What is it?

Strabismus, more commonly known as cross-eyed or wall-eyed, is a vision condition in which a person can not align both eyes
simultaneously under normal conditions. One or both of the eyes may turn in, out, up or down. An eye turn may be constant (when the eye
turns all of the time) or intermittent (turning only some of the time, such as, under stressful conditions or when ill). Whether constant or
intermittent, strabismus always requires appropriate evaluation and treatment. Children do not outgrow strabismus!
Who has strabismus?
It is estimated that up to 5 percent of all children have some type or degree of strabismus. Children with strabismus may initially have double
vision. This occurs because of the misalignment of the two eyes in relation to one another. In an attempt to avoid double vision, the brain will
eventually disregard the image of one eye (called suppression). Learn all about strabismus.
What is Strabismus?
Strabismus or tropia are the medical terms for eye conditions commonly called by various names: eye turns, crossed eyes, cross-eyed, wall-
eyes, wandering eyes, deviating eye, etc. Strabismus is not the same condition as "lazy eye" (amblyopia).
A strabismus is defined as a condition in which the eyes deviate (turn) when looking at the object of regard. The object of regard would be the
target that you, the patient, regards (aims eyes toward, looks at!). Eye doctors generally look for the presence of a strabismus when looking at
distance (20 feet or more); at near (16 inches for an adult and 13 inches for a child); and the lateral and vertical directions (up, down, left, or
right).
When the eye turn occurs all of the time, it is called constant strabismus. When the eye turn occurs only some of the time, it is called
intermittent strabismus. With intermittent strabismus, the eye turn might be observed only occasionally, such as during stressful situations
or when the person is ill.
Constant or Intermittent Strabismus?
This is one of the most important findings the eye doctor makes! This distinction has a great impact on decisions regarding timing and types
of treatment. It is important for you, as a parent, or patient to understand the difference. See Constant or Intermittent?
Different Types of Strabismus
Strabismus is classified into many different types. Each type has its own causes, characteristics, and appropriate treatment plan. Dr. Cooper's
article, All About Strabismus, discusses all the types of strabismus and their treatments. You can also refer to the pull-lists in the yellow box
on every page.
All About Strabismus
by Dr. Jeffrey Cooper & Rachel Cooper (no relation). 2001-2009
Development, Causes, Diagnosis,
Types, and Treatments.
What is Strabismus?
When two-eyed vision breaks down.
Is It Lazy Eye?
Is strabismus a lazy eye condition?
What Causes Strabismus?
Eye muscles or the brain?
What Does Strabismus Cause?
What does my child with strabismus see?
Early Detection and Treatment.
When should my child have the first eye exam?
When is it too late for treatment?
What is the "critical period?
Why does my eye doctor say it is "too late?"
What are basic treatment options?
Types of Strabismus and their Recommended Treatments

Evolution of Two-eyed Vision

Two Eyes to the Side
Nature has given animals the physical attributes necessary for survival. Lateral placement of the eyes is essential to the survival of hunted
animals or herbivorous animals (e.g., horse, rabbit, cow) as it allows them to increase side or peripheral vision.
Side vision (increased by lateral placement) is a sensitive detector for motion or movement. Peripheral vision allows creatures to effectively
scan for danger. The rabbit must be constantly aware of its natural enemies while it eats your garden greens. At the first sign of danger,
peripheral vision, the motion detector system, alerts the rabbit that there is danger. The immediate reflexive response is for the rabbit to run.
Two Eyes in Front
Faster moving carnivorous hunters do not need as much peripheral vision as the hunted. It is more important for hunters to locate their prey
and accurately determine the distance from themselves to that prey. Therefore, animals that hunt (carnivorous or meat eating animals, e.g.
lion, cat) as well as humans have frontal placement of the two eyes in order to determine the exact location of their prey. The hunters sacrifice
the large peripheral motion detection system afforded by side placement of the eyes in favor of the incredibly accurate depth perception
system created by frontal placement of the eyes. To make up for the loss of peripheral vision, most carnivorous animals have also developed a
sophisticated, pivoting system which extends the range of side vision...that is, the neck.
The Benefits of Two Eyes in Front
Frontal placement of the eyes allows for a remarkable visual phenomenon called stereopsis. Stereopsis is the 3D perception that occurs as a
result of both eyes working together to create relative depth perception.
