Fascinating article from Israel in the May 2015 issue of Pediatric Neurosurgery: Horizontal Tonic Conjugate Gaze Deviation in a 4-Week-Old Infant: What Can the Eyes (of the Parents) Tell? It’s a reminder of how significant early evaluation of a child’s eye movements or looking behavior can be. The parents of this 4-week-old healthy infant noticed that their baby failed to make eye contact when approached from the left. The child was evaluated by the authors at 11 weeks of age, and left tonic conjugate gaze deviation was noted. Brain MRI showed a left frontotemporal large tension arachnoid cyst, and surgical decompression resulted in complete restoration of horizontal gaze and considerable reduction in the size of the cyst. After 3 months a cystoperitoneal shunt was placed due to increased intracranial pressure secondary to impaired drainage of the cyst. Since then the infant has done well, with normal developmental and neurological examination during his last follow-up at the age of 5 years. Although the central ocular motor control of gaze is still underdeveloped and chaotic eye movements are present during early infancy, this case report reminds us that a thorough examination of eye movements should be undertaken during neurodevelopmental evaluation.
It has been reported that the left frontotemporal region is the most common location of these cysts. They can be congenital, often result from either spontaneous or trauma-induced splitting within the arachnoid layers, and have been linked with altered CSF flow dynamics. Here is a nice review from Medscape Ophthalmology on the Pathogenesis and Treatment of Intracranial Arachnoid Cysts in Pediatric Patients Younger Than 2 Years of Age.
Not for the faint of heart, here is a YouTube video of a surgical procedure to remove a large pressure-filled symptomatic arachnoid cyst of the left frontotemporal region.