-B- SUBJECTIVE:
Parent complained that child’s RE turns upward and LE turning inward. Mother noticed the condition since the child was around 6 months old. At that time she reported that there was no vertical deviation of the RE and only the LE appear to be turning inward.
However lately, mother began to notice more frequent turning of the eyes especially when the child is focusing at near object.
However lately, mother began to notice more frequent turning of the eyes especially when the child is focusing at near object.
· No reported of excessive or constant eye rubbing.
· Child watches TV at normal distance around 3 metres.
· No reported AHP.
· History of minor trauma; child fell off from the bed at 2 years of age.
· No history of high fever or epilepsy.
· Child was born healthy & at full term (Caesarean delivery).
· Child’s development is normal. Child can talk very well and was active during the examination.
-C- OBJECTIVE:
REFRACTION | RE | LE |
Vision Unaided | Binocular: 6/38 (Lea symbol) | |
Refraction | +2.00 | +1.75 / -0.50 X 90 |
Failed to obtain VA to non-compliance | ||
OCULAR DEVIATION | RE | LE |
Hirschberg | Central & Symmetry | |
Bruckner Test |  | |
Hyperopia Equal brightness | ||
Cover Test (∞) Cover Test (N) | Othophoria @ 1° position Othophoria @ 1° position | |
LE ET upon the right gaze, no improvement in strabismic angle with +3.00 D. | ||
OCULAR DOMINANCY Hand Dominancy | Right handed |
MOTOR FUNCTION | RE | LE |
Ocular Motility |  |  |
EXTERNAL EXAMINATION | Constant mild ptosis | NAD |
OBSERVATION | Patient was given a colouring book & pencil, we observe a very close working distance of about 15 cm. | |
1. Listed below are the differential diagnoses for this case. Which one of these is the right diagnosis?
· Abducens nerve palsy
· Duane Syndrome
· Brown Syndrome
· Infantile Esotropia
-->prepared by Group 4 :D
this case is going to be very interesting guys.
ReplyDeleteLot of photos, informations/data, & illustrations.
Prepared by Nana, Atikah, Eli and Azuwan (group 4).
good
ReplyDeleteit is Duane syndrome..this is a congenital eye movement disorder. the eye is unable to abduct in the unaffected eye and in this case RE is unable to abduct.
ReplyDeletei assume he has Duane Syndrome type 1 as he has underaction of RE LR (RE unable to abduct).
as oppose to type 2 Duane Syndrome, they have limitation to adduct in the affected eye. for type 3, they have combination of bothe limitation of adduction and abduction of the affected eye.
some more info:
http://www.cybersight.org/data/1/rec_imgs/1758_strab%20book%202.50.jpg
more info on duane syndrome type 1:
ReplyDelete*limited abduction of affected eye
*widening of lid fissure of affected eye on abduction
*narrowing of lid fissure of affected eye on adduction
*up and down shoot in adduction
*ET in primary position
*head turn towards involved side
this is not brown's syndrome because brown syndrome characterized by inability to elevate the eye in adduction. SO, muscle tendon or trochlea are abnormal.
ReplyDeleteabduscent nerve palsy and infantile ET are also excluded as in primary position, the pt's eyes are orthophoria whereas in abduscent nerve palsy and infantile ET, constant ET at primary position can be seen.
Duane's retraction syndrome type 3.
ReplyDeleteInprimary position, it is Ortho, no AHP and no globe retraction.
compared to DRS 1 and DRS 2,
DRS 1: ET in primary position, globe retraction on ABDuction and has AHP.
DRS 2 : XT in primary position, globe retraction on ABDuction and has AHP.
Duane's retraction syndrome type 3.
ReplyDeleteInprimary position, it is Ortho, no AHP and no globe retraction.
compared to DRS 1 and DRS 2,
DRS 1: ET in primary position, globe retraction on ABDuction and has AHP.
DRS 2 : XT in primary position, globe retraction on ABDuction and has AHP.
Abducens nerve pasly (LR) CN6.
ReplyDeleteaka Granedigo's syndrome.
due to CN6 palsy and middle ear infection...
symptoms:
-retro orbital pain.
-ipsilateral paresis of CN6.
-otitis media.
-photophobia.
-excess lacrimation.
-fever.
-reduce corneal sensitivity.
Brown's syndrome:
-congenital or acquired.
-good BSV.
-chin up and face turn to unaffected.
-hypotropia in primary position.
-elevation limited in ADDuction.
-positive FDT on elevation in ADDuction.
-minimal or no action of SO.
-intorsion in attempted upo gaze.
-tight post tendon fibres.
usually a limitation and does not improve on its own.
Infantile ET
-large constant angle >40 PD.
-poor prognosis to BSV.
-IO overaction.
