What is the initial step in managing a 5-year-old child with a misaligned eye?

Initial Management of Eye Misalignment in a 5-Year-Old Child

The initial step is to perform a corneal light reflex test (Hirschberg test) to confirm and characterize the eye misalignment, followed by a cover test if the child cooperates, before determining the urgency of ophthalmology referral. 1

Immediate In-Office Assessment

Corneal Light Reflex Test (Answer C)

• This is the appropriate first diagnostic maneuver to objectively confirm the misalignment and determine its type (esotropia vs. exotropia vs. vertical deviation). 1
• The examiner should have the child fixate on a penlight from 12 inches (30 cm) away and observe the position of corneal light reflexes in both eyes. 1
• Symmetric reflexes centered on the pupils (or slightly displaced nasally) indicate normal alignment, while asymmetric reflexes confirm strabismus. 1
• If esotropia is present, one reflex will be temporally displaced; if exotropia, one reflex will be nasally displaced. 1

Distinguish True Strabismus from Pseudoesotropia

• Children with prominent epicanthal folds and/or a wide, flat nasal bridge may have the illusion of esotropia (pseudoesotropia) despite normal binocular alignment. 1
• The corneal light reflex test will show symmetric reflexes in pseudoesotropia, ruling out true misalignment. 1

Cover Test (If Child Cooperates)

• The cover test is more accurate than the corneal light reflex test but requires more cooperation and examiner skill. 1
• While the child fixes on a distant or near target, swiftly cover the right eye and observe the left eye for refixation movement, then repeat with the opposite eye. 1
• Any refixation movement indicates strabismus; no movement indicates normal alignment. 1

Additional Screening Components

Visual Acuity Testing

• Perform monocular visual acuity testing using age-appropriate optotypes (HOTV or LEA SYMBOLS® charts for a 5-year-old). 1
• Test each eye separately with the fellow eye properly occluded using an adhesive patch or tape to prevent peeking. 1
• Compare visual acuity between eyes to detect amblyopia, which is present in 1-4% of preschool children. 1

Red Reflex Examination

• Perform red reflex testing to rule out media opacities (cataracts) or retinal abnormalities (retinoblastoma). 1, 2
• Asymmetric or abnormal red reflex requires immediate ophthalmology referral. 3

Pupillary Examination

• Assess pupils for size, shape, symmetry, and response to light. 1
• Perform the swinging-light test to detect a relative afferent pupillary defect, which indicates optic nerve or anterior visual pathway pathology. 1

Referral Decision Algorithm

Non-Urgent Referral (Within Days to Weeks)

• Confirmed strabismus with normal visual acuity in both eyes, normal red reflex, and no other concerning findings warrants referral to pediatric ophthalmology. 1
• Early detection and treatment of strabismus can prevent amblyopia development and improve visual outcomes. 1

Urgent/Immediate Referral Indications

• Abnormal or asymmetric red reflex. 3, 2
• Abnormal pupillary response or relative afferent pupillary defect. 3
• Significant visual acuity difference between eyes (≥2 lines). 1
• New-onset strabismus with associated neurological symptoms. 4

Why Other Options Are Incorrect

Option A (Refer to Pediatric Ophthalmology Next Day)

• While referral is ultimately necessary, performing the corneal light reflex test first confirms the diagnosis and characterizes the misalignment, which informs the urgency of referral. 1
• Not all apparent misalignment is true strabismus (pseudoesotropia), making confirmation essential before referral. 1

Option B (Urgent Glasses)

• Glasses cannot be prescribed without proper refraction, which requires cycloplegic examination by an ophthalmologist. 1
• While refractive errors may contribute to accommodative strabismus, this determination requires comprehensive ophthalmologic evaluation first. 1

Option D (Detailed History for Perinatal Trauma)

• While history is important, the immediate priority is objective confirmation and characterization of the misalignment through examination. 1
• Perinatal trauma history does not change the immediate diagnostic approach of performing corneal light reflex testing. 1

Critical Pitfalls to Avoid

• Failing to distinguish pseudoesotropia from true strabismus can lead to unnecessary referrals or missed diagnoses. 1
• Inadequate occlusion during visual acuity testing allows children to peek with the "covered" eye, producing falsely reassuring results. 1
• Delaying referral in children who fail visual acuity screening – children who are testable and fail should be referred after the first screening failure. 1
• Missing amblyopia risk factors – untestable preschoolers are at least twice as likely to have vision disorders as testable children who pass screening. 1