Endgames

Case report

A 3½ year old girl presenting with strabismus

BMJ 2009; 338 doi: 10.1136/bmj.b68 (Published 21 January 2009)
Cite this as: BMJ 2009;338:b68

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  1. Catherine E Stewart, research fellow and clinical orthoptist,
  2. Clare M Wilson, research fellow and specialist registrar, ophthalmology,
  3. Alistair R Fielder, professor emeritus, ophthalmology
  1. 1Department of Optometry and Visual Science, City University, London EC1V 0HB
  1. Correspondence to: C E Stewart c.e.stewart{at}city.ac.uk

    A 3½ year old white girl attended the paediatric eye clinic. Her mother had noticed she had been screwing her eyes up and blinking excessively. This occurred mainly when she was reading and towards the end of the day, and it had worsened over six months. The child was otherwise well, was taking no drugs, and had been born at full term by normal delivery at a weight of 3200 g. She had not had any previous eye treatment. Her mother and maternal grandfather had had strabismus from early childhood. Testing revealed a constant slight right convergent strabismus for near and distance fixation (near 12 prism dioptres; distance 8 prism dioptres). Unaided vision of the right and left eyes was 6/30 (0.7) and 6/7.5 (0.1). Depth perception was negative. Ophthalmoscopy was normal and cycloplegic refraction revealed bilateral moderate hypermetropia (long sightedness) with significant anisometropia (difference in refractive error between the two eyes; +5.00 dioptre spheres (DS) in the right eye and +3.50 (DS) in the left eye).

    Questions

    • 1. What is the diagnosis?

    • 2. Which are the risk factors for strabismus?

    • 3. What are the characteristic findings in this diagnosis?

    • 4. How should this child be treated?

    Answers

    Short answers

    • 1. Right constant convergent strabismus with anisometropic hypermetropia. Anisometropic and strabismic (mixed) amblyopia.

    • 2. A family history of strabismus; premature birth; low birth weight at full term; low socioeconomic status; visual deprivation (for example, cataract); and refractive error—particularly long sightedness and a difference in refractive error between the two eyes.

    • 3. Constant unilateral strabismus; refractive error (>1 DS or >1.5 dioptre cyl …

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