week 3 response 2

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.

Reese has findings that are concerning for strabismus, probably esotropia. The child is at risk for amblyopia if intervention is not pursued quickly. Relevant Questions I would ask the parents about onset, progression, and exacerbating factors. I would want to know how long ago they noticed the deviation in his eye and if it is present all the time. Do they notice if it gets worse when he becomes tired or is sick? Also, I would ask if they have noticed it seeming to get worse since they first noticed it. I would inquire if Reese has demonstrated behaviors such as rubbing his eyes, closing one eye to see, or difficulty tracking items. Questions regarding Reese’s birth history, such as if he was premature or had any birth complications, would be pertinent. Asking about any neurologic history would be important as well. Family history of strabismus, amblyopia, or having to wear corrective lenses at a young age would be helpful to know, as there can be a genetic component to many eye conditions. Last, I would ask if there were any red flag symptoms, such as acute onset, headache, or vomiting, to assess for possible serious neurologic issues (Burns et al., 2022). Exam to Perform The exam should include testing visual acuity and performing a complete eye exam. Testing visual acuity can be done with picture charts or by simply observing fixation and tracking of objects. Testing eye alignment with the corneal light reflex, also known as the Hirschberg test, is important. Asymmetrical light reflection indicates strabismus. However, the cover-uncover test would be the best test to perform to confirm this diagnosis. By covering each eye in succession, a manifest deviation, or tropia, can be identified. An alternate cover test can be performed to identify latent deviations, or phorias. Assessment of extraocular movements would be prudent to evaluate cranial nerves II through VI. A red reflex exam should be performed in children to rule out cataracts or retinoblastoma. Additionally, referral for cycloplegic refraction should be sent to a

pediatric ophthalmologist (American Academy of Ophthalmology [AAO], 2023). Management Pediatric ophthalmology should be contacted, and Reese should be seen as soon as possible. Although not always necessary, children that are treated early for their crossed eyes have less risk for long-term complications. Refractive errors are typically treated first with glasses. If amblyopia is also present, occlusion of the good eye can force use of the amblyopic eye. Atropine drops can also be used to blur vision in the good eye. Vision therapy may also help these eyes work together. Some patients may need surgery to correct the eye muscle alignment. Parents should be educated that the sooner the condition is treated, the better the outcomes will be, and vision loss can be prevented (AAO, 2023). Potential Complications if Left Untreated The biggest complication of leaving Reese’s condition untreated is amblyopia. The brain will suppress the image seen by the weaker eye resulting in loss of vision in that eye. Loss of binocular vision will also occur, affecting depth perception. Over time, the crossed eyes may become permanent. Other problems due to impaired vision can arise such as delays in motor skills, difficulty coordinating, and social issues (Burns et al., 2022).