Many of you have experienced exaggerated demonstrations of stereoscopic depth by viewing I-Max 3D movies or old stereoscopes. Or,
perhaps, you have seen photos of theatergoers in the 1950's wearing special Polaroid glasses in order to view 3D movies.
What is Stereopsis?
Stereopsis results from the combination of the two images received by the brain from each eye. Each eye views the world from a slightly
different vantage point (See Fig 1).
The fusion of these two slightly different pictures from our two "cameras" (the eyes) gives us the
sensation of strong three-dimensionality or relative depth.
At near, there is a greater difference in what the two eyes view as compared to far. Thus, stereopsis is
strongest and most important at near distances. At near is where man uses accurate hand-eye
coordination to make tools and other items!
The Benefits of Stereopsis
Stereopsis has been very important in human development. Keen and accurate two-eyed depth
perception has allowed man to develop tools and the manufacture of goods, a central aspect of modern
civilization. Stereopsis plays a role in many other human activites, such as, catching a ball, parking a
car, threading a needle, performing surgery, or any other activity that requires accurate depth perception
at close distances.
Animals that have lateral position of the eyes and individuals who have constant strabismus (eye turn)
lack stereopsis. This does not mean that they have absolutely no depth perception. There are many one-
eyed (monocular) depth perception cues that allow us to make reasonably accurate depth judgements.
These monocular depth perception cues may be familiar to you and include: perspective, overlay,
Figure 1 shadowing, aerial perspective (color of the sky), relative motion, relative size, etc.
Binocular vision cues (from two eyes), such as stereopsis and parallax, are dependent on accurate
alignment of the eyes and appropriate unification of the two images by the brain. People with only monocular or one-eye depth perception
skills can do fine in many situations. However, they are not allowed to fly a rocket ship, drive the trains in New York city subways, and they
definitely should not be surgeons. They may have trouble catching a fly ball or becoming a NBA point guard. However, many jobs do not
require stereopsis and thus the lack of stereopsis does not preclude a successful life.
Stereopsis does enhance quality of life and life choices, however! Some eye doctors might tell you that it is a luxury, but it is part and parcel
of our evolution and human potential. 3D vision is a human skill we all want and deserve. Every attempt should be made to develop this
visual-motor skill in a child [and it's not too late for many adults!]
What is the "critical period?"
In the early 1960's, two Nobel Prize winners from Harvard , Hubel and Weisel, did research on the development of vision. They studied
monkeys and cats who have stereoscopic vision similar to humans. This led to conclusions regarding a "critical period" of development for
stereopsis.
What is the "critical period" and what does it mean in regards to you or your child and your treatment options. Explore this controversial
topic by reading the following two articles by Dr. Jeffrey Cooper and Dr. Paul Harris, two different experts on strabismus. Dr. Harris refers to
the famous 1960s Hubel and Weisel study as well as later studies by Hubel and Weisel and others. Many of the more recent studies call into
question the idea of a finite "critical period." Dr. Cooper explains the Hubel and Weisel study and its implications in detail.
The Myth of the Critical Period
by Dr. Paul Harris
Development of Vision (Critical Periods)
by Dr. Jeffrey Cooper
Why does my eye doctor say it is "too late?"
Whenever an eye doctor tells you that it is "too late" to treat your child's loss of binocular vision (or eye turn or "lazy eye"), he or she is
probably referring to his or her earlier education regarding the "critical period." He or she might even be directly or indirectly referring to the
aforementioned research dating from the 1960s.
Remember, a great deal has been learned about the human brain since the 1960s! For example, a new ground-breaking study on the brain's
plasticity (its ability to change and grow) was released to broad media fanfare in the year 2000.
We recommend that you find a doctor who is more up-to-date on the latest in developmental vision and the brain (neuronal plasticity).
When is it too late to treat strabismus or lazy eye?
It is often asked at what age should treatment no longer be attempted. The answer is, everyone deserves a chance! Age should not be a
deterrent, though treatment under age 6 (especially before 2) is ideal and allows better results than later treatment. After age 6, age is not
important.
The best chance of success in eliminating the effects of the most difficult conditions, amblyopia or constant strabismus, occurs before the
age of two. However, this does not preclude excellent success in many older patients and at least partial success in most patients older than 6
years of age. There are numerous studies that demonstrate that treatment after the age of 6 is very successful. One study compared treatment
before age 6 to treatment after age 6. They found no statistical difference between the two groups. As a matter of fact, loss of an eye in
patients over the age of 65 who were never treated for their amblyopia experienced a spontaneous improvement in vision in over one-third of
the cases.
