Unveiling restrictive strabismus in a Complex presentation With residual esotropia – A case report

IntroductionThe onset of ocular misalignment can be either congenital or acquired, with each type of strabismus exhibiting distinct clinical features that help differentiate it from others. In this case, we aim to discuss conditions that mimic restrictive strabismus and their management.Case descriptionA 14-year-old girl presented with a complaint of her left eye turning inward, which had been present since infancy. Clinical examination revealed bilateral medial rectus overaction. She had underwent surgery for a meningocele five years ago. The left eye examination: visual acuity was 2/60, anterior segment was normal, esotropia, and a -3 limitation of abduction and the force duction test was positive. She was diagnosed with congenital esotropia, with restrictive esotropia considered as a differential diagnosis. She underwent surgery to released cicatricial tissue and recession rectus medial. After the surgery, the left eye esotropia still remained. Neuroimaging was conducted to identify the underlying cause. The result described left fronto-orbital meningoencephalocele caused fibrosis around the left medial rectus tendon. A second surgery involving lateral rectus resection was performed, and orthophoria was achieved at both eyes.ConclusionsThis case report illustrates that any abnormalities involving the orbital structures can be a potential cause of restrictive strabismus, especially when certain clinical features are incongruent with the initial diagnosis. Meticulous history taking and thorough clinical examination are essential to achieve an accurate diagnosis and management.