II. Definitions
- Strabismus
- Eye misalignment in children
III. Epidemiology
- Accounts for 50% of Amblyopia (most common cause)
- Affects up to 4% of children in U.S.
IV. Types
- Esotropia or Esodeviation (Crossed Eyes, Convergent Strabismus)
- Both eyes turn inward
- Most common Strabismus cause, accounting for >50% of ocular deviations in children
- Typically present by age 18 to 36 months of age
- Accommodative Esotropia occurs when a child with uncorrected Farsightedness looks at a near object
- Congenital Esotropia is due to excessive convergence and is high risk for Amblyopia
- Exotropia or Exodeviation (Walleye, Divergent Strabismus)
- One eye turns outward while other eye faces forward
- Deviation most evident with distant Vision and therefore only occurs intermittently
- Typical onset in preschool aged children
- Parents often note changes on a bright day, or when children are tired or inattentive
- Eye deviates outward
- Child closes one eye
- Often children are able to self correct Exotropia with concentration
- Accommodative Exotropia occurs when a child with uncorrected Nearsightedness looks at a distant object
- Fourth Cranial Nerve palsy (superior oblique palsy)
- Eye rises when Head Tilted to side of palsy
- Findings
- Hypertropia (deviated eye turns up)
- Hypotropia (deviated eye turns down)
V. Signs: Screen at every well child check
- Test Specifically for Strabismus
- Only 50% children with Strabismus have obvious defect
VI. Signs: Organized by Strabismus type
- Manifest (Tropia): Strabismus that is always present
- Corneal Light Reflex
- Cover-Uncover exam
- Bruckner Test (Red Reflex)
- Fixation and following
- Intermittent Strabismus
- Healthy newborns develop alignment after age 4 weeks
- Intermittent exodeviation under 6 months
- Esodeviation much more likely to be pathologic
- Latent (Phoria): Present if binocular Vision blocked
- Only found when specifically tested
- Cover-Uncover exam
VII. Signs: Small-Angle Strabismus (Accommodative Esotropia)
- Identified with Cover Testing
- Seen in Farsighted toddlers
- Corrected with glasses or bifocals
- Abnormal use of accommodative convergence
- Normal reflex for near Vision
- Farsighted children use convergence all the time
VIII. Screening
-
General
- See testing above
- Photoscreening (picture of eyes and Red Reflex)
- May be used in future for mass screening
- Timing
- Screen frequently in first 3 years of life
- Example protocol: 8, 12, 18, 25, 31, 37 months of age
- Early diagnosis results in best outcome
- References
IX. Diagnosis: Immediate Ophthalmology Consult Indications
- Manifest (constant) deviation in any age
- Intermittent Exodeviation >6 months
- Intermittent Esodeviation >2 months
X. Diagnosis: Pitfalls - Pseudostrabismus
- Esotropia may be apparent despite normal alignment
- Iris appears to be surrounded by different white
-
Illusion of different amount white on each side of iris
- Flat Nasal Bridge
- Large epicanthal folds
- Differentiate from Strabismus with proper testing
- See Strabismus signs above
- Refer to Ophthalmology for any question of misalignment
XI. Management
- Early ophthalmology Consultation is critical
- Amblyopia treated prior to realignment surgery
- Accommodative Esotropia
- Farsightedness correction with bifocals
- Surgical correction if refractory
- Congenital Esotropia
- High risk for Amblyopia if not corrected by age 2 years old
