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This 6-year-old boy has Down’s syndrome.  He was given glasses by an optometrist, who said that the child can see well, but the family is concerned that the boy habitually raises his chin while looking straight ahead.

1.	What is the most likely reason that this boy would assume the head posture of chin up and look down?
	d -- He can see better. The most common reason for a child like this assuming this head posture would be to see better, by avoiding diplopia or damping nystagmus.
2.	As you approach this child and simply observe him, what would you be looking for first?
	c -- nystagmus If this child had nystagmus and the reason for assuming this head posture was to damp the nystagmus in order to see better, this could be seen by simply watching the child for a short time.  If the child did not have nystagmus, then further examination would be required to check for strabismus, the next most likely cause of this kind of head posture.  The child could have Brown syndrome, double elevator palsy, vertical incomitance “A” or “V” with aligned eyes looking down, or some other condition that would lead him to raise his chin and keep the eyes in depression in order to see better.
3.	If this boy could be helped to assume a more normal head posture while enjoying best vision what would be the likely treatment?
	a -- eye muscle surgery In case of nystagmus or strabismus, the most likely treatment would be eye muscle surgery to treat the strabismus or null point nystagmus.