Thus, every attempt should be made to improve strabismus and lazy eye, though treatment might not be as effective after the age of six, and
definitely requires more work. Also, remember that if an eye turn occurs only some of the time (intermittent), the cells of the brains do not
develop the changes associated with the more challenging cases of constant eye turns.
An analogy to understanding the relationship of age in regards to the treatment of eye muscle anomalies would be to consider the relationship
of one's age in learning to speak a second language. During the period of neurological development, around the first year of life, language
development is natural and spontaneous. Children raised in families that speak two languages from birth automatically learn both languages.
However, if the second language is introduced in later school years, language development takes a longer time and is more arduous. Yet,
remember, people learn languages well into their sixties and seventies. The very same is true of visual development. It is easier to develop
normal vision during the critical period, but with work, many people can develop normal binocular vision in later years.
All About Strabismus
by Dr. Jeffrey Cooper & Rachel Cooper (no relation). 2001-2009
Treatment Options
Strabismus Surgery
Orthoptics -- Pre- and/or post-surgical
Vision Therapy --Non-surgical or in conjunction with surgery, as appropriate.
Orthoptics
Orthoptics is the medical term for eye muscle training procedures, provided by orthoptists and/or optometrists, which address eye teaming
and visual clarity (acuity) only. Technically, there are broad distinctions between Orthoptics and Vision Therapy (which includes Orthoptics).
Orthoptics regards strabimus as an eye muscle problem and treatment is directed toward muscle strength. Optometrists who provide Vision
Therapy look at the neurological control system of the eyes and thus treat the whole visual system (and whole person). Vision Therapy alters
the entire nervous system and reflexive behavior, thus resulting in a lasting cure. In general, orthoptics is home-based therapy. In general,
Vision Therapy is performed under supervision in an optometrist's office and home therapy is an adjunct. Recent scientific research has
shown that office-based Vision Therapy with homework is more successful than home-based therapy alone. See National Eye Institute: More
Effective Treatment Identified for Common Childhood Vision Disorder
Vision Therapy
Vision Therapy is an individualized, supervised, non-surgical treatment program designed to correct eye movements and visual-motor
deficiencies. Vision Therapy sessions include procedures designed to enhance the brain's ability to control:
eye alignment,
eye teaming,
eye focusing abilities,
eye movements, and/or
visual processing.
Visual-motor skills and endurance are developed through the use of specialized computer and optical devices, including therapeutic lenses,
prisms, and filters. During the final stages of therapy, the patient's newly acquired visual skills are reinforced and made automatic through
repetition and by integration with motor and cognitive skills.
While Vision Therapy includes the eye muscle training methods of orthoptics, it has advanced far beyond it to include training and
rehabilitation of the eye-brain connections involved in vision. Clinical and research developments in Vision Therapy were closely allied with
developments in neuroscience during the twentieth century. Research continues in the 21st century.
In Vision Therapy programs, optometrists look at the neurological control system and thus are treating the whole visual-motor system and
altering reflexive behavior, which results in a lasting cure. Also, most optometrists rely on office based therapy, which they believe is more
accurately performed and monitored.
Vision Therapy for strabismus generally consists of either weekly or bi-weekly office based therapy. Some doctors reinforce in-office therapy
with home therapy. This is based upon a case-by-case determination. Milder intermittent cases may be handled with home therapy. Older
children are generally more cooperative and thus obtain a greater benefit from therapy.
All About Strabismus
by Dr. Jeffrey Cooper & Rachel Cooper (no relation). 2001-2009
Does the Person Have Constant or Intermittent Strabismus?
This is one of the most important findings the eye doctor makes! It is important for you as a parent or patient to understand the difference
between constant and intermittent strabismus. This distinction has great bearing on timing and types of treatment.
When the eye turn occurs at all distances and at all times, it is called constant strabismus. When the eye turn occurs only some of the time, it
is called intermittent strabismus or alternating strabismus. With intermittent strabismus, the eye turn might be observed only occasionally,
such as during stressful situations or when the person is ill. Please note that if the eye turn is constant at a certain
Up to the first 6 months of age, intermittent strabismus is a normal developmental milestone. After 6 months, it needs to be evaluated.
Treatment of Constant Strabismus
Constant turns are to be dealt with immediately if one wants to re-establish proper use of both eyes. Treatment for this condition should be
early and aggressive. If the eye turn is constant and simple things like patching, drops, and/or glasses (bifocal, prismatic, etc) do not eliminate
the eye turn, Vision Therapy, Orthoptics, or Surgery needs to be considered.