- Onabotulinumtoxin A injection is an initial option in some cases
- Surgical Realignment of eyes
- Exotropia
- Surgical correction if constant, frequent or large exodeviation
- Hypertropia or Hypotropia
- Refer all cases to ophthalmology or pediatric neurology
XII. Prognosis
- Up to 40% of children with Strabismus will progress to Amblyopia
XIII. References
- Berson (1987) Ophthalmology Study Guide, AAO, p. 95-110
- Essman (1992) Am Fam Physician 46(4):1243-52 [PubMed]
- Mills (1999) Am Fam Physician 60(3):907-16 [PubMed]
- Reedy-Cooper (2023) Am Fam Physician 108(1): 40-50 [PubMed]
- Simon (2001) Am Fam Physician 64(4):623-8 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
| Definition (MSHCZE) | Esotropie – manifestní, přetrvávající forma strabismu. Jeden nebo oba oční bulby jsou deviovány konvergentně. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ ) |
| Definition (MSH) | A form of ocular misalignment characterized by an excessive convergence of the visual axes, resulting in a "cross-eye" appearance. An example of this condition occurs when paralysis of the lateral rectus muscle causes an abnormal inward deviation of one eye on attempted gaze. |
| Concepts | Disease or Syndrome (T047) |
| MSH | D004948 |
| ICD9 | 378.00, 378.0 |
| ICD10 | H50.0 , H50.00 |
| SnomedCT | 194074002, 194085000, 155193001, 16596007 |
| English | Convergent Strabismus, Esotropia, Esotropias, Strabismus, Convergent, Esotropia, unspecified, Constant comitant esotropia, Convergent concomitant strabismus, Manifest convergent squint, crossed eyes, eyes cross, eyes are crossed (symptom), eyes are crossed, esotropia (diagnosis), esotropia, Esodeviation, Esodeviations, Esotropia NOS, Unspecified esotropia, Esotropia [Disease/Finding], crossing eyes, cross eye, cross eyes, cross-eye, crossings eyes, disorders esotropia, esotropias, convergent squint, crossed eye, esodeviation, crossing eye, Cross Eye, Cross-Eye, Cross-Eyes, Internal Strabismus, Strabismus, Internal, Internal strabismus, Unspecified esotropia (disorder), Esotropia NOS (disorder), Cross-eye, Convergent strabismus, Convergent squint, Esotropia (disorder), concomitant; strabismus, convergent, convergent; strabismus, strabismus; concomitant, convergent, strabismus; convergent, Esotropia, NOS, Crossed Eyes |
| Dutch | convergent scheelzien, convergent bijkomend strabismus, esotropie, niet-gespecificeerde esotropie, concomitans; strabismus, convergens, convergens; strabismus, strabismus; concomitans, convergens, strabismus; convergens, Strabismus concomitans convergens, Esotropie, Scheelzien naar binnen, Strabismus convergens, Strabismus internus |
| French | Strabisme convergent concomitant, Esotropie, Esotropie, non précisée, Ésotropie, Strabisme convergent |
| German | konvergentes Begleitschielen, Esotropie, unspezifisch, konvergentes Schielen, Esotropie, Konvergenter Strabismus, Strabismus concomitans convergens, Strabismus convergens, Innenschielen, Strabismus convergens internus, Strabismus, konvergenter, Einwärtsschielen |
| Italian | Esotropia non specificata, Esodeviazione, Occhio strorto, Strabismo interno, Strabismo convergente, Esotropia |
| Portuguese | Esotropia NE, Estrabismo concomitante convergente, Estrabismo convergente, Esotropia, Estrabismo Convergente, Estrabismo Interno |
