything improve the deviation, such as rest or a particular head position?

Timing:

Is the deviation constant or does it change at different times of the day?

Has it been noticed more in certain activities (e.g., watching TV, playing with toys, reading)?

Severity:

How severe does the deviation appear?

Does it impact Reese’s daily activities, such as playing or recognizing objects?

Other related questions:

Has Reese had any previous eye infections, injuries, or surgeries?

Are there other symptoms (headaches, abnormal head posture, diplopia, asthenopia/eye strain)?

Has she ever had an eye exam at her routine well-child visits?

Has she been referred to a pediatric ophthalmologist? If yes, when and what were the results?

Has she ever been prescribed glasses or undergone patching therapy?

Has she had any previous treatments for strabismus or vision issues?

Is there a family history of vision problems, strabismus, amblyopia, or refractive errors?

Have any family members required vision correction or eye surgery?

Does she have any developmental delays?

Are there any concerns about reaching visual milestones?

Are there any other medical problems (e.g., neuromuscular or genetic disorders)?

Is there any history of exposure to toxins or medications that could affect vision? (Coats & Paysse, 2025).

 

2)What type of exam (s) should you perform?

General physical exam: This exam can evaluate overall health and neurological status, including developmental assessment. Any abnormal head posture, such as tilting or turning, should be documented, as it may indicate paralytic, restrictive, or pattern strabismus (Coats & Paysse, 2025).

 

Eye exam: The primary care provider's eye examination should assess visual function, pupillary reactivity, eyelid position, and extraocular movements (ductions/versions). It should also include the corneal light reflex test, the cover test, and the cover/uncover test (Coats & Paysse, 2025).

Corneal Light Reflex (Hirschberg Test)

The corneal light reflex test, also known as the Hirschberg test, is a common initial screening tool for strabismus. This test can detect strabismus and the misalignment of the eyes by assessing light reflection asymmetry. In this test, an accommodative target (e.g., a small toy) is placed several feet in front of the child's face, with a penlight positioned next to the target. In normal ocular alignment, the light reflex appears centrally and symmetrically in both eyes. If a moderate to large ocular misalignment is present, the corneal light reflex in one eye will be deflected. Each millimeter of deflection corresponds to approximately 7 to 10 degrees of deviation. Since this test may not detect small deviations, it should be used in conjunction with the cover test and the cover/uncover test (Coats & Paysse, 2025).

Cover Test

The cover test is a key method for detecting manifest strabismus (tropia). The child is instructed to visually fixate on a target at either near or distance. The examiner then briefly covers one eye while observing the movement of the uncovered eye. In normal ocular alignment (orthotropia), no movement occurs when covering either eye. If manifest strabismus is present, the uncovered eye will shift to refixate on the target when the previously fixating eye is covered. The test should be performed on both eyes, and if a tropia is detected, referral to a pediatric ophthalmologist is warranted (Coats & Paysse, 2025).

Cover/Uncover Test

This test is used to identify latent strabismus (phoria). Cover-uncover test to determine the presence and extent of any deviation and misalignment. This test determines if strabismus is manifest (tropia) or latent (phoria). If the cover test already reveals a tropia, the cover/uncover test is unnecessary, as an abnormal cover test alone warrants referral to an ophthalmologist (Coats & Paysse, 2025). In the cover/uncover test, the child fixates on a target, and one eye is covered for a few seconds before being rapidly uncovered. The previously covered eye is then observed for any refixation movement. If a phoria is present, this eye will shift back into proper alignment to restore binocular vision. Small, barely perceptible phorias are common and not necessarily pathological, but larger phorias associated with symptoms like eye strain (asthenopia) or double vision (diplopia) should be evaluated by an ophthalmologist (Coats & Paysse, 2025).

Visual Acuity Test: Age-appropriate assessment using fix and follow or Teller acuity cards. In infants, 'CSM' method is a simple technique to observe fixation and followability. Although challenging at the age of 2, using age-appropriate methods like fixation preference testing, matching pictures, or using Teller Acuity Cards can help estimate her visual acuity. At the age of 2, toddlers have a visual acuity of 20/50 to 20/60 (Coats & Paysse, 2025).

Extraocular Movements Test: To assess eye movements. We need to ensure full range of motion to differentiate from cranial nerve palsies (CN III, IV, VI) (Coats & Paysse, 2025).

