This was a retrospective study that included all children (under the age of 16 years) presenting for an ocular examination to a tertiary eye center in South India, who were diagnosed to have FNP, over the period of 1 year. Institutional Review Board (IRB)/Ethics Committee decided approval was not required for this study.
A detailed analysis of all the records, with respect to the ocular findings, systemic diagnoses, neuroimaging fi ndings and response to management modalities was done. All the children underwent a complete assessment, including medical history and ophthalmological and orthoptic examinations. An experienced pediatric ophthalmologist evaluated them and the neuroimaging studies, where available, were reviewed by a neuroradiologist. Visual acuity was recorded with the help of a Snellen’s chart and in cases where verbal visual acuity measurements were not possible due to age or associated systemic issues, the testing of visual response was done by monitoring the fixation in each eye by the Central, Steady, Maintained (CSM) method, where C refers to centrality and can be assessed by the location of the corneal light reflex as the patient looks at the examiner’s light with the opposite eye occluded, S refers to the steadiness of fixation on the examiner’s light under monocular conditions and M refers to the ability of the patient to maintain alignment under binocular conditions. Orthoptic examination included evaluation of ocular movements and angle of strabismus. Angles of deviation were measured with the prism and alternate cover test for near (1/3 m) and distance fixation where possible. All children underwent evaluation with a slit lamp biomicroscope, cycloplegic refraction and dilated fundus examination with indirect ophthalmoscopy.

Results

A total of 22 cases were identified. Of the 22, 15 (68.18%) patients were male and seven (31.81%) were female. The average age at presentation was 6.08 years (range, 4 months to 16 years).
Only one patient (4.54%) had bilateral FNP and 21 cases (95.45%) had unilateral FNP.
The etiology of FNP in our series was variable. Seventeen patients (77.27%) had congenital palsy and of these, five patients had a syndromic association, three had birth trauma and nine patients had idiopathic palsy. Two patients were diagnosed to have Moebius syndrome, one each had Dandy Walker syndrome, oculoauriculovertebral malformation (Figure 1) and hemifacial microsomia (HFM).
The ocular findings included secondary effects of the FNP as well as features related to various syndromes.
Three patients had ipsilateral sixth nerve palsy, one underwent strabismus surgery for the resulting esotropia, both had amblyopia and required treatment. Two children were diagnosed to have Moebius syndrome and were treated conservatively. One child had an ipsilateral Duane’s syndrome with ipsilateral hearing loss (Figure 2). The Duane’s caused a mild face turn and patient did not require surgical management.
(A) Left eye—upshoot on adduction, limitation of adduction; (B) left eye—lagophthalmos due to FNP; (C) left eye—limitation of abduction. 
Corneal involvement was seen in eight patients (36.36%). Of these, three patients had superficial punctate erosions,  two had a corneal opacity, three had exposure keratopathy, of which one developed a corneal ulcer and one was referred with a corneal perforation with vitreous prolapse. Six patients were treated conservatively with lubricants, two needed a lateral tarsorrhaphy and the patient with corneal perforation required a therapeutic penetrating keratoplasty with cataract extraction and anterior vitrectomy.

Paralysis of the facial nerve can potentially affect vision, causes lack of facial expression and impacts social interaction⁽⁴⁾.

A large proportion of pediatric facial nerve palsies are secondary in nature and thus prompt diagnosis and treatment is very important. Idiopathic FNP is the commonest cause of FNP in children^(5,6). We found no identifiable cause in ten out of 22 children (45.4%). Birth trauma is quite common; with 78-90% of facial nerve palsies in the new born being attributed to birth trauma⁽³⁾. We had three patients (13.63%) with birth trauma due to forceps delivery. Congenital FNP is associated with a number of syndromes including Moebius syndrome, CHARGE syndrome, Goldenhar syndrome, Di George syndrome and muscular dystrophy⁽⁷⁾. In our study, five patients (22.72%) had a syndromic association, of these, two had Moebius syndrome, one had Dandy Walker syndrome, one had oculoauriculovertebral malformation, and one had HFM. HFM is a craniofacial disorder in which facial nerve dysfunction is common and has important implications in treatment⁽⁸⁾. Acute otitis media and other infectious causes have been said to be very common causes of FNP in children^(3,4), but our study did not show similar findings. This may be explained by the fact that our study was carried out at an ophthalmic center while previous studies were done in otolaryngology centers. We emphasize the need for a detailed systemic evaluation in all children presenting with FNP, to rule out any syndromic association or a potentially life threatening cause such as a neoplasm. Neuroimaging is a very useful tool in the evaluation and management of these children. In our study, neuroimaging results showed skull bone fractures in trauma, posterior fossa cyst, pontine gliosis and neoplasms. We recommend that all children presenting with FNP, congenital or acquired undergo neuroimaging. Corneal manifestations can range from superfi cial punctate erosions to severe exposure keratopathy with corneal perforation. Treatment must be initiated at the earliest. Mild keratopathy may be treated with lubricants, whereas severe exposure keratopathy may need surgical correction^(9,10). These children are at risk for amblyopia due to a number of reasons. The corneal exposure may result in corneal opacities and predispose the child to stimulus deprivation amblyopia, the associated sixth nerve palsies result in strabismus and can result in amblyopia, also we found that four of the children in our series, had a component of anisometropia contributing to their amblyopia. Our study, thus, highlights the need for careful visual acuity testing and institution of prompt amblyopia therapy in these children. 

Conclusions