ABSTRACT
An 11-year-old female presenting diplopia only at distance was found to have comitant esotropia of 20 prism diopters (PD) at distance and normal alignment at nearer proximity. Other ocular movement, including abduction, was normal and a thorough neurologic examination was also normal. The deviation angle of esotropia was increased to 35 PD in 6 months, and a brain magnetic resonance imaging with venogram at that time demonstrated no intracranial lesion. A lumbar puncture showed increased opening pressure but the cerebrospinal fluid composition was normal. The patient was diagnosed as having idiopathic intracranial hypertension and treated with oral acetazolamide. Three months after treatment, the deviation angle decreased to 10 PD. This is a case report of divergence insufficiency in pediatric idiopathic intracranial hypertension, with an increasing deviation angle of esotropia. Although sixth cranial nerve palsy is a common neurologic manifestation in intracranial hypertension, clinicians should be aware of the possibility of divergence insufficiency. Also, ophthalmoparesis may not be apparent and typical at first presentation, as seen in this case, and therefore ophthalmologists should be aware of this fact, while conducting careful and proper evaluation, follow-up, and intervention.
Subject(s)
Child , Female , Humans , Acetazolamide/administration & dosage , Administration, Oral , Diagnosis, Differential , Diuretics/administration & dosage , Esotropia/diagnosis , Exotropia/diagnosis , Eye Movements , Follow-Up Studies , Intracranial Pressure , Magnetic Resonance Imaging , Pseudotumor Cerebri/complications , Spinal Puncture/methods , Vision, Binocular , Visual AcuityABSTRACT
PURPOSE: To report a case of bilateral papilledema and visual field defect in pediatric idiopathic intracranial hypertension. CASE SUMMARY: The 5-year-old female patient was admitted to the hospital, complaining of headache and vomiting of 3 weeks duration. After admission, she complained of diplopia. The uncorrected visual acuity was 0.3 in the right eye and 0.8 in the left. An alternative prism cover test showed approximately 35 PD esotropia, with a -2 abduction limitation of both eyes. Fundus examination showed bilateral papilledema and peripapillary retinal hemorrhages. No abnormality was found in the MRI and CT, symptoms of headache, vomiting, bilateral papilledema, and esotropia with normal neurologic examination. Therefore, she was diagnosed with pediatric idiopathic intracranial hypertension. In Humphrey visual field test, MD was -14.15 dB in right and -16.58 dB in the left eye. Also, the general sensitivity of visual field decreased. Acetazolamide (Diamox(R)) was given orally for 30 days. Forty-four days after the initial visit, peripapillary retinal hemorrhages and vessel tortuosity decreased. Furthermore, visual acuity improved to 1.0 in the right eye and 0.9 in the left. The esotropia reduced to 5 PD, and MD improved to -4.83 dB in the right eye and -5.24 dB in the left.