Keep in mind that ophthalmologists are eye surgeons and they infrequently offer or recommend Vision Therapy or orthoptics as treatment
options. See Is Eye Muscle Surgery the Only Treatment Option for Strabismus? For information on Vision Therapy or Orthoptics as treatment
options, consult a developmental (or behavioral) optometrist.
Treatment of Intermittent Strabismus
With intermittent strabismus, the eye does not turn in all the time, so the brain is probably receiving adequate stimulation for the development
of binocular vision.
After 6 months of age, this condition does need attention, but neither the eye doctor nor parent needs to panic. As long as the eyes are straight
some of the time, the brain will develop normal functioning of the eyes (stereoscopic depth perception). Children with intermittent eye turns
should be handled with judicious patching, special glasses, and/or Vision Therapy. Surgery, if considered at all, should be a last resort. See
Eye Muscle Surgery as Treatment for Strabismus, including Intermittent Exotropia
A Parent's Choice re: Treatment for Intermittent Exotropia
Read what several parents have written regarding making the choice between Strabismus Eye Muscle Surgery or Vision Therapy for
Intermittent Exotropia and Lazy Eye.
A Common Cause of Intermittent Exotropia (Intermittent Strabismus)
Convergence Insufficiency, if untreated, can cause intermittent exotropia (an outward eye turn that comes and goes). Convergence
Insufficiency (CI) is also the leading cause of eyestrain, blurry vision, double vision (diplopia), and/or headaches. A scientific study by the
National Institutes of Health/National Eye Institute has concluded that the best treatment for convergence insufficiency is Vision Therapy in a
clinical office with some home reinforcement. Learn more at What is Convergence Insufficiency Disorder?

Strabismus (Esotropia and Exotropia)

Definition
Strabismus is a visual disorder where the eyes are misaligned and point in different directions. This misalignment may be constantly present,
or it may come and go. Sometimes, only one eye is affected turning inward (esotropia), outward (exotropia) or downward while the
other eye is directed straight ahead.
Strabismus is a common condition among children. Normal alignment of both eyes during childhood allows the brain to fuse the two pictures
into a single 3-dimensional image. Strabismus or abnormal alignment can block this normal binocular development and cause amblyopia or
reduced vision in one eye. If vision is reduced, the brain of the child will only learn to recognize the stronger image and ignore the weaker
image of the amblyopic eye. This will eventually cause a loss of depth perception and, if not treated before 6-7 years of age, can result in
permanent visual loss in the affected eye. If strabismus develops in an adult, the patient will often experience double vision because the brain
has been trained to receive images from both eyes.
The exact cause of the eye misalignment that leads to strabismus is not fully understood. Six eye muscles control eye movement and are
attached to the outside of each eye. Two muscles in each eye move the eye right or left while the other four muscles move it up or down and
control tilting movements. To focus both eyes on a single target, all eye muscles must work together with the corresponding muscles of the
opposite eye. The brain coordinates these eye muscles. A cataract or eye injury that affects vision can also cause strabismus.
In infants, it is often difficult to determine the difference between eyes that appear to be crossed and true strabismus. Young children often
have a wide, flat nasal bridge and a fold of skin at the inner eyelid that tends to hide the eye when looking to the side, thus causing the eyes to
appear crossed. An ophthalmologist can readily distinguish true strabismus from the optical illusion called pseudo-strabismus which resolves
spontaneously with growth during childhood development. Children should undergo vision screening by the family doctor, pediatrician, or
ophthalmologist at birth, 6 months of age, 3 years of age, and pre-school to detect potential eye problems while they can still be treated.
Symptoms
Decreased vision
Misaligned eyes
The symptoms described above may not necessarily mean that your child has strabismus. However, if you observe one or more of these
symptoms, contact your child's eye doctor for a complete exam.
Treatment
The treatment goal for strabismus is to preserve vision, to straighten the eyes, and to restore 3-dimensional vision. If amblyopia is detected in
the first few years of life, treatment is often successful. If treatment is delayed until later, amblyopia or reduced vision generally becomes
permanent. Occlusive patching of the better seeing eye can force use of the amblyopic eye and improve vision. Depending on the cause of the
strabismus, treatment may involve repositioning the unbalanced eye muscles, removing a cataract, or correcting other conditions that are
causing the eyes to turn. After a complete eye examination, including a detailed study of the inner parts of the eye, an ophthalmologist can
recommend appropriate optical, medical or surgical treatment.
