Understanding Strabismus in Children: Causes, Diagnosis & Treatment

Dr Parth Shah is the principal ophthalmologist at Clarity Eye Surgeons in Canberra. He understands that when it comes to your child’s eye health, you have many questions and concerns. In this comprehensive guide, I will shed light on Strabismus in children, its causes, treatment options, and how parents can support their little ones through this journey.

What is Strabismus?

Strabismus, often referred to as “crossed eyes” or “squint” is a condition where a child’s eyes do not align properly. This misalignment can be constant or intermittent, causing one eye to turn inwards, outwards, upwards, or downwards while the other remains straight. It can affect one or both eyes.

Strabismus is common in children, and it can occur at any age. If left untreated, it can impact a child’s vision and overall development.

Causes of Strabismus in Children

Several factors can contribute to the development of Strabismus in children:

  1. Congenital Esotropia: It is also known as infantile esotropia, is a type of strabismus that is present at birth or develops within the first six months of life. It involves a consistent inward turning of one or both eyes. The exact cause is often unknown, but it may be related to genetic factors or abnormalities in the development of the eye muscles or brain pathways that control eye movement.

  2. Accommodative Esotropia: It typically develops in children between the ages of 2 and 3. It is caused by significant farsightedness (hyperopia). When a child with farsightedness tries to focus on an object, the eyes converge excessively, leading to one eye turning inward. Corrective glasses or contact lenses can often manage this condition by reducing the need for the eyes to work hard to focus.

  3. Refractive Esotropia: It is similar to accommodative esotropia but specifically refers to inward eye turning caused directly by refractive errors such as hyperopia. The excessive effort to focus on close objects can cause the eyes to cross. Corrective lenses can help align the eyes properly.

  4. Intermittent Exotropia: It is a condition where one or both eyes turn outward occasionally, typically when the child is tired, ill, or focusing on distant objects. It can occur intermittently and may progress to more frequent occurrences. Treatment options include eye exercises, glasses, or surgery to strengthen the eye muscles.

  5. Pseudo-Strabismus: It is the appearance of strabismus when the eyes are actually aligned correctly. This can occur due to the facial structure, such as a broad nasal bridge or epicanthal folds (skin folds near the inner corner of the eyes) that create the illusion of misalignment. Pseudo-strabismus does not require treatment as it is not a true eye misalignment.

  6. Duane’s Syndrome: It is a rare congenital eye movement disorder where the eye has limited horizontal movement. It occurs due to improper development of the sixth cranial nerve, which controls lateral rectus muscle movements. This can result in one eye not moving outward properly and sometimes turning inward instead. Treatment may involve surgery or special glasses to improve eye alignment and function.

  7. Brown’s Syndrome: It is a mechanical problem where one eye cannot move up properly, particularly when looking inward. This is due to an abnormality or tightness in the superior oblique tendon. It can be congenital or acquired from trauma or inflammation. Treatment options include observation, steroids for inflammation, or surgery to correct the tendon issue.

  8. Sensory Esotropia: It occurs when there is a significant decrease in vision in one eye, causing the eye to turn inward. This condition can result from cataracts, retinal disease, or other vision impairments. Treating the underlying cause of vision loss is essential, and sometimes strabismus surgery may be necessary to realign the eyes.

  9. Congenital Exotropia: It is also known as infantile exotropia, is an outward turning of the eye(s) that is present at birth or develops within the first six months of life. It is less common than congenital esotropia and often requires surgical intervention to correct the eye alignment.

  10. Nerve Palsies: Nerve palsies refer to paralysis or weakness of the cranial nerves responsible for eye movements. The most common are:

  • Sixth Nerve Palsy: Affects the ability to move the eye outward.
  • Third Nerve Palsy: Affects multiple eye movements, including upward, downward, and inward, often causing the eye to turn outward and droop (ptosis).
  • Fourth Nerve Palsy: Affects the superior oblique muscle, leading to difficulty in moving the eye downward and inward.

