Peds
Strabismus
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Strabismus
See Also
Amblyopia
Anisometropia
Congenital Cataract
Cover Test
Visual Fixation
Pediatric Eye Exam
Pinhole Test
Epidemiology
Accounts for 50% of
Amblyopia
(most common cause)
Types
Esodeviation (Cross-Eyed)
Both eyes turn inward
Accounts for >50% of ocular deviations in children
Exodeviation (walleye)
One eye turns outward while other eye faces forward
Deviation most evident with distant
Vision
Parents often note changes on a bright day
Eye deviates outward
Child closes one eye
Fourth
Cranial Nerve
palsy (superior oblique palsy)
Eye rises when
Head Tilt
ed to side of palsy
Findings
Hypertropia
(deviating eye turns up)
Hypotropia
(deviating eye turns down)
Signs
Screen at every well child check
Test Specifically for Strabismus
Only 50% children with Strabismus have obvious defect
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
Signs
Small-Angle Strabismus (Accommodative esotropia)
Identified with
Cover Test
ing
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
Screening
Gene
ral
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
Williams (2002) BMJ 324: 1549-51 [PubMed]
Diagnosis
Immediate Ophthalmology Consult Indications
Manifest (constant) deviation in any age
Intermittent Exodeviation >6 months
Intermittent Esodeviation >2 months
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
Management
Early
Consultation
is critical
Surgical Realignment of eyes
Amblyopia
treated prior to realignment surgery
Prognosis for congenital esotropia
Repair under age 1 year
Offers best chance of near-normal binocular
Vision
Repair over age 1 year
Significantly worse prognosis for binocular
Vision
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]
Simon (2001) Am Fam Physician 64(4):623-8 [PubMed]
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