Early surgery is often recommended to correct strabismus in younger infants, who can then develop normal acuity and binocular (stereo)
vision once the eyes are straightened. As a child gets older, the chance of developing normal sight and depth perception decreases. Crossed
eyes can also have a negative effect on a child's social interaction and self-confidence.
Strabismus surgery involves making a small incision in the tissue covering the eye, which allows the ophthalmologist to access the
underlying eye muscles. The eyeball is never removed from the socket during this kind of eye surgery. Which eye muscles are repositioned
during the surgery depends upon the type of strabismus. It may be necessary to perform eye muscle surgery on one or both eyes. When
strabismus surgery is performed on children, a general anesthetic is required; a local anesthetic is often an option for adults.
Eye muscle surgery is generally performed as an outpatient procedure in a hospital or a surgery center. Recovery time is rapid and the patient
is usually able to resume normal activities within a few days. Following surgery, glasses or prisms may sometimes be needed. Over-or-under
correction can occur and further "touch-up" surgery may be needed. As with any surgery, eye muscle surgery has certain risks which include
infection, bleeding, excessive scarring, and other complications that very rarely may lead to loss of vision.
Strabismus (Cross-Eyes)
What is strabismus and how do I know if my baby has it?
The problem of crossed or wandering eyes is called strabismus (say: "stra-biz-muss"). It's normal for newborn babies to have eyes that cross
or wander sometimes, especially when they're tired. However, tell your doctor if you see your child's eyes cross or see one eye wander to the
side after 3 months of age, even if it happens only once in a while. You should also tell your doctor if your child often looks at you with one
eye closed, or with his or her head turned to one side.
Why is strabismus a problem?
Normal vision needs both eyes to look in the same direction at the same time. When a child has a crossed or wandering eye, he or she gets a
different picture from each eye. The child's brain blocks out the picture from the weaker eye. If this problem is not fixed when a child is
young, the child's brain will always ignore the pictures from the weak eye. This kind of vision loss is called amblyopia (say: "am-blee-o-pee-
ah"). This is the most serious problem caused by crossed or wandering eyes.
What can be done to fix strabismus?
Treatment can help your child to have normal vision. The earlier the treatment is started, the better. The goal of treatment is to make the weak
or wandering eye do more work and get stronger. Sometimes this means the child has to wear corrective glasses. Or the child might wear a
patch on the "good" eye or have drops put in it. This blocks the vision in the stronger eye, which forces the weaker eye to work harder. Your
child may not like to have these treatments, because the weak eye doesn't see as well at first as the other eye. Even if your child doesn't want
to wear glasses or an eye patch, this treatment is very important. It can help your child see better as a child and as an adult.

Some children need an operation to straighten their eyes. The operation is usually considered after the weak eye has gotten stronger by being
used more with the treatments listed above. The surgery is fairly simple, but it doesn't always make the eyes exactly straight. Sometimes it
has to be performed again later on.
How long does treatment last?
Since the most important part of treating strabismus is to force the weak eye to work harder, it's very important that you follow the directions
the doctor gives you for eye patching or eye drops. Usually the treatment will go on for months or even a few years. Sometimes less patching
(or fewer eye drops) will be needed as time goes by. This treatment usually helps make the weak eye as strong as the good eye.

When your child is about 7 or 8 years old, the vision in the weak eye will be as good as it can get with treatment. The earlier treatment starts,
the easier it is to fix the problem. So watch for signs that your child doesn't see well, or for eyes that cross or wander apart. If you have any
questions, always ask your family doctor.

Strabismus

Strabismus is misalignment of the eyes, which produces deviation from the parallelism of normal gaze. Diagnosis is clinical, including
observation of the corneal light reflex and use of a cover test. Treatment may include correction of visual impairment with patching and
corrective lenses, alignment by corrective lenses, and surgical repair.
Strabismus occurs in about 3% of children. Although most strabismus is caused by refractive errors or muscle imbalance, rare causes
include retinoblastoma or other serious ocular defects and neurologic disease. Left untreated, about 50% of children with strabismus have
some visual loss due to amblyopia (see Eye Defects and Conditions in Children: Amblyopia).
Several varieties of strabismus have been described, based on direction of deviation, specific conditions under which deviation occurs,
and whether deviation is constant or intermittent. Description of these varieties requires the definition of several terms.
