Asymmetric Elevation of the Eyes

Abstract

A 26-month-old girl presented with a transient head-posturing to the left that the mother reported since early months. She had a normal growth and psychomotor development, and her parents reported a notion of good vision. The mother denied pain complaints, previous traumatic events, or systemic diseases. Her family history is unremarkable for any history of ophthalmologic problems.On ophthalmologic examination, head-posturing was evident, chin up and a face turn to the left side when asked to look at a symbol of the LEA Vision Chart Test (Figure 1). In the primary position, a minimal right hypotropia was present, and during ocular motricity examination, a limited elevation in adduction of the right eye was present (Figure 2) . An audible but painless superior nasal click was elicited, on ocular rotations up and nasalward. The children had a 10/20 visual acuity of both eyes but had a bad performance during the evaluation of stereoscopic vision, with Lang Test 2. Laboratory exams, which included screening for systemic lupus and juvenile rheumatoid arthritis, were normal. Orbit high-resolution magnetic resonance imaging did not detect any muscular atrophies, signs of inflammation, or orbital tumors. Final DiagnosisCongenital Brown syndrome.