Pediatric strabismus (crossed eyes)

What is pediatric strabismus (crossed eyes)?

Strabismus (stra·​bis·​mus) is a condition in which a person's eyes are not aligned. It is commonly called "crossed eyes" in the United States. While one eye focuses, the child's other eye may turn inward or outward, up or down. If a child with strabismus stops using the affected eye, they may develop amblyopia (lazy eye), which can lead to vision loss.

Risk factors

Between 4 and 5% of people have strabismus. The condition usually develops in toddlers younger than 3.

What are the different types of pediatric strabismus (crossed eyes)?

• Esotropia: Inward turning, also known as crossed eyes

• Exotropia: Outward turning, also known as walleye

• Hypertropia: Upward turning

• Hypotropia: Downward turning

What are the signs and symptoms of pediatric strabismus (crossed eyes)?

Children and babies often cross their eyes, especially when they're tired. An obvious sign of strabismus is if your child has one eye that doesn't look straight ahead. A child with strabismus may turn her head or close one eye completely to look at you.

Other signs of strabismus include:

• Eyes that cross or are misaligned

• Eyes that don't move together (uncoordinated)

• Double vision

• Loss of vision or depth perception

How is pediatric strabismus (crossed eyes) diagnosed?

For most kids, the cause of strabismus is unknown, although more than half the time it is present either at, or shortly after, birth. This is known as congenital strabismus. Strabismus is almost always due to problems with neuromuscular control rather than muscle strength.

A child's ability to focus, as well as their depth perception and eye muscle coordination all develop by 6 months of age. By 9 months, the vision system is set. Any disruption to the system before approximately 4 years may result in strabismus.

Strabismus can be hard to detect in some children, so all infants should have an eye exam by their first birthday. Signs of strabismus include crossed or misaligned eyes, double vision or a loss of depth perception.

Strabismus is also associated with several disorders, including:

• Cerebral palsy (CP)

• Down syndrome

• Congenital rubella

• Traumatic brain injury (TBI)

• Apert syndrome

• Hemangioma

• Noonan syndrome (NS)

• Intercontinental pigmenti (IP)

• Prader-Willi syndrome (PWS)

• Retinopathy of prematurity (ROP)

• Retinoblastoma

• Edwards syndrome (trisomy 18)

An ophthalmologist will begin the diagnosis by asking you about your child's medical history.

Questions may include:

• At what age did you first notice your child's misalignment?

• Do you have a family history of congenital eye problems?

The doctor will then perform a physical exam to make sure there isn't an underlying eye disease that's causing the disorder.

Tests to detect strabismus include:

• Corneal reflex

• Cover test (measures the amount of deviation between the eyes)

• Retinal exam

• Visual acuity test

• A neurological exam

What are the causes of pediatric strabismus (crossed eyes)?

Most cases of strabismus are present or develop in otherwise normally developed kids shortly after birth. Children with brain disorders such as cerebral palsy (CP) and Down syndrome are at a greater risk for strabismus.

How is pediatric strabismus (crossed eyes) treated?

If your child has amblyopia, they will need to be treated for that first. “Patching” is usually used to treat amblyopia. Your child's strong eye is covered, which over time allows the weak one to work harder.

Once the amblyopia has been dealt with, treatment can begin on the strabismus. Treatments for strabismus include prescription lenses (if necessary) or, if the cause is weak eye muscles, surgery.

Surgery

Eye muscle repair corrects misaligned eyes that result from muscle problems. Your child will receive general anesthesia before the procedure. The surgeon may remove a section of muscle or tendon to make a muscle stronger. To weaken a muscle, the doctor will reattach it toward the back of the eye (recession).

The younger your child is when the surgery is done, the better her chance of achieving normal or near-normal vision. Some children may have to wear glasses even after surgery.