This patient had mild esotropia at distance (top) amd exaggerated esotropia upon accommodation.

History
A 34-year-old black female presented to the emergency service complaining of double vision of one day’s duration. She also complained of blurred vision O.U. and a frontal headache.

Her ocular history was remarkable for a similar event a month earlier. She sought no medical attention at that time because the blurry, double vision resolved within a few days. Her systemic history was remarkable for hypertension.

Diagnostic Data
Uncorrected visual acuity at this visit was 20/400 O.U. and 20/60 with pinhole O.U.

External examination revealed miotic pupils (2mm O.U.) that were sluggish to direct light, but there was no evidence of an afferent pupillary defect.

Cover testing revealed a constant alternating esotropia (variable from 10PD at distance to 40PD at near). Abduction was limited on versions O.U., but a full range of motion was observable upon ductions O.U.

Retinoscopy uncovered -6.00D sphere O.D. and -3.75D sphere O.S., but it was difficult to obtain an endpoint reading O.U. Retinoscopy yielded acuity of 20/60 to 20/100 O.U. Wet refraction uncovered +1.75D sphere O.D. and +1.50D sphere O.S. for 20/60 O.U.

The anterior segment exam was normal O.U., and IOP measured 16mm Hg O.U. The dilated fundus evaluation was unremarkable O.U.

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