Brückner Test (Simultaneous Red Reflex Test)

This is a simple, quick ophthalmoscope-based screening method used to detect refractive errors, strabismus, and other ocular abnormalities, particularly in young children. The Brückner test is useful for detecting small-angle strabismus. Red Reflex involves shining a light into the eyes and observing the reflection (Coats & Paysse, 2025). The red reflex from the retina is a quick and non-invasive test used to identify opacities in the visual axis to detect:

· Abnormalities in the normally transparent visual axis or in the retina (Maaks et al., 2019).

· Strabismus and unequal refractive errors (Maaks et al., 2019).

The examiner, positioned 18 to 20 inches away from the child, uses a direct ophthalmoscope with the largest light diameter to assess both eyes’ red reflexes simultaneously. The lenses are adjusted until the skin around the eyes is in focus while the child fixates on a target near the ophthalmoscope. Both red reflexes should appear identical in size, shape, color, and brightness (Coats & Paysse, 2025). Any asymmetry in these characteristics suggests a potential ocular disorder, such as strabismus, significant anisometropia (refractive imbalance), or media opacities (e.g., cataract, anterior chamber or vitreous abnormalities, coloboma, or retinal tumor). In such cases, referral to a pediatric ophthalmologist is necessary (Coats & Paysse, 2025).

Additional Evaluation

Further evaluation depends on the suspected cause of strabismus. While blood tests (e.g., complete blood count, erythrocyte sedimentation rate, C-reactive protein) and neuroimaging are rarely required for routine strabismus, neuroimaging should be considered in cases involving craniofacial malformations, neurological disorders, abnormal neurological findings, head or orbital trauma, or acute-onset paralytic or restrictive strabismus (Coats & Paysse, 2025).

3) How should you manage Reese?

The treatment for strabismus depends upon the etiology. Improved ocular alignment and binocularity (including stereopsis) are the goals of therapy (Maaks et al., 2019).

Treating Alignment:

Strabismus management may involve observation with routine follow-ups or medical and surgical interventions. Regular ophthalmologic monitoring is appropriate for children with a small deviation (less than 5 to 8 degrees) that is intermittent, well-controlled, or moderately controlled, and when fusion or stereopsis is present. Both surgical and nonsurgical approaches are used to correct ocular misalignment (Coats & Paysse, 2025).

Referral to Pediatric Ophthalmology & Strabismology: Persistent esotropia at this age requires specialist evaluation (Coats & Paysse, 2025).

Correct Refractive Error: If accommodative esotropia is suspected, prescription glasses may help correct alignment.

· Nonsurgical Treatments: These include prescription glasses or contact lenses, prism therapy, miotic eye drops to adjust accommodation, occlusion therapy, and visual training exercises (orthoptics).

· Surgical Interventions: Procedures to enhance ocular alignment involve modifying the extraocular muscles through techniques such as recession, resection, and transposition. If non-accommodative or refractory esotropia is present, surgical intervention may be necessary to realign extraocular muscles.

· Extraocular Muscle Recession: This procedure involves repositioning the muscle insertion further back on the sclera, reducing its strength and influence on eye movement.

· Extraocular Muscle Resection: This technique shortens the muscle, increasing its effect on globe positioning by acting as a passive restraint.

· Regular Follow-Up:

Katherine

 Taylor is 7-year-old who is brought to the clinic by her aunt because she has had redness in her right eye for 3 days. Today when she woke up, her right eye was swollen, red, and tender. She denies fever.

What should you ask Taylor about her eye?  It’s important that the APRN takes into consideration the patients age when asking question. Some questions that can be asked are

· "Can you tell me when your eye started to hurt?"

· "Does your eye feel itchy, burning, or like something is stuck in it?"

· "Do you have any tears coming out of your eye? Is it sticky or yellow?"

· "Does it hurt more when you touch it or move your eye around?"

· "Can you see clearly, or is everything blurry?

· "Did anything get into your eye, like dust or sand?"

· "Do you remember hitting or hurting your eye?"

· "Have you been near anyone who had red or itchy eyes?"

· "Do you feel okay otherwise, or do you feel tired or sick?

· What type of exam(s) should be performed?

Check for swelling, redness, discharge, crusting, or eyelid drooping.

           Assess for protrusion of the eye (proptosis), which may indicate a serious infection.

 

· What would be your management for this patient?

· Amoxicillin-clavulanate  OR Cephalexin

· Supportive care such as Warm compresses 3-4 times daily,

· Acetaminophen or ibuprofen for pain relief

· Close follow-up in 24-48 hours to ensure improvement.