General: She is alert and playful.
External: Her left eye is crossed inward (esotropic). Her face is symmetric.
Vision: She tracks toys well using both eyes. With the left eye covered, she fixes and follows easily. However, she fusses when the right eye is covered and has difficulty following with this left eye.
Motility: Full extraocular movements. No nystagmus.
Pupils: PERRL; no APD. No leukocoria.
Corneal reflection test (Hirschberg test): Reflection of a penlight directed at the infant is located over the right pupil and temporally to the center of the left pupil.
Cover-uncover test: On covering the R eye, the left eye shifts outward and fixes intermittently to a toy. When the right eye is uncovered, the left eye shifts back inward.
Alternate-cover test: When the cover is alternated from one eye to the other, there is an outward shift of the opposite eye on uncovering. Deviation measured at approximately 25 prism diopters base out.
Stereopsis: Unable to determine given patient age.
Retinoscopy: mild hyperopia OU (+1.00) without astigmatism, no lens opacities noted
DFE: C/D 0.2, crisp disc margins, no optic nerve hypoplasia, +foveal light reflexes, vessels wnl