Strabismus in Children

Strabismus refers to the condition when the eyes do not look straight ahead. This gives a cross-eyed appearance. This is often first seen in baby photos as in the one below. If you look at the light reflection from the flash, you can see it in the center of the right eye but to the right of center on the left eye. This means the eyes are pointing inwards - a so-called convergent squint. If the eyes looked away from center, it would be called a divergent squint.

Before 6 months of age, babies will often have a wandering eye. This is normal as the eyes develop. It is usually intermittent and not there all the time. When it is present all the time, it is called a constant strabismus - this should be reviewed by your doctor.

After the age of 6 months, it is always abnormal for an infant to have a wandering eye or permanent cross eyes, so after 6 months of age, strabismus in children is always abnormal, whether it is intermittent or constant.

An intermittent strabismus is when the eye is only occasionally cross-eyed. This often happens before 6 months of age and is just part of normal development. If it still occurs after 6 months of age, please see your doctor for a full diagnosis and treatment plan.

Constant strabismus is when the eyes always look crossed. All babies with constant strabismus need full examination by a developmental optometrist (pediatric eye doctor) for a diagnosis and treatment plan.

To develop binocular vision, both eyes need to see the same thing as they develop. If the eyes are not pointing straight, they will see different things. The way the brain deals with this is to suppress one of the images. If this happens over a long time and particularly over the first 2 years of life, binocular vision will not develop and the brain will permanently suppress the images from one eye, meaning that eye will have poor vision that cannot be corrected. This situation is called amblyopia (or sometimes referred to as lazy eye).

Children with amblyopia have problems with depth perception and spatial awareness. This will make many tasks and sports difficult, so it is important to try and prevent amblyopia by early diagnosis and treatment of strabismus (eye squint).

Lazy eye is the term used for ambylopia, which is means that the eye has reduced vision that cannot be corrected by eye glasses (spectacles) or contact lenses or eye surgery.

There are many causes of ambylopia but one is strabismus that is not treated. So if you have an infant or toddler with cross eyes (squint, strabismus) and it is not treated in time, the brain will start to permanently suppress the image from one of the eyes resulting in permanent reduced vision that cannot be fixed.

There are various treatments that may be used and the treatment plan will be made by a developmental optometrist. The treatment options include:

• correction of refractive error - so eye glasses (spectacles) if needed
• intermittent patching of the good eye so the weaker eye has to work harder and get stronger - usually only for 2 hours per day
• intermittent eye drops in the good eye to make the eye blurry and so make weaker eye work harder - usually only a couple of days per week
• eye exercises - often in conjunction with patching. Eye exercises are usually those that involve hand-eye co-ordination at a near distance
• surgery

Treatment will often start with correcting any refractive error - so using eye glasses to correct vision. If this fails to improve the squint (strabismus) then patching or eye drops (atropine) may be used. Surgery would usually only be considered if there had been inadequate improvement with other measures.

Treatment should be started as soon as possible after diagnosis. Ideally treatment should begin before 6 years of age, and best results come if treatment begins before 2 years of age.

However, treatment has been successfully started at later ages, but the best results come with treatments that are started earliest.

There are many clues you may get to suggest your child has a problem with their vision, including:

• saying they have a problem seeing - always take this seriously
• holding one eye closed
• tilting head to one side to get a good view
• you notice the eyes wander or are permanently crossed
• you notice asymmetry in the way the eyes look in photographs

A tilt of the head is called torticollis. This can be because of tight muscles in the neck or because of an eye problem - ocular torticollis. Some children with strabismus tilt their heads so they get a clearer image by aligning the eyes differently - they are trying to correct the difference in the images the eyes make. This is called ocular torticollis.

Some children have widely set eyes and so the eyes can look like they are looking inward. However, if you look at where a light reflects (as with a flash in a photo) then the reflection will be in symmetrical in the eyes.

Yes. Several studies have shown an increase in the incidence of strabismus in children with the autistic spectrum disorder, including autism. All children with autism should have an eye examination with a developmental optometrist as part of routine treatment.

See a doctor if you notice any of the following:

• your baby has eyes that cross after the age of 6 months - often called a wandering eye
• your baby has permanent cross eyes at any age
• when you take a flash photo, there are different "red eye" appearances - the red eye should look the same in both eyes as in the photo above. If not and there is a "white eye" appearance, it may indicate a tumour or other serious condition
• your baby or toddler always seems to tilt his head when he is looking at objects
• your child complains of blurry vision
• your child holds one eye closed when looking at objects

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• Shotton K, Elliott S. Interventions for strabismic amblyopia. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD006461. (Review) PMID: 18425952
• Kaplan, Melvin; Edelson, Stephen M.; Rimland, Bernard. Strabismus in Autistic Spectrum Disorder.Focus on Autism and Other Developmental Disabilities, v14 n2 p101-05 Sum 1999

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• Lazy Eye
• Strabismus
• Prevent Blindness
• The Eye Patch Club for children

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Last reviewed 31 July 2009

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