| Spanish | Esotropía no especificada, Mirada bizca convergente, Estrabismo concomitante convergente, esotropía, SAI, esotropía no especificada, esotropía, SAI (trastorno), esotropía no especificada (trastorno), bizquera, esotropía (trastorno), esotropía, estrabismo convergente, Estrabismo Convergente, Estrabismo Interno, Esotropía |
| Japanese | 内斜視、詳細不明, 輻輳性共同斜視, ﾅｲｼｬｼ, ﾅｲｼｬｼｼｮｳｻｲﾌﾒｲ, ﾌｸｿｳｾｲｷｮｳﾄﾞｳｼｬｼ, 内斜視, 内斜視-輻輳, 輻輳内斜視 |
| Swedish | Inåtskelning |
| Finnish | Esotropia |
| Russian | EZOTROPIIA, KONVERGIRUIUSHCHEE KOSOGLAZIE, KOSOGLAZIE KONVERGIRUIUSHCHEE, KOSOGLAZIE SKHODIASHCHEESIA, КОНВЕРГИРУЮЩЕЕ КОСОГЛАЗИЕ, КОСОГЛАЗИЕ КОНВЕРГИРУЮЩЕЕ, КОСОГЛАЗИЕ СХОДЯЩЕЕСЯ, ЭЗОТРОПИЯ |
| Czech | Ezotropie, blíže neurčená, Konvergentní konkomitantní strabismus, Ezotropie, Konvergentní šilhání, konvergentní strabismus, konvergentní sbíhavé šilhání, ezotropie, esotropie |
| Korean | 공동 내사시 |
| Croatian | EZOTROPIJA |
| Polish | Zez zbieżny |
| Hungarian | Esotropia, nem meghatározott, Konvergáló kancsalság, Esotropia, Konvergáló concomittáló strabismus |
| Norwegian | Esotropi, Innoverskjeling, Konvergent strabisme |
Ontology: Exotropia (C0015310)
| Definition (MSHCZE) | Manifestní, přetrvávající forma strabismu. Jeden nebo oba oční bulby jsou deviovány divergentně. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ ) |
| Definition (MSH) | A form of ocular misalignment where the visual axes diverge inappropriately. For example, medial rectus muscle weakness may produce this condition as the affected eye will deviate laterally upon attempted forward gaze. An exotropia occurs due to the relatively unopposed force exerted on the eye by the lateral rectus muscle, which pulls the eye in an outward direction. |
| Concepts | Disease or Syndrome (T047) |
| MSH | D005099 |
| ICD9 | 378.10, 378.1 |
| ICD10 | H50.1 , H50.10 |
| SnomedCT | 194086004, 155194007, 75400001, 194098009, 399054005, 399252000 |
| English | Divergent Strabismus, Exodeviation, Exodeviations, Exotropia, Strabismus, Divergent, Exotropia, unspecified, exotropia, exotropia (diagnosis), Exotropia NOS, Unspecified exotropia, Exotropia [Disease/Finding], divergent squint, exodeviation, divergent strabismus, Exotropia NOS (disorder), Unspecified exotropia (disorder), Divergent concomitant strabismus, Divergent strabismus, External strabismus, Divergent squint, Divergent concomitant strabismus (disorder), Exotropia (disorder), concomitant; strabismus, divergent, divergent; strabismus, strabismus; concomitant, divergent, strabismus; divergent, Exotropia, NOS, XT - Exotropia |
| Spanish | exotropía (trastorno), exotropía, Mirada bizca divergente, Exotropía no especificada, Estrabismo concomitante divergente, exotropia (trastorno), exotropia, exotropía, SAI, exotropía no especificada, estrabismo divergente, estrabismo concomitante divergente, exotropía no especificada (trastorno), exotropía, SAI (trastorno), estrabismo externo, estrabismo divergente concomitante (trastorno), estrabismo divergente concomitante, Estrabismo Divergente, Exotropía |
| Dutch | divergente bijkomende strabismus, niet-gespecificeerde exotropie, divergent scheelzien, exotropie, concomitans; strabismus, divergens, divergens; strabismus, strabismus; concomitans, divergens, strabismus; divergens, Strabismus concomitans divergens, Exotropie, Scheelzien naar buiten, Strabismus divergens |
| French | Strabisme divergent concomitant, Exotropie, non précisée, Exotropie, Strabisme divergent |
