subtle reductions in extraocular movement, ophthalmology consultation is most likely appropriate Of note, depending on the patient’s age and clinical circumstance, some children may not cooperate fully with portions of the examination If a child will not follow an examiner’s target but will fix on the examiner, the examiner can ask the parent to gently move the patient’s head to each side and then up and down The examiner can also guide the child by putting one hand on the child’s head ( Fig 28.2 ), although care must be used to avoid heightening the patient’s anxiety As the patient continues to look straight ahead when the head is being turned, the eyes are moving passively in reference to the head and orbit When the head is turned to the left, the eyes move into right gaze to maintain fixation straight ahead ( Fig 28.2 ) If the head is tilted up, the eyes are moved into relative downgaze Essentially, this is the “doll’s eye” maneuver used in the assessment of comatose patients If the eyes move symmetrically and fully on passive movement of the head, this rules out the presence of a neurogenic or restrictive problem with the same accuracy as if the patient had voluntarily followed a target After these ophthalmologic exam maneuvers, computed tomography (CT) scan of the orbit with both coronal and axial views is the imaging modality of choice when there is limited extraocular motility in patients in whom orbital fracture is suspected (see Chapters 107 Facial Trauma and 114 Ocular Trauma ) The causes of pediatric strabismus are summarized in Tables 28.2 to 28.4 The first considerations ( Figs 28.4 and 28.6 ) are neurogenic palsies and restrictive strabismus Myasthenia gravis and thyroid eye disease can mimic virtually any strabismus with deficiency of extraocular movement and must always be considered in the differential diagnosis in any pattern of ocular misalignment Myasthenia may cause intermittent strabismus and variable ptosis, whereas thyroid disease causes retraction of the upper lid The pupils are not involved in either condition ESOTROPIA EMERGENCIES Figure 28.7 summarizes the approach to a patient with esotropia and exotropia Patients with a restrictive or neurogenic esotropia (deficiency of abduction) may adopt an abnormal head position to place the eyes in the position of best alignment to avoid double vision By turning the face in the direction of the deficiency (e.g., right face turn for right sixth nerve palsy) when looking straight ahead, the eyes align and appear straight ( Fig 28.2 ) The patient’s head must be held in the straight up position to notice that the affected eye is actually crossed