What is the management for a patient with a headache and strabismus (cross-eye) after hitting their head, without any swelling?

Management of Head Trauma with Headache and Strabismus

This patient requires urgent ophthalmologic evaluation and neuroimaging to rule out life-threatening orbital or central nervous system trauma, as strabismus following head trauma may indicate extraocular muscle damage, orbital fracture with entrapment, or cranial nerve injury. 1

Immediate Assessment Priority

The primary goal is to exclude globe injury, sight-threatening conditions, and neurological emergencies before addressing the strabismus itself. 1 The combination of headache and new-onset strabismus after head trauma warrants serious concern for:

• Direct orbital trauma with muscle damage, hemorrhage, or orbital fracture 1
• Cranial neuropathy affecting extraocular muscle innervation 1
• Central nervous system injury causing supranuclear defects 1
• Oculocardiac reflex if muscle entrapment is present (manifesting as bradycardia, nausea, vomiting, or loss of consciousness) 1

Required Ophthalmologic Examination

Perform a comprehensive eye examination including: 1

• Visual acuity testing and refraction if possible
• Pupillary examination to detect afferent defects or cranial nerve III involvement
• Intraocular pressure measurement (elevated IOP may indicate orbital compartment syndrome)
• Confrontational visual field testing
• Slit-lamp examination for anterior segment injury
• Dilated fundus examination (if safe) with attention to fundus torsion, optic nerve appearance, and retinal injury
• Exophthalmometry to detect proptosis or enophthalmos
• Facial sensation testing for infraorbital nerve injury

Detailed Sensorimotor Examination

A specialized motility assessment must document: 1

• Versions and ductions in all gaze positions
• Saccades, pursuit, vergence, and near reflex
• Alignment measurements in primary and secondary gaze positions with attention to primary and secondary deviations
• Forced duction and forced generation testing to distinguish mechanical restriction from muscle paresis 1
• Specialized testing with Double Maddox rod, Lancaster red-green, or Hess screen if available

Vital Signs Monitoring

Check for signs of oculocardiac reflex: 1

• Bradycardia or heart block
• Dizziness, nausea, vomiting
• Loss of consciousness

These findings indicate possible muscle entrapment requiring urgent medical and surgical intervention. 1

Neuroimaging Requirements

CT scan is the initial imaging modality of choice for acute orbital trauma, as it: 1

• Rapidly identifies orbital fractures and bone fragments
• Detects muscle entrapment
• Rules out ferrous-metallic foreign bodies
• Provides sufficient information for acute management

MRI should be considered if: 1

• More precise soft tissue detail is needed
• Extraocular muscle or pulley system injury requires better characterization
• There is concern for central nervous system pathology
• No metallic foreign body is suspected

Red Flags Requiring Immediate Intervention

Certain findings mandate urgent subspecialty consultation: 1, 2

• Oculocardiac reflex signs (bradycardia with nausea/vomiting) - requires urgent surgical decompression
• Ptosis with strabismus - suggests cranial nerve III palsy or orbital apex syndrome
• Papilledema or optic disc blurring - indicates increased intracranial pressure
• Multiple cranial nerve involvement - suggests skull base or brainstem injury 2
• Pupillary abnormalities - may indicate serious neurological injury
• Gait abnormalities or consciousness impairment - requires immediate neurological evaluation 2

Initial Management Strategy

If Examination Reveals Orbital Trauma:

Observation period of 6 months is standard, as diplopia may be transient following ocular trauma, but if not resolved by 6 months, spontaneous resolution is unlikely. 1

During this period: 1

• Counsel the patient on diagnosis and natural history
• Monitor for resolution with serial examinations
• Symptomatic treatment with occlusion (patch, Bangerter filter, or satin tape on glasses) if diplopia is bothersome
• Prism therapy may be attempted temporarily if deviation is stable

If Superior Oblique Palsy is Suspected:

Head trauma is one of the most common causes of acquired superior oblique palsy. 1 Perform Parks-Bielschowsky three-step test and assess for excyclotorsion. 1 Neuroimaging is generally not required for isolated unilateral superior oblique palsy with known trauma history. 1

If Sixth Nerve Palsy is Present:

Neuroimaging should be considered in young patients or if other neurological signs are present. 1 In older patients with vasculopathic risk factors, lack of resolution over time warrants imaging. 1

Surgical Considerations

Strabismus surgery is generally deferred until at least 6 months post-injury to allow for spontaneous improvement and stabilization of the deviation. 1 Surgery was required in only 7-24% of orbital floor fracture cases in published series. 1

Critical Pitfalls to Avoid

• Do not dismiss headache and strabismus as minor after head trauma - this combination may indicate serious orbital or intracranial pathology 1, 2
• Do not delay imaging if red flags are present, particularly signs of muscle entrapment with oculocardiac reflex 1
• Do not perform MRI first if metallic foreign body is possible - use CT initially 1
• Do not rush to surgery - most post-traumatic strabismus cases improve spontaneously within 6 months 1
• Do not overlook concurrent globe injury - always rule out sight-threatening conditions first 1