| German | divergentes Schielen, divergentes Begleitschielen, Exotropie, unspezifisch, Strabismus concomitans divergens, Exotropie, Strabismus divergens, Auswärtsschielen, Schielen, Auswärts- |
| Italian | Exotropia, non specificata, Exodeviazione, Strabismo divergente, Exotropia |
| Portuguese | Estrabismo concomitante divergente, Exotropia NE, Estrabismo divergente, Estrabismo Divergente, Exotropia |
| Japanese | 開散性共同斜視, 外斜視、詳細不明, ｶﾞｲｼｬｼｼｮｳｻｲﾌﾒｲ, ｶﾞｲｼｬｼ, ｶｲｻﾝｾｲｷｮｳﾄﾞｳｼｬｼ, 斜視-外, 外転(眼), 斜視-開散, 外斜視, 開散斜視 |
| Swedish | Utåtskelning |
| Czech | exotropie, Exotropie, blíže neurčená, Divergentní konkomitatní strabismus, Divergentní šilhání, Exotropie, exodeviace, divergentní strabismus |
| Finnish | Uloskarsastus |
| Russian | EKZOTROPIIA, STRABIZM DIVERGIRUIUSHCHII, KOSOGLAZIE RASKHODIASHCHEESIA, KOSOGLAZIE DIVERGIRUIUSHCHEE, КОСОГЛАЗИЕ ДИВЕРГИРУЮЩЕЕ, КОСОГЛАЗИЕ РАСХОДЯЩЕЕСЯ, СТРАБИЗМ ДИВЕРГИРУЮЩИЙ, ЭКЗОТРОПИЯ |
| Korean | 공동 외사시 |
| Polish | Zez rozbieżny |
| Hungarian | Exotropia, nem meghatározott, Divergáló concomittáló strabismus, Divergáló kancsalság, Exotropia |
| Norwegian | Utoverskjeling, Eksotropi, Strabismus divergens, Strabisme, divergerende |
Ontology: Hypertropia (C0020575)
| Definition (NCI) | Vertical strabismus in which there is permanent upward deviation of the visual axis of one eye. |
| Concepts | Disease or Syndrome (T047) |
| MSH | D013285 |
| ICD9 | 378.31 |
| ICD10 | H50.2 |
| SnomedCT | 194109005, 40608009 |
| English | Hypertropias, Unspecified hypertropia, hypertropia (diagnosis), hypertropia, nonparalytic hypertropia, Unspecified hypertropia (disorder), Hypertropia (disorder), Hypertropia |
| Dutch | hypertropie, Hypertropie |
| Spanish | Hipertropía, Hipertropia, hipertropía no especificada (trastorno), hipertropía no especificada, hipertropía (trastorno), hipertropía |
| Japanese | 上斜視, ｼﾞｮｳｼｬｼ |
| Portuguese | Hipertropia |
| French | Hypertropie |
| German | Hypertropie, Fixation nach oben |
| Czech | Hypertropie, hypertropie |
| Hungarian | Hypertropia |
| Italian | Ipertropia |
| Norwegian | Hypertropi |
Ontology: Strabismus (C0038379)
| Definition (MSHCZE) | Obecný pojem pro všechny formy šilhavosti (abnormální souhyb očních bulbů). Skryté, latentní šilhání se obecně nazývá heteroforie, manifestní šilhání heterotropie. Ezoforie (ezotropie) označuje konvergentní, sbíhavé šilhání, exoforie (exotropie) šilhání divergentní. Patognomicky se s. rozděluje na tři základní skupiny. Neparalytický (konkomitující) s. se vyskytuje nejčastěji, je typický u dětí. Paralytický s. je vždy způsoben kompletní nebo částečnou parézou příslušného okohybného nervu, která může být kongenitální nebo získaná (traumata, neuroinfekce, postvirové syndromy, cévní příčiny, systémové onemocnění aj.). Strabické syndromy zahrnují speciální, zvláštní typy s. nejč. způsobené strukturálními anomáliemi okohybných svalů. Šilhá jen jedno oko, popř. se oči střídají. Dvojitému vidění zabrání „vypnutí“ obrazu přicházejícího z odchylujícího se oka, které však může trvale slábnout (vzniká tupozrakost, amblyopie). Léčí se speciálními brýlemi (současně bývá obv. i refrakční vada), speciálními očními „cviky“ (tzv. ortoptika), někdy operativně. Léčit je nutné včas a důsledně. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ ) |