The prefix eso refers to nasal deviations, and the prefix exo refers to temporal deviations. The prefix hyper refers to upward
deviations, and the prefix hypo refers to downward deviations (see Fig. 1: Eye Defects and Conditions in Children: Ocular deviations in
strabismus. ). Manifest deviations, detectable with both eyes open so that vision is binocular, are designated as tropia. Tropia can be
constant or intermittent and may involve one eye or both eyes. Latent deviation, detectable only when one eye is covered so that vision is
monocular, is designated as phoria. The deviation in phoria is latent because the brain, using the extraocular muscles, corrects the minor
misalignment. Deviations that are the same (amplitude or degree of misalignment remains the same) in all gaze directions are designated
as comitant, whereas deviations that vary (amplitude or degree of misalignment changes) depending on gaze direction are referred to as
incomitant.
Fig. 1

Ocular deviations in strabismus.

Strabismus involves both eyes; the left eye is

shown here. The direction of the deviation is
designated by the prefixes eso-, exo-, hyper-,
and hypo-. When the deviation is visible is
indicated by the suffixes -tropia and -phoria.
Etiology
Strabismus may be congenital (the term infantile is preferred, because detection of strabismus at birth is uncommon, and infantile permits
inclusion of varieties that develop within the 1st 6 mo of life) or acquired (includes those that develop after 6 mo).
Risk factors for infantile strabismus include family history (1st- or 2nd-degree relative), genetic disorders (Down syndrome and Crouzon
syndrome), prenatal drug exposure (including alcohol), prematurity or low birth weight, congenital eye defects, and cerebral palsy.
Acquired strabismus can develop acutely or gradually. Causes of acquired strabismus include tumors (eg, retinoblastoma), head trauma,
neurologic conditions (eg, cerebral palsy; spina bifida; palsy of the 3rd, 4th, or 5th cranial nerves), viral infections (eg, encephalitis,
meningitis), and acquired eye defects. Specific causes vary depending on the type of deviation.
Esotropia is commonly infantile. Infantile esotropia is considered idiopathic, although an anomaly of fusion is the suspected cause.
Accommodative esotropia, a common variety of acquired esotropia, develops between 2 yr and 4 yr of age and is associated with
hyperopia. Sensory esotropia occurs when severe visual loss (due to conditions such as cataracts, optic nerve anomalies, or tumors)
interferes with the brain's effort to maintain ocular alignment.
Esotropia can be paralytic, so designated because the cause is a 6th (abducens) cranial nerve palsy, but it is an uncommon cause. Esotropia
can also be a component of a syndrome. Duane's syndrome (congenital absence of the abducens nucleus with anomalous innervation of
the lateral rectus extraocular muscle by the 3rd [oculomotor] cranial nerve) and Mbius' syndrome (anomalies of multiple cranial nerves)
are specific examples.
Exotropia may be intermittent and idiopathic. Less often, exotropia is constant and paralytic, as with 3rd (oculomotor) cranial nerve palsy.
Hypertropia can be paralytic, caused by 4th (trochlear) cranial nerve palsy that occurs congenitally or after head trauma or less commonly,
as a result of 3rd cranial nerve palsy.
Hypotropia can be restrictive, caused by mechanical restriction of full movement of the globe rather than neurologic interference with eye
movement. For example, restrictive hypotropia can result from a blowout fracture of the orbit floor or walls. Less commonly, restrictive
hypotropia can be caused by Graves' ophthalmopathy (thyroid eye disease). Third cranial nerve palsy and Brown syndrome (congenital or
acquired tightness and restriction of the superior oblique muscle tendon) are other uncommon causes.
Symptoms and Signs
Unless severe, phorias rarely cause symptoms.
Tropias sometimes result in symptoms. For example, torticollis may develop to compensate for the brain's difficulty in fusing images from
misaligned eyes and to reduce diplopia. Some children with tropias have normal and equal visual acuity. However, amblyopia frequently
develops with tropias; it is due to cortical suppression of the image in the deviating eye to avoid confusion and diplopia.
Diagnosis
Physical and neurologic examinations at well-child checkups
Tests (eg, corneal light reflex, alternate cover, cover-uncover)
Prisms
Strabismus can be detected during well-child checkups. History should include questions about family history of amblyopia or strabismus
and, if family or caregivers have noticed deviation of gaze, questions about when the deviation began, when or how often it is present, and
whether there is a preference for using one eye for fixation. Physical examination should include an assessment of visual acuity, pupil
reactivity, and the extent of extraocular movements. Neurologic examination, particularly of the cranial nerves, is important.