-DVD.
Nystagmus.
-cross fixation.
#differential diagnosis of Duane's retraction syndrome type 1 : congenital ET.
Abducens nerve pasly (LR) CN6.
ReplyDeleteaka Granedigo's syndrome.
due to CN6 palsy and middle ear infection...
symptoms:
-retro orbital pain.
-ipsilateral paresis of CN6.
-otitis media.
-photophobia.
-excess lacrimation.
-fever.
-reduce corneal sensitivity.
Brown's syndrome:
-congenital or acquired.
-good BSV.
-chin up and face turn to unaffected.
-hypotropia in primary position.
-elevation limited in ADDuction.
-positive FDT on elevation in ADDuction.
-minimal or no action of SO.
-intorsion in attempted upo gaze.
-tight post tendon fibres.
usually a limitation and does not improve on its own.
Infantile ET
-large constant angle >40 PD.
-poor prognosis to BSV.
-IO overaction.
-DVD.
Nystagmus.
-cross fixation.
#differential diagnosis of Duane's retraction syndrome type 1 : congenital ET.
to all,
ReplyDeleteDon't easily come out into diagnosis yet....(saje cari pasal).
if you have already had the Dx,what the management can be?
this patient has mild ptosis on RE, what will happen if patient look upward binocularly?
and what can we say about the bruckner test finding? is it normal for this pt?
ATTENTION EVERYONE!!! we would like to make a correction here. It's not RE XT upon the right gaze, instead it is LE ET upon the right gaze...
ReplyDeletePlease look carefully on our OMT findings, the RE unable to abduct upon right gaze..
@GROUP 4
ReplyDeletesorry for the inconvenience.
we can simply say 'no/limited abduction of RE on right gaze'
Everyone has to be certained about the Dx, characteristics and treatment.
ReplyDeleteBased on the history taking,my hypothesis is infantile esotropia as the mother claimed to see her child's eye turn inward since 6 months old...
ReplyDeleteBut the CT shows no ET at primary gaze at distance..
For group 4, what is the magnitude of LE ET on right gaze?Do you do PCT on this patient?
@M.Sobri
ReplyDeletesobri, we do measure the deviation using PCT, but the value is insignificantly low. moreover, patient did not comply during the test was performed.
But, please not that. There is no deviation in primary position. No ET @ primary position.
DX: Duane Retraction syndrome Type 1
ReplyDeleteMx:the only way to treat is by surgery.
sorry for the late appearance..
ReplyDeleteyes, exactly this patient having Duane syndrome type 1
whereby he has limited abduction on RE. menawhile in type 2 DS patient will has limitation in adduction and if in type 3, patient has both limitation in adduction and abduction.
MX:
- if no strabismus in primary gaze and can maintain SBV- routine follow up (annually) and educate pt and his parents regarding the condition.
- if there is significant strabismus in primary gaze or AHP, surgery may be indicated.
answering azuwan's question on Bruckner test:
shows patient is hyperopic eye..it is normal finding since this child is 2 years old, where at this age, it is expected to be hyperopic around +3.00DS..
sorry for the late coming...
ReplyDeletebased on infomation given, i think it is Duane Syndrome type 1...his mother complaint the LE turning inward...also based on OMT, he has limitation on abduction on RE...
the goal of treatment of duane syndrome are to:
~improve head posture
~eliminate or reduce upshoot and downshoot in adduction
~eliminate or reduce enophthalmos
~improve the alignment of eyes in primary position
so, the best t(x) for this case is surgery...
Yes..confirm Duane syndrome type 1..
ReplyDeletesalam..sori for the late coming..
ReplyDeleteinteresting case i think..u guys already comeout with diagnosis..
hmm..what make it different with abducens nerve palsy or paresis? is it that, there is no movement on primary gaze?
i'm just thinking, during the examination, is there any narrowing of palpebral fissure on adduction and retraction on globe on abduction?
@che nur
ReplyDeletesince patient has RE ptosis,'dua-dua matanya juga sepet. lol', so it was difficult to observe. But then, there was slight narrowing of palpebral fissure on adduction attempted.
Che nur, in paresis, usually, there will be diplopian and an eso deviation in primary position. This patient didn't have any.
@azuwanok, if that case, i will agree that this is duane syndrome type 1..
ReplyDeleteDifference between paresis and palsy. I would say paresis would have some movement but very limited or little. As for paralysis, muscle wouldn't be able to move at all.
ReplyDeleteSince patient primary gaze was not affected I think doctor would not do do the surgery. Base on from what I've read, surgery is indicated when there's constant tropia at primary gaze. Surgery for Duane's cases are only done for cosmetic purposes. Patient education and annual follow up would be the best management in line one the diagnosis is confirmed.