| Definition (NCI) | Strabismus is the intermittent or constant misalignment of an eye so that its line of vision is not pointed at the same object as the other eye. Strabismus is caused by an imbalance in the extraocular muscles which control the positioning of the eyes. Strabismus is normal in newborns but should resolve by the time the baby is 6 months old. In older children with strabismus, the brain may learn to ignore the input from one eye, and this may lead to amblyopia, a potentially permanent decrease in vision in that eye if not corrected. |
| Definition (MSH) | Misalignment of the visual axes of the eyes. In comitant strabismus the degree of ocular misalignment does not vary with the direction of gaze. In noncomitant strabismus the degree of misalignment varies depending on direction of gaze or which eye is fixating on the target. (Miller, Walsh & Hoyt's Clinical Neuro-Ophthalmology, 4th ed, p641) |
| Concepts | Disease or Syndrome (T047) |
| MSH | D013285 |
| ICD9 | 378.40, 378.30, 378.4 |
| ICD10 | H50.5 , H50.9, H50.40, H50.50 |
| SnomedCT | 14619009, 155196009, 194107007, 194114009, 194116006, 246726008, 194137003, 267745004, 155192006, 22066006, 128602000 |
| LNC | MTHU013559 |
| English | Phorias, Squint, Strabismus, Phoria, Heterophoria, HETEROTROPIA, SQUINT, STRABISMUS, Disord binoc eye movem, Heterophoria, unspecified, Heterotropia, unspecified, Strabismus NOS, Strabismus, unspecified, strabismus, heterotropia (diagnosis), strabismus (diagnosis), heterotropia, squinting (symptom), squinting, heterophoria (diagnosis), heterophoria, Binocular eye movement disorder NOS, Unspecified disorder of binocular eye movements, Heterophoria NOS, Heterotropia NOS, Unspecified heterotropia, Unspecified heterophoria, Unspecified strabismus, Strabismus [Disease/Finding], eye deviation, crossed eye, Squinting, phoria, phorias, deviations eye, Unspecified heterotropia (disorder), Heterophoria NOS (disorder), Ocular dissociation (finding), Disorder of binocular eye movements (disorder), Strabismus NOS (disorder), Unspecified heterophoria (disorder), Eye deviation, Binocular eye movement disorder, Heterotropia, Disorder of binocular eye movements, Ocular dissociation, Heterotropia (disorder), Strabismus (disorder), eye; deviation, eye; movement disorder (binocular), Heterophoria, NOS, Heterotropia, NOS, Squint, NOS, Strabismus, NOS, squint |
| French | STRABISME, Strabisme SAI, Hétérotropie, Anomalie non précisée des mouvements binoculaires, Anomalie des mouvements conjugués des yeux SAI, Hétérophorie, non précisée, Hétérotropie, non précisée, DEFAUT CONVERGENCE AXES VISUELS, Anomalie des mouvements conjugués des yeux, Hétérophorie, Strabisme, Phories |
| Portuguese | ESTRABISMO, Estrabismo NE, Heterotropia NE, Alteração binocular dos movimentos do olho NE, Heteroforia NE, Heterotropia, Alteração dos movimentos binoculares do olho NE, HETEROTROPIA, PISCAR DE OLHOS, Estrabismo não Manifesto, Estrabismo Paralítico, Estrabismo Manifesto, Heteroforia, Alteração binocular dos movimentos do olho, Estrabismo, Forias, Vergo Estrabismo |
| Spanish | ESTRABISMO, estrabismo latente, Estrabismo NEOM, Heteroforia no especificada, Heterotropía, Heterotropía no especificada, Trastorno de los movimientos binoculares de los ojos NEOM, Bizco, Trastorno no especificado de los movimientos binoculares de los ojos, HETEROTROPIA, heteroforia, SAI (trastorno), heteroforia, SAI, heterotropía no especificada, heteroforia no especificada (trastorno), heterotropía no especificada (trastorno), heteroforia no especificada, estrabismo, SAI, estrabismo, SAI (trastorno), Estrabismo no Manifesto, Estrabismo Paralítico, Estrabismo Manifesto, estrabismo (trastorno), estrabismo, heterotropía (trastorno), heterotropía, Heteroforia, Trastorno de los movimientos binoculares de los ojos, Estrabismo, Estrabismo Curvo, Foria |