The corneal light reflex test is a good screening test, but it is not very sensitive for detecting small deviations. The child looks at a light
and the light reflection (reflex) from the pupil is observed; normally, the reflex appears symmetric (ie, in the same location on each pupil).
The light reflex for an exotropic eye is nasal to the pupillary center, whereas the reflex for an esotropic eye is temporal to the pupillary
center. Vision screening machines operated by trained personnel are being introduced to identify children at risk.
When performing the alternate cover test, the child is asked to fixate on an object. One eye is then covered while the other is observed for
movement. No movement should be detected if the eyes are properly aligned, but strabismus is present if the unoccluded eye shifts to
establish fixation once the other eye, which had fixed on the object, is occluded. The test is then repeated on the other eye.
In a variation of the cover test, called the cover-uncover test, the patient is asked to fix on an object while the examiner alternately covers
and uncovers one eye and then the other, back and forth. An eye with a latent strabismus shifts position when it is uncovered. In exotropia,
the eye that was covered turns in to fixate; in esotropia, it turns out to fixate. Tropia can be quantified by using prisms positioned such that
the deviating eye need not move to fixate. The power of the prism used to prevent deviation quantifies the tropia and provides a
measurement of the magnitude of misalignment of the visual axes. The unit of measurement used by ophthalmologists is the prism
diopter. One prism diopter is a deviation of the visual axes of 1 cm at 1 m.
Strabismus should be distinguished from pseudostrabismus, which is the appearance of esotropia in a child with good visual acuity in both
eyes but a wide nasal bridge or broad epicanthal folds that obscure much of the white sclera nasally when looking laterally. The light
reflex and cover tests are normal in a child with pseudostrabismus.
Prognosis and Treatment
Patching
Contact lenses or eyeglasses
Topical agents
Eye exercises
Surgical repair to align eyes
Strabismus should not be ignored on the assumption that it will be outgrown. Permanent vision loss can occur if strabismus and its
attendant amblyopia are not treated before age 4 to 6 yr. As a result, all children should have formal vision screening in the preschool
years.
Treatment aims to equalize vision and then align the eyes. Children with amblyopia require patching or penalization of the normal eye;
improved vision offers a better prognosis for development of binocular vision and for stability if surgery is done. Patching is not, however,
a treatment for strabismus. Eyeglasses or contact lenses are sometimes used if the amount of refractive error is significant enough to
 interfere with fusion, especially in children with accommodative esotropia. Topical miotic agents, such as echothiophate iodide Some
Trade Names
PHOSPHOLINE IODIDE
Click for Drug Monograph
0.125%, may facilitate accommodation in children with accommodative esotropia. Orthoptic eye exercises can help correct intermittent
exotropia with convergence insufficiency.
Surgical repair is generally done when nonsurgical methods are unsuccessful in aligning the eyes satisfactorily. Surgical repair consists of
loosening (recession) and tightening (resection) procedures, most often involving the rectus muscles. Surgical repair is typically done in
an outpatient setting. Rates for successful realignment can exceed 80%. The most common complications are overcorrection or
undercorrection and recurrence of the strabismus later in life. Rare complications include infection, excessive bleeding, and vision loss.
Last full review/revision June 2007 by Albert W. Biglan, MD
Content last modified June 2007
Strabismus
MedlinePlus Topics
Patient Instructions
Eye muscle repair - discharge
Strabismus is a disorder in which the eyes do not line up in the same direction when focusing. The condition is more commonly known as
"crossed eyes."
Causes
Strabismus is caused by a lack of coordination between the eyes. As a result, the eyes look in different directions and do not focus at the same
time on a single point.
In most cases of strabismus in children, the cause is unknown. In more than half of these cases, the problem is present at or shortly after birth
(congenital strabismus).
In children, when the two eyes fail to focus on the same image, the brain may learn to ignore the input from one eye. If this is allowed to
continue, the eye that the brain ignores will never see well. This loss of vision is called amblyopia, and it is frequently associated with
strabismus.
