The sclera are visible between the upper eyelid and the iris,Sunsetting sign is seen usually in hydrocephalus due to loss of upward conjugate gaze caused by raised intracranial pressure (ICP)
However, it can also be transiently elicited in healthy infants up to 7 months of age by changes of position or removal of light (benign setting-sun phenomenon). The benign form might represent immaturity of the reflex systems controlling eye movements.
When persistent, this sign is one of the most frequent markers of elevated intracranial pressure, appearing in 40% of children with hydrocephalus (whatever the cause of Hydrocephalus as obstructive, communicating, Dandy-Walker anomaly/syndrome) and in 13% of patients with ventriculoperitoneal shunt dysfunction. It is an earlier sign of hydrocephalus than enlarged head circumference, full fontanelle, separation of sutures, irritability or vomiting. Consequently, this sign is a valuable early warning of an entity requiring prompt neuroimaging and urgent surgical intervention.
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