Pediatric ocular motor abnormalities: clinical features and neurological correlates.

INTRODUCTION: Pediatric ocular abnormalities may indicate underlying neurological or ophthalmological disorders; however, comprehensive analyses remain limited. This study aimed to investigate associations between specific ocular motor abnormalities and their underlying etiologies. METHODS: We retrospectively reviewed pediatric patients with ocular motor abnormalities presenting to our tertiary referral medical center between 2005 and 2025. They were classified by final diagnosis into the neurologic (N group) and ophthalmologic-only (O group) etiology groups. Associations among ocular signs, disease categories, and accompanying non-ocular symptoms were analyzed. RESULTS: Among the 141 patients included, ophthalmoplegia, nystagmus, ocular motor apraxia, and ocular deviation were observed in 33, 85, 8, and 21 patients, respectively; six patients had overlapping ocular motor abnormalities. Ophthalmoplegia, vertical/torsional nystagmus, ocular motor apraxia, and upgaze deviation were more frequently observed in the N group (n = 70). Specific correlations with neurological conditions included ophthalmoplegia with brain tumors, cerebrovascular and demyelinating diseases; vertical/torsional nystagmus and ocular motor apraxia with congenital/metabolic/degenerative disorders; and ocular motor apraxia and upgaze deviation with neurodevelopmental disorders. Accompanying non-ocular symptoms showed significant correlations: headache/vomiting with brain tumors/cerebrovascular disorders, tone abnormalities with congenital/metabolic/degenerative disorders, and ataxia with demyelinating diseases. Isolated ocular symptoms most commonly occurred with neurodevelopmental disorders and ocular myasthenia gravis (MG). CONCLUSION: Pediatric patients presenting with ophthalmoplegia, vertical/torsional nystagmus, ocular motor apraxia, upgaze deviation, or associated systemic symptoms of headache/vomiting, tone abnormalities, or ataxia may have underlying neurological disorders. Even isolated ocular manifestations may indicate neurodevelopmental disorders or ocular MG. Early recognition may facilitate differentiation between neurological and ophthalmological etiologies, thereby optimizing patient management and reducing unnecessary diagnostic investigations.