Some other disorders associated with strabismus in children include:
Apert syndrome
Cerebral palsy
Congenital rubella
Hemangioma near the eye during infancy
Incontinentia pigmenti syndrome
Noonan syndrome
Prader-Willi syndrome
Retinopathy of prematurity
Retinoblastoma
Traumatic brain injury
Trisomy 18 (a child has 3 copies of chromosome 18, instead of the normal 2 copies)
Strabismus that develops in adults can be caused by:
Botulism
Diabetes (causes a condition known as acquired paralytic strabismus)
Guillain-Barre syndrome
Injuries to the eye
Shellfish poisoning
Stroke
Traumatic brain injury
Vision loss from any eye disease or injury
A family history of strabismus is a risk factor. Farsightedness may be a contributing factor. In addition, any other disease causing vision loss
may cause strabismus.
Symptoms
Crossed eyes
Double vision
Eyes that do not align in the same direction
Uncoordinated eye movements (eyes do not move together)
Vision loss in one eye, includes a loss of the ability to see in 3-D (loss of depth perception)
Exams and Tests
A physical examination will include a detailed examination of the eyes. Tests will be done to determine the strength of the eye muscles.
Eye tests include:
Retinal exam
Standard ophthalmic exam
Visual acuity
A neurological examination will also be performed.
Treatment
Treatment involves strategies to strengthen the weakened muscles and realign the eyes. Glasses and eye muscle exercises may be prescribed.
If the condition is caused by a lazy eye, the doctor may prescribe an eye patch. Some children may need surgery. For more information on
treating lazy eye, see: Amblyopia
Outlook (Prognosis)
With early diagnosis and treatment, the problem can usually be corrected. Delayed treatment may lead to permanent vision loss in one eye.
When to Contact a Medical Professional
Strabismus requires prompt medical evaluation. Call for an appointment with your health care provider or eye doctor if your child:
Appears to be cross-eyed
Complains of double vision
Has difficulty seeing
Note: Learning difficulties or problems at school can sometimes be due to a child's inability to see the blackboard or reading material.
Alternative Names
Crossed eyes; Esotropia; Exotropia; Squint; Walleye
References
Hatt SR, Leske DA, Kirgis PA, Bradley EA, Holmes JM. The effects of strabismus on quality of life in adults. Am J Ophthalmol. 2007
Nov;144(5):643-7.
Update Date: 7/28/2008
Strabismus and Cerebral Palsy
Cerebral palsy is a group of disorders that usually affect motor function in people, often in the form of gait problems. Cerebral palsy does
have a variety of symptoms, however. Strabismus is fairly common in people who have cerebral palsy. Strabismus is a vision problem
affecting the eye muscles.
Strabismus in people with cerebral palsy can be usually physically detected due to the misplacement of the eyes. Usually the eyes are not
aligned correctly because there are differences in the strengths of both the left and the right eye muscles. If the strabismus occurs at a young
age, the childs body usually compensates by having one eye work better than the other. Sometimes this can lead to the weaker eye having
worse eyesight, which can be problematic for children with movement disorders like cerebral palsy.
Since the muscles of the two eyes do not work in conjunction with one another, strabismus causes the brain to not be able to put together the
visual images from both eyes. Symptoms that a person with cerebral palsy has strabismus include: eyes that do not look in the same
direction, eyes that do not move at the same time, severe squinting of one eye, and an awkward gait that results in accidents or collisions with
things around them.
Strabismus in cerebral palsy can either be concomitant or incomitant. Concomitant strabismus is when both eyes retain their relationship
regardless of which direction they look in. This generally means that both eyes have the same amount of muscle function but do not look in
the same direction.
Incomitant strabismus occurs when the eyes relationship changes with the gaze. This means that the eyes have varying muscle strengths.
Types of incomitant strabismus in cerebral palsy are: esotropia (one eye turning inward), exotropia (one eye turning outward), hypertropia
(one eye turning upward), and hypotropia (one eye turning downward).
There are several types of treatments and surgeries that can be performed for strabismus. Treatments can include application of things like
patches or certain glasses can help. Other treatments can use Botox A injections, prescription drugs, or even eye exercises.
Most children with cerebral palsy and strabismus will need to have some form of strabismus surgery. These surgeries can help in realigning
the eyes of the child. The surgery usually consists of either weakening or strengthening the eye muscles, which ever is seen to be the best
course of treatment. If the strabismus surgery is undertaken to weaken the eye muscle then procedures called recessions take place. If the
strabismus surgery is to strengthen the muscles then resections occur.
If the cerebral palsy was caused by a medical mistake or preventable problem, then potentially all of the costs of strabismus surgery for
cerebral palsy can be covered. Contact an experienced cerebral palsy lawyer through this Web site for a free consultation to see if you
qualify.