What is the next step in managing a 5-year-old child with a misaligned right eye in a pre-school clinic setting?

Management of Misaligned Right Eye in a 5-Year-Old Child

The Hirschberg corneal reflex test (option C) is the appropriate next step in managing a 5-year-old child with a misaligned right eye in a pre-school clinic setting. 1

Initial Assessment Algorithm

1. Corneal Light Reflex Assessment (Hirschberg test)

   • Position the child to fixate on a penlight from 12 inches (30 cm)
   • Observe the positions of corneal light reflexes in both eyes
   • Normal finding: Symmetric reflexes centered on pupils or slightly nasally displaced
   • Abnormal finding: Asymmetric reflexes indicating misalignment
     • Temporally displaced reflex suggests esotropia
     • Nasally displaced reflex suggests exotropia
     • Vertically displaced reflex suggests vertical misalignment 1

2. Follow with Cover Testing (if child is cooperative)

   • More accurate than corneal light reflection test but requires more cooperation
   • Have child fixate on distant or near target
   • Cover one eye while observing the other for refixation movement
   • Repeat with the other eye
   • No movement indicates normal alignment; refixation movement indicates strabismus 1

Why Hirschberg Test is the Best Initial Step

The Hirschberg test is particularly valuable for initial assessment of strabismus in young children because:

• It can be performed quickly in a primary care setting
• Requires minimal cooperation from the child
• Provides immediate objective information about eye alignment
• Helps differentiate between true strabismus and pseudostrabismus (common in children with epicanthal folds) 1

Why Other Options Are Not Appropriate First Steps

• Referring to pediatric ophthalmology next day (option A): While referral will eventually be needed if strabismus is confirmed, performing the Hirschberg test first allows for initial assessment and more appropriate triage. Immediate referral without basic assessment is premature. 1

• Urgent glasses (option B): Prescribing glasses without determining the type of misalignment and without refraction is inappropriate. Refractive errors should be assessed after confirming the presence and type of strabismus. 1

• Detailed history about perinatal injury (option D): While history is important, the immediate priority is to objectively assess the eye misalignment. History can be gathered concurrently or after confirming the presence of strabismus. 1

Clinical Significance and Follow-up

Strabismus in a 5-year-old requires prompt attention because:

• It may indicate or lead to amblyopia (present in 1-4% of preschool children) 1
• Early detection and treatment improve visual outcomes and prevent permanent vision loss
• Untreated strabismus may harm school performance, learning ability, and self-image 1

After performing the Hirschberg test and confirming misalignment:

1. Complete basic eye examination including:

   • Red reflex examination to rule out media opacities
   • Pupillary examination for size, shape, symmetry, and response to light
   • Fixation testing to assess ability to follow targets 1

2. Refer to pediatric ophthalmologist for comprehensive evaluation including:

   • Cycloplegic refraction
   • Detailed motility assessment
   • Sensory testing for fusion and stereoacuity
   • Funduscopic examination 1

Common Pitfalls to Avoid

• Mistaking pseudoesotropia for true strabismus: Children with prominent epicanthal folds and/or a wide, flat nasal bridge often appear to have esotropia when alignment is normal 1

• Delaying referral after confirming strabismus: Once true misalignment is confirmed, prompt referral is essential as early intervention improves outcomes 1

• Overlooking accommodative esotropia: This common, treatable form of strabismus requires proper cycloplegic refraction and may respond well to glasses 1, 2

• Failing to document the child's level of cooperation: This is important for interpreting results and making comparisons over time 1