A 3-year-old boy is brought to the pediatrician by his parents because his right eye “turns inward,” especially when he is tired. They first noticed this 6 months ago. He was born at term and has met all developmental milestones. There is no history of trauma or infection. On physical examination, the corneal light reflex is displaced laterally in the right eye. During the cover–uncover test, covering the left eye causes the right eye to move outward to fixate on the target. Visual acuity testing reveals decreased vision in the right eye compared with the left.
Which of the following is the most appropriate next step in management?
The correct answer is:
D) Occlusion therapy of the unaffected eye
This child has strabismus, specifically esotropia, as evidenced by inward deviation of the eye and the cover–uncover test findings. The decreased visual acuity in the affected eye indicates amblyopia, which results from suppression of visual input from the misaligned eye during early childhood. The primary goal of treatment is to prevent permanent vision loss by forcing use of the weaker eye. Occlusion therapy (patching) of the unaffected eye is first-line management for amblyopia in young children. Early treatment is critical, as amblyopia becomes irreversible after approximately age 7–8.
Answer choice A: Botulinum toxin injection into the medial rectus muscle, is incorrect. Botulinum toxin or surgical correction may be considered for persistent or severe strabismus, but amblyopia must be addressed first with occlusion therapy to optimize visual development.
Answer choice B: Magnetic resonance imaging of the brain and orbits, is incorrect. Neuroimaging is not indicated in a child with isolated, chronic strabismus and no neurologic deficits or signs of increased intracranial pressure.
Answer choice C: Observation and reassurance, is incorrect. Observation alone is inappropriate because untreated amblyopia can lead to permanent vision loss. Early intervention is essential.
Answer choice E: Prescription of topical atropine drops in both eyes, is incorrect. Atropine penalization can be used as an alternative to patching but is applied to the unaffected eye only, not both eyes.
Key Learning Point
Strabismus in early childhood can lead to amblyopia, which requires prompt treatment with occlusion or penalization of the unaffected eye to prevent permanent vision loss.
