A 3              . K       6/6  6/60 unaided.

unaided. There is a large esotropia and the child seems to have difficulty in abducting left eye past the midline. Describe your management of this case. Main points in question 3 year old child, unilateral large esotropia,  ., vision 6/60 Introduction From the history of the child , it seems that he may be suffering from some neuromuscular disorder with amblyopia. However , I would perform a full orthoptic check up and ocular exam to exclude other possibilities. HistoryI will inquire about Duration, birth trauma, history of squint surgery , orbital fracture, family h/o retinoblastoma , cataracts , squints,refractive disorders I will also inquire about his milestones,& check for hearing &speech disorder, Differential diagnosis duanes type 1 ----esotropia with restriction of abduction Medial wall fracture with MR entrapmentbut no h/o orbital fracture Left LR palsy- LR myositis? Parasitic infestation on LR ? No pain ,inflammation strabismus fixus mostly bilateral consecutive esotropia following overcorrection of exodeviation but here no h/o squint surgery infantile esotropialarge ange, but no restriction of abduction sensory esotropia - intraocular pathology- retinoblastoma, macular scarring cataract. None present, no nystagmus Examination Orthoptic Visual acuity unaided & aided ( if spectacle wearer), PH vision ( if cooperative). Retinoscopy under cycloplegia will be done after complete orthoptic exam Head postureface turn to left Hershberg test, -- large esotropia Cover test- fixation pattern, Nystagmus, alternate cover test to measure total deviation, note DVD, Krimsky test to measure the squint

Ocular movements - versions ductions abduction deficits . note decrease in palpaberal fissure on adduction, upshot downshoot, . convergence problem in LE. , any IO overaction? Retinoscopy under cycloplegia. Ocular Pupillary reaction direct consensual , near Slit lamp exam-& Dilated fundus exam - look for corneal scars, cataract, maculopathy, optic atrophy, myopic fundus, that may lead to sensory esotropia, exclude retinoblastoma If media opacity- Ultrasounsd B scan can be done to exclude RB, RD Diagnosis The child seems to be having duanes type 1     amblyopia.(probably anisometropic or strabismic ) Management I will give him full cycloplegic correction ( subtracting Distance) I will suggest him simultaneous squint correction but inform the parents that he will have to follow the patching 3 hours pe r day for 3 weeks ( child is 3 yr old) otherwise chances of recurrence of squint. Indication of surgery here is cosmetically unacceptable amount of squint, head posture&amblyopia I will perform the surgery under GA, and would recess LE MR maximum by 5mm ,      in these cases,If co contraction of muscle is severe then I will perform verticaltransposition of SR & IR 2-3 mm from superior and inferior border of the LR & simultaneous Recession of LMR     /   ,    1   . Encourage the parent and child to / continue occluding Le as directed, if signs of improvement in vision are there. When vision improves , I will taperthe patching and try to stop. I will suggest six monthly review of my patient. ------------------------------------------------------------------------1      d / followed by lateral rectus palsy Normally unless there is anisometropia there should not be amblyopia check for cycloplegic refraction and recheck vision with pre verbal tests like preferential looking test or Allen cards or Lees chart If it is straight forward case treat amblyopia if any and do a bimedial recession with calculation in prisms of the secondary deviation with fixing affected eye Forced duction test will confim the diagnosis of Duanes rest luks fine-TSS DR T S SURENDRAN