| German | STRABISMUS, unspezifische Stoerung der binokulaeren Augenbewegungen, Heterotropie, Heterophorie, unspezifisch, Heterotropie, unspezifisch, binokulaere Augenbewegungsstoerung NNB, Strabismus NNB, BEGLEITSCHIELEN, SCHIELEN, Strabismus, nicht naeher bezeichnet, Heterophorie, binokulaere Augenbewegungsstoerung, Phorie, Schielen, Strabismus |
| Italian | Disturbo del movimento binoculare dell'occhio, Eteroforia, Disturbo del movimento binoculare dell'occhio NAS, Eteroforia, non specificata, Eterotropia, Disturbi non specificati dei movimenti binoculari dell'occhio, Eterotropia, non specificata, Strabismo NAS, Forie, Strabismo |
| Dutch | scheelzien, heteroforie, niet-gespecificeerd, heterotropie, niet-gespecificeerde stoornis van binoculaire oogbeweging, niet-gespecificeerde heterotropie, binoculaire oogbewegingsafwijking NAO, strabismus NAO, Strabisme, oog; bewegingsstoornis (binoculair), oogstand; deviatie, Heteroforie, Strabismus, niet gespecificeerd, binoculaire oogbewegingsafwijking, heteroforie, strabismus, Strabismus, Scheelzien |
| Japanese | 眼球斜位、詳細不明, 斜視、詳細不明, 両眼球運動障害ＮＯＳ, 眼球斜位, 両眼球運動障害, 斜視ＮＯＳ, 詳細不明の両眼の眼球運動の障害, ｶﾞﾝｷｭｳｼｬｲｼｮｳｻｲﾌﾒｲ, ﾘｮｳｶﾞﾝｷｭｳｳﾝﾄﾞｳｼｮｳｶﾞｲ, ｼｬｼｼｮｳｻｲﾌﾒｲ, ｶﾞﾝｷｭｳｼｬｲ, ｼｬｼ, ｼｬｼNOS, ﾘｮｳｶﾞﾝｷｭｳｳﾝﾄﾞｳｼｮｳｶﾞｲNOS, ｼｮｳｻｲﾌﾒｲﾉﾘｮｳｶﾞﾝﾉｶﾞﾝｷｭｳｳﾝﾄﾞｳﾉｼｮｳｶﾞｲ, やぶにらみ, 上斜位, 上斜視, 斜位(眼球), 斜視 |
| Swedish | Skelning |
| Czech | šilhání, strabismus, Strabismus, Heterotropie, blíže neurčená, Heteroforie, blíže neurčená, Heteroforie, Šilhání, Binokulární okohybná porucha, Blíže neurčené binokulární okohybné poruchy, Binokulární okohybná porucha NOS, Heterotropie, Strabismus NOS, šilhavost |
| Finnish | Karsastus |
| Russian | KOSOGLAZIE, STRABIZM, КОСОГЛАЗИЕ, СТРАБИЗМ |
| Korean | 상세불명의 사시, 사위 |
| Croatian | STRABIZAM |
| Polish | Zez |
| Hungarian | Heterophoria, Kancsalság, Heterotropia, nem meghatározott, Binocularis szemmozgás-betegség, Binocularis szemmozgás zavar k.m.n., Heterophoria, nem meghatározott, Heterotropia, Strabismus k.m.n., Nem meghatározott binocularis szemmozgás zavar |
| Norwegian | Skjeling, Strabisme, Fori |
Ontology: Hypotropia (C0152208)
| Definition (NCI) | Vertical strabismus in which there is permanent downward deviation of the visual axis of one eye. |
| Concepts | Disease or Syndrome (T047) |
| ICD9 | 378.32 |
| SnomedCT | 29491004 |
| English | hyop - Hypotropia, hypotropia (diagnosis), hypotropia, deviation downward eye, downward deviation of eyes, Downward deviation of eyes, Hypotropia, Hypotropia (disorder), Downward Ocular Deviation, Sunset Sign |
| Dutch | neerwaartse afwijking van de ogen, hypotropie |
| French | Hypotropie, Déviation du regard vers le bas |
| German | Hypotropie, nach unten gerichtete Abweichung der Augen |
| Italian | Ipotropia, Deviazione degli occhi verso il basso |
| Portuguese | Hipotropia, Desvio dos olhos para baixo |
| Spanish | Hipotropía, Desviación hacia abajo de los ojos, hipotropía (trastorno), hipotropía |
| Japanese | 下斜視, 眼の下方偏位, ｶｼｬｼ, ﾒﾉｶﾎｳﾍﾝｲ |
| Czech | Deviace očního bulbu dolů, Hypotropie |
| Hungarian | Hypotropia, Szemek lefele irányuló deviatiója |
