Can medial deviation of the eyeballs in an intubated baby be a sign of absent seizures?

Eye Deviation in Intubated Neonates: Seizure Recognition

Yes, medial deviation of the eyeballs (eye deviation toward the medial canthus) in an intubated baby can absolutely represent seizure activity and should be treated as such until proven otherwise. This is a subtle seizure manifestation that is easily missed in critically ill neonates.

Clinical Recognition of Subtle Seizures

Eye deviation is a well-recognized manifestation of subtle or subclinical seizures in neonates and critically ill children:

• In severe malaria and other critical illnesses, 25% of seizures are subtle or subclinical, commonly manifesting as eye deviation, irregular respiratory pattern, or drooling 1
• Eye movements during absence seizures typically consist of conjugate lateral or upward deflection, with oculomotor phenomena beginning 1.7-3 seconds after electrographic discharge onset 2
• In versive seizures, eye movements are conjugate and contralateral to the hemisphere of seizure onset in 100% of focal-onset seizures, predominantly saccadic (89.3%) with an oblique upward vector (86.8%) 3

Critical Diagnostic Considerations

Immediate Assessment Required

• Check point-of-care glucose immediately - hypoglycemia may precipitate seizures or abnormal posturing and must be excluded first 1, 4
• Assess for other subtle seizure signs: irregular respiratory pattern, drooling, abnormal posturing 1
• In 88% of electroclinical neonatal seizures, eyes are open; persistent eye closure makes seizure unlikely 5

EEG Confirmation

• Clinical diagnosis of neonatal seizures without EEG confirmation is difficult and unreliable 6
• EEG should be part of the neurodiagnostic evaluation, with high strength of evidence 7
• Many neonatal seizures have electrographic activity without obvious clinical manifestations 1

Management Approach

Immediate Interventions

1. Establish high-flow oxygen and ensure adequate airway management - as important as anticonvulsant administration 1
2. Correct hypoglycemia immediately with D10%-containing isotonic IV solution if present 4
3. Check for other metabolic derangements (hypocalcemia, hypomagnesemia) 4

Seizure Treatment Protocol

If seizures are confirmed or highly suspected, follow standard anticonvulsant algorithm 1:

• Lorazepam 0.1 mg/kg IV/IO as first-line
• If seizures persist >10 minutes: repeat lorazepam 0.1 mg/kg
• If still uncontrolled: Phenytoin 18 mg/kg IV over 20 minutes OR Phenobarbital 15-20 mg/kg IV over 10 minutes
• Refractory seizures require anesthesia consultation for rapid sequence intubation (though already intubated in this case)

Common Pitfalls to Avoid

• Never dismiss subtle eye movements as "normal" in a critically ill intubated neonate - these may be the only clinical manifestation of ongoing seizure activity 1
• Do not delay metabolic correction (hypoglycemia, hypocalcemia, hypomagnesemia) while waiting for anticonvulsants or EEG 4
• Avoid attributing eye deviation solely to sedation or mechanical ventilation without EEG confirmation 1
• In the peri-ictal state, pupillary signs and conscious level may be misleading for assessing raised intracranial pressure 1

Underlying Etiology Investigation

Once seizures are controlled, systematic evaluation for etiology is essential 4:

• Head ultrasound as initial bedside imaging if unstable, identifying intraventricular hemorrhage, hydrocephalus, and white matter changes 4
• MRI with diffusion-weighted imaging when stable - identifies etiology in 39.8% more cases than ultrasound alone 4
• Hypoxic-ischemic injury accounts for 46-65% of neonatal seizures, with 90% occurring within first 2 days of life 8
• Consider infection, intracranial hemorrhage (10-12%), metabolic disorders, and genetic causes 8