What's the next step for a 10-year-old girl with over 20 diopters of exotropia and diplopia after a head injury near the occipital and parietal lobes, with normal computed tomography (CT) scan and magnetic resonance imaging (MRI) results?

Management of Traumatic Exotropia with Diplopia in a 10-Year-Old Girl

The next step for this 10-year-old girl with traumatic exotropia and diplopia should be referral to a pediatric ophthalmologist for evaluation and consideration of temporary prism therapy, followed by strabismus surgery if the condition does not improve. 1

Initial Assessment and Management

Evaluation of Traumatic Exotropia

• This case presents as acquired exotropia (20 diopters) with diplopia following head trauma
• Normal neuroimaging (CT and MRI) rules out structural brain injury but doesn't exclude cranial nerve or muscle injury
• The large angle (>20 diopters) and presence of diplopia indicate a significant deviation requiring intervention

Immediate Management

1. Temporary prism therapy

   • Base-out prisms in eyeglasses to alleviate diplopia 1
   • Prisms can provide immediate symptomatic relief while determining if spontaneous improvement will occur
   • This approach allows time to assess if the condition is stable or improving

2. Close monitoring of alignment and symptoms

   • Follow-up within 4-6 weeks to assess stability of the deviation
   • Monitor for changes in the angle of deviation and symptoms

Definitive Management

Surgical Intervention

If the exotropia remains stable without improvement after 3-6 months:

• Strabismus surgery is indicated for persistent large-angle exotropia with diplopia 1
• Surgical options include:
  • Bilateral lateral rectus muscle recessions
  • Unilateral lateral rectus recession with medial rectus resection
  • For this case with 20 diopters of exotropia, either approach can be effective

Surgical Planning Considerations

• Measurements with best optical correction should be repeated at near and distance
• The pattern of deviation (A or V pattern) should be assessed
• Any vertical component should be evaluated
• Thirty minutes of monocular occlusion (patch test) may help elicit the full deviation 1

Important Clinical Considerations

Potential Complications

• Risk of consecutive esotropia after surgery, which could cause persistent diplopia
• Possibility of amblyopia development if the deviation is not addressed promptly
• Loss of stereoacuity if binocular vision is not restored

Special Considerations for Traumatic Cases

• Traumatic strabismus may have different surgical outcomes compared to non-traumatic cases
• The presence of diplopia suggests the condition is acquired rather than congenital
• Prism testing before surgery can help determine if the patient will tolerate surgical correction without persistent diplopia 1

Follow-up Protocol

• After initial evaluation: 4-6 weeks
• If prism therapy initiated: every 6-8 weeks to adjust prism power as needed
• Post-surgery: within 1 week, then at 1 month, 3 months, and 6 months
• Long-term: every 6-12 months to monitor for recurrence 1

Warning Signs Requiring Immediate Reassessment

• Worsening diplopia
• Increasing angle of deviation
• Development of new neurological symptoms
• Development of amblyopia

This approach prioritizes restoration of binocular vision and prevention of amblyopia while allowing time to determine if spontaneous improvement will occur before proceeding to surgery.