접수번호: 2008-081 Korean Journal of Ophthalm ology 2009;23:228-231 ISSN : 1011-8942 DOI : 10.3341/kjo.2009.23.3.228 Acute Comitant Esotropia in a Child With a Cerebellar Tumor Jong-Min Lee, MD, Sin-Hoo Kim, MD, Jeong-Il Lee, MD, Ji-Yong Ryou, MD, Sook-Young Kim, MD, PhD Department of Ophthalmology, College of Medicine, Catholic University of Daegu, Daegu, Korea We report a case of acute comitant esotropia in a child with a cerebellar tumor. A 3-year-old boy was referred for management of a 9 month history of acute acquired comitant esotropia. On first presentation, the patient’s angle of esodeviation was 50 prism-diopters (PD) at distance and near fixation without any lateral incomitance. The cycloplegic refraction revealed +0.75 diopters in both eyes. Very mild bilateral papilledema was found on the fundus examination, but the neurological examination did not reveal any other pathological findings. Brain MRI showed a 5 cm mass located in the midline of the cerebellum as well as hydrocephalus. The mass was completely excised and histological examination confirmed the diagnosis of pilocytic astrocytoma. Despite neurosurgery, the patient’s strabismus remained unresolved. One year after neurosurgery, both medial rectus muscles were surgically recessed by 6 mm, resulting in esotropia of 8PD at distant and near fixation without restoration of bifoveal fusion at follow-up 2 years after the eye muscle surgery. Therefore, acute onset comitant esotropia in a child can be the first sign of a cerebellar tumor, even without any other neurological signs and symptoms. Korean J Ophthalmol 2009;23:228-231 ⓒ 2009 by the Korean Ophthalmological Society. Key Words: Acute onset, Cerebellar tumor, Comitant esotropia If acute onset of esotropia is comitant, its cause is generally thought to be benign and further neurological investigationis not warranted.1,2 However, several reports3-7 have described patients with intracranial tumors who present with comitant esotropia and that the onset of comitant esotropia without any other neurological sings and symptoms in a child can be the first sign of a brain tumor. We describe a 3-year-old boy with acute comitant esotropia associated with a cerebellar pilocytic astrocytoma in the absence of other neurological findings. To the best of our knowledge, this is the first report in Korea of acute comitant esotropia associated with a brain tumor. Case Repo rt A 3-year-old boy was referred for management of acute acquired comitant esotropia. His family noticed sudden inward deviation of his left eye 9 months ago, and as time passed, this deviation became increasingly noticeable. On first presentation, the angle of esodeviation was 50 prism diopters (PD) at distant and near fixation. The patient’s visual acuity and sensory status were not checked, but he demonstrated alternate fixation. There was no lateral incomitance and no deficit of abduction bilaterally Received: August 21, 2008 Accepted: July 28, 2009 Reprint requests to Sook-Young Kim, MD, PhD. Department of Ophthal- mology, Catholic University of Daegu, #3056-6 Daemyeong 4-dong, Nam- gu, Daegu 705-718, Korea. Tel: 82-53-650-4739, Fax: 82-53-627-0133, E-mail: kimsy@cu.ac.kr * This manuscript was presented as a poster at the 98th meeting of Korean Ophthalmological Society, November, 2007. 228 (Fig. 1). No difference in the size of the deviation was found with fixation of the right versus the left eye. The cycloplegic refraction with 1% cyclopentolate revealed +0.75 diopters in both eyes. Very mild bilateral papilledema was found on fundus examination. No nystagmus was noticed, and there was no fa- mily history of strabismus or amblyopia. There was no prece- ding trauma or febrile illness before the onset of acute stra- bismus. Review of old photographs demonstrated that at 1 year of age, the patient’s corneal light reflexes were centered. He was referred to a pediatric neurologist, but the neurolo- gical examination did not reveal any additional pathological findings. A brain MRI revealed a 5 cm mass with an enhanced peripheral rim at the midline of the cerebellum as well as hy- drocephalus (Fig. 2). The tumor was completely excised and a shunt was placed. Histological examination of the excision confirmed the diagnosis of pilocytic astrocytoma. Three months after neurosurgery the patient’s visual acuity was 20/125 in each eye and the angle of esodeviaton increased up to 60PD at distance and near fixation without any deficit of abduction. Alternating six-hour occlusion therapy was ini- tiated. Eight months after the initiation of occlusion therapy, the patient’s visual acuity had improved to 20/50 in the right eye and 20/40 in the left eye. The angle of esodeviation was reduced to 50PD at distance and near fixation, and the esotropic angle did not show any sign of decrease. One year after neurosurgery, a bilateral 6 mm recession of medial rectus muscles was performed. Immediately after the strabismus surgery, he was orthotropic at distant and near fixa- tion. One month later, the angle of esodeviation became 10PD at distance and 6PD at near fixation. The visual acuity was 20/ 50 in the right eye and 20/40 in left eye. Occlusion therapy