Nerve palsies can result from congenital issues, trauma, infections, or Neurological disorders. Treatment involves addressing the underlying cause and may include surgery, prism glasses, or eye exercises.    

Recognising Strabismus in Children

Recognising Strabismus in your child is crucial for early intervention. Signs and symptoms may include:

  • An eye that consistently turns inwards, outwards, upwards, or downwards.
  • Squinting or closing one eye in bright sunlight.
  • Some children may adopt a head tilt or turn to compensate for their misaligned eyes. 
  • Observe your child’s eyes closely. If one eye constantly fails to follow the other, this is an indicator of Strabismus.
  • If your child frequently complains of seeing double or overlaps in their vision, especially when reading or focusing on objects up close, this could be a sign of Strabismus.

Remember, detecting Strabismus early is crucial for effective treatment, so pay close attention to any changes in your child’s eye alignment or vision.

If you notice any of these signs, it is recommended to seek an assessment.

Diagnosis and Evaluation

The diagnosis of Strabismus involves a thorough eye examination by an optometrist or ophthalmologist. This evaluation may include:

  • Visual Acuity Test: To assess how well each eye sees.
  • Cover Test: To detect eye misalignment.
  • Refraction Test: To check for focusing errors.
  • Eye Muscle Movement Assessment: To determine the extent of the misalignment.


This evaluation helps determine the type and severity of Strabismus and guides the treatment plan.

Treatment Options

The good news is that Strabismus can usuaLLy be treated effectively, and the treatment plan is tailored to each child’s unique needs. Treatment options include:

  • Eyeglasses: Correcting refractive errors with prescription glasses can sometimes improve eye alignment.
  • Patching: Covering the stronger eye with a patch to encourage the weaker eye to work harder.
  • Surgery: eye muscle surgery can align the eyes by adjusting the position or length of the eye muscles.


Here is an overview of Strabismus surgery:

  • Procedure: The surgery involves adjusting the length or position of eye muscles to re-align the eyes. It is usually performed under general anaesthesia, ensuring your child feels no pain during the procedure.
  • Recovery: After surgery, your child may experience mild discomfort, but this can usually be managed with over-the-counter pain relievers. The eyes may be red and swollen for a few days, but this typically resolves within a week or two.
  • Success Rates: The success rate of Strabismus surgery is generally high, with most children experiencing improved eye alignment.
  • Follow-Up Care: After surgery, your child will require regular follow-up appointments to monitor their progress and ensure the eyes are aligning properly. In some cases, further treatment may be needed (e.g. glasses and/or patching). 
  • Risk of Recurrence: While surgery can effectively align the eyes, there is a risk of Strabismus recurring in the future, which might necessitate additional procedures.


It is essential to discuss the best approach with your ophthalmologist, considering your child’s age and the severity of their condition.

The Importance of Early Intervention

Early intervention is crucial in managing Strabismus effectively. Untreated Strabismus can lead to:

  • Amblyopia (lazy eye), where the brain ignores input from the misaligned eye.
  • Decreased depth perception.
  • Social and self-esteem issues as children may feel self-conscious about their appearance.

Your Role as a Parent

Supporting your child through Strabismus treatment is essential. Be sure to:

  • Attend all scheduled appointments.
  • Encourage your child to wear glasses or patches as prescribed.
  • Provide a positive and understanding environment.

Conclusion

In conclusion, Strabismus is a treatable condition, and early intervention is key to success. Remember, as a parent, you are not alone in this journey. Clarity Eye Surgeons are here to support you every step of the way. 

If you suspect your child has Strabismus or have any questions, please don’t hesitate to reach out to us. 

Author Bio

Dr Parth Shah is a director and principal ophthalmologist at Clarity Eye Surgeons in Canberra, specialising in strabismus surgery and cataract surgery. With extensive training and experience, he is renowned for his expertise in the field. Dr Shah is dedicated not only to performing successful surgeries but also to patient education. His compassionate approach, combined with technical proficiency, has earned him the trust and gratitude of countless patients. He is a true advocate for eye health and a trusted name in the Canberra ophthalmology community.

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