Pediatric patient presents with new-onset diplopia and headache

A 7-year-old boy presented to the Tufts Medical Center emergency department with a 2-week history of headache and 1-week history of binocular horizontal diplopia. He had no medical history. His ocular history was significant only for mild myopia for which he was already wearing glasses.On evaluation in the emergency department, the patient endorsed a 2-week history of headache, which was associated with nausea, vomiting, decreased appetite and a 10-pound weight loss. The patient had taken Tylenol for the headaches without relief of symptoms. Additionally, the patient endorsed new-onset horizontal double vision over the past week. His parents noted that both eyes seemed to be turning inward. The patient also reported intermittently blurred vision in both eyes. He denied any episodes of complete loss of vision. He had no fevers, chills or rash. He denied any other focal neurologic complaints including weakness, numbness or tingling. The patient had no sick contacts. He denied any recent travel. Pediatric ophthalmology was consulted for evaluation of new-onset diplopia.