Convergent Squint- a Symptom Of Thrombosis

Anticoagulative treatment of children has always presented problems due to a lack of generally approved clinical standards. We present the case of a 5 -year-old boy with bilateral convergent strabismus. It was preceded by otitis, which was treated with antibiotics for a few days before admission to hospital. In the last two days before admission his condition worsened, he complained of a headache and started vomiting. In neurological examination on the second day of his stay, the boy presented with decreased spontaneous activity and hypersomnia. This muscle tone, reflexes were decreased and he had, poor motor coordination. There were no abnormal reflexes and cerebellar testing showed no aberrations. There was 1 cm nuchal rigidity. Examination of cranial nerves showed sixth nerve palsy on both sides. Ophtalmological examination revealed bilateral papilledema. Neuroimaging showed thrombosis of the transverse and sigmoid sinus. A lumbar puncture was not performed because anticoagulative treatment, had been started. The final diagnosis was: bilateral sixth nerve palsy due to sinovenosous thrombosis as a complication of otitis in a patient with a genetic disorder The patient received anticoagulative, antiinflammatory, antibiotic and anti - edemal treatment. He responded to therapy, showing clinical improvement followed by normalisation in neuroimaging. On examination after 1.5 months his general condition was good. Motor coordination was poor and muscle tone was lowered as before. His comprehension was good. Speech was limited to the first syllables of words, as before. He had convergent strabismus in his left eye, without sixth nerve palsy symptoms. Movements of the right eye were normal. In thrombophilic investigation the presence of factor V Leiden mutation was found. The boy is now in outpatient care. He is undergoing vision therapy and speech therapy. Convergent squint can be a symptom of thrombosis in children. Neuroimaging is essential in diagnosis.