Strabismus in Children: Causes, Symptoms, Types, and When to See an Eye Doctor

Strabismus, commonly known as crossed eyes or eye misalignment, is a condition in which the eyes do not point in the same direction at the same time. Parents may notice that one eye turns inward, outward, upward, or downward, or that the eyes do not appear properly aligned.

Strabismus can affect more than the appearance of the eyes. In young children, it may interfere with normal visual development and, in some cases, lead to amblyopia, commonly known as lazy eye, if it is not detected and treated early.

The treatment of strabismus in children depends on several factors, including the type of eye deviation, its cause, the child’s age, the degree of misalignment, and whether vision in either eye has been affected.

At Sayyad Eye Center, children with suspected strabismus undergo a comprehensive eye examination to assess vision, eye alignment, eye movements, refractive errors, and the overall health of the eyes before an individualized treatment plan is recommended.

In this article, we explain the main types, causes, and symptoms of strabismus in children, the difference between true strabismus and pseudostrabismus, and when your child should be examined by a pediatric ophthalmologist.

What Is Strabismus in Children?

Strabismus is a condition in which the eyes are not properly aligned. One eye may look straight ahead while the other turns inward, outward, upward, or downward.

Several muscles surrounding each eye control its movement. These muscles work together with the nervous system to keep both eyes aligned and moving in coordination.

When this coordination is disrupted, one or both eyes may deviate from their normal position.

In young children, the brain may respond to two different visual images by suppressing, or ignoring, the image coming from the misaligned eye. If this continues during the period when vision is still developing, the child may develop amblyopia.

For this reason, early diagnosis and treatment are important in helping protect normal visual development.

Strabismus in Babies: When Is It Normal?

Parents may occasionally notice that a newborn or young infant’s eyes do not appear perfectly aligned.

Intermittent eye wandering can occur during the first few months of life as visual coordination is still developing. However, constant eye misalignment at any age should be evaluated.

If an eye deviation continues or occurs repeatedly after approximately 4 months of age, the child should be examined by a pediatric ophthalmologist.

An eye turn that is clearly present from birth, becomes more frequent, or becomes constant should also be assessed.

What Is Pseudostrabismus?

Some babies appear to have crossed eyes even though their eyes are actually properly aligned. This is called pseudostrabismus..              

Pseudostrabismus is particularly common in infants and young children because of facial features such as a broad nasal bridge or skin folds near the inner corners of the eyes. These features can make the eyes appear to turn inward, especially when the child looks to the side.

An ophthalmologist can distinguish between true strabismus and pseudostrabismus using eye alignment tests and by examining the light reflex from the eyes.

Pseudostrabismus itself does not require treatment. However, an eye examination is useful to confirm that true strabismus is not present.

Types of Strabismus in Children

Strabismus can be classified according to the direction in which the eye deviates.

Esotropia: Inward Turning of the Eye

Esotropia occurs when one or both eyes turn inward toward the nose.

Some forms of esotropia are associated with farsightedness, also known as hyperopia. This is called accommodative esotropia.

In these children, focusing effort may contribute to the inward eye turn, and properly prescribed glasses can significantly improve or, in some cases, fully correct the alignment.

Other forms of esotropia can appear during infancy or early childhood and are not caused solely by refractive error.

Treatment depends on the type and severity of the condition. Some children may be treated with glasses, while others may require additional treatment or eye muscle surgery.

Exotropia: Outward Turning of the Eye

Exotropia occurs when one eye drifts outward, away from the nose.

A common form in children is intermittent exotropia, in which the eye is straight most of the time but occasionally drifts outward.

Parents may notice this more often when the child is tired, daydreaming, unwell, or looking into the distance.

If the outward drift becomes more frequent or lasts for longer periods, the child should be evaluated to determine whether treatment is required.

Vertical Strabismus

Vertical strabismus occurs when one eye sits higher or lower than the other.

This may be related to abnormalities involving one or more eye muscles, the nerves controlling eye movement, or other conditions affecting ocular alignment.

Because the causes can vary, a detailed eye movement examination is important.

What Causes Strabismus in Children?

There is no single cause of childhood strabismus, and in some children no specific underlying cause can be identified.

Factors associated with strabismus include:

·        Farsightedness, particularly in accommodative esotropia

·        A significant difference in prescription between the two eyes

·        Reduced vision in one eye

·        A family history of strabismus

·        Premature birth or low birth weight

·        Certain neurological or developmental conditions

·        Eye diseases that reduce the clarity of vision

·        Congenital cataract or other conditions that prevent a clear image from reaching the retina

In rare cases, newly developed strabismus may be associated with a more serious problem affecting the eye or nervous system.

A sudden eye turn in a child who previously had straight eyes should therefore be evaluated, particularly if it is associated with double vision, headache, vomiting, abnormal eye movements, or neurological symptoms.

What Are the Symptoms of Strabismus in Children?

The most noticeable sign is often an eye that appears to turn away from its normal position.

Other signs parents may notice include:

·        One eye turning inward, outward, upward, or downward

·        Intermittent eye drifting, especially when the child is tired or distracted

·        Closing or covering one eye, particularly in bright light

·        Tilting or turning the head to look at objects

·        Appearing to favor one eye

·        Double vision in older children who are able to describe their symptoms

·        Difficulty with depth perception or judging distances in some cases

The presence of one of these signs does not necessarily mean that a child has strabismus, but it is a reason to arrange an eye examination.

Can Strabismus Cause Lazy Eye?

Yes. Some forms of strabismus can lead to amblyopia, particularly when one eye is constantly misaligned.

When the eyes are pointing in different directions, the brain receives two different images.

In a young child, the brain may begin to ignore the image from the misaligned eye in order to avoid confusion or double vision.

If this continues while the visual system is still developing, vision in that eye may not develop normally, resulting in amblyopia.

For this reason, the goal of treatment is not only to improve eye alignment, but also to preserve and develop the best possible vision in both eyes.

How Is Strabismus Diagnosed in Children?

Diagnosis begins with a careful medical and family history, including when the eye turn was first noticed and whether it is constant or intermittent.

A pediatric ophthalmology examination may include:

·        Measuring visual acuity in each eye using age-appropriate methods

·        Assessing eye alignment and measuring the amount of deviation

·        Cover tests to identify the type of strabismus

·        Examining eye movements in different directions

·        Evaluating how well the two eyes work together

·        Checking for amblyopia

·        Measuring refractive errors such as farsightedness, nearsightedness, and astigmatism

·        Examining the internal and external structures of the eyes

Dilating eye drops are commonly used in children to relax the focusing system and allow an accurate measurement of the child’s prescription.

This is particularly important in young children and in cases where accommodative esotropia is suspected.

When Should Your Child See a Pediatric Ophthalmologist?

A child should be examined if the parents notice a persistent or recurrent eye turn, especially if the deviation continues beyond the first few months of life.

Constant strabismus at any age should be assessed.

An examination should also be arranged if the child develops a sudden eye turn, double vision, an unusual head position, abnormal eye movements, or any other new visual symptoms.

Early assessment can help identify refractive errors, amblyopia, or other eye conditions during a period when treatment can have the greatest impact on visual development.

If you notice a change in the alignment of your child’s eyes, you can schedule an examination with the pediatric ophthalmology and strabismus team at Sayyad Eye Center for a comprehensive assessment and individualized treatment plan.