Strabismus (Misaligned Eyes)

Specialized Strabismus Care for Children and Adults

Does your child’s eye turn inward, drift outward, or seem to point in a different direction? These are common signs of strabismus, a condition in which the eyes do not align properly. Strabismus, sometimes called crossed eyes or wandering eyes, can affect infants, children, and adults. One eye may turn inward, outward, upward, or downward. The misalignment may be constant or appear only occasionally, particularly when a child is tired, sick, or focusing on something.

What Is Strabismus?

Normally, the eyes work together to focus on the same object. The brain coordinates the movements of both eyes through a complex system involving the eye muscles and the nerves that control them. Strabismus occurs when the eyes are not properly aligned. One eye may look straight ahead while the other turns in a different direction, or the misalignment may alternate between the eyes. Some people have strabismus all the time, while others experience intermittent eye drifting.

In children, strabismus can interfere with normal visual development and may lead to amblyopia (lazy eye), reduced depth perception, or difficulty using both eyes together. In adults, strabismus may cause double vision, eye strain, abnormal head positioning, or other visual symptoms. Strabismus is not simply a cosmetic concern. Proper diagnosis and treatment can be important for visual development, binocular vision, and everyday functioning.

Types of Strabismus

Strabismus is generally classified by the direction the eye turns, although there are many different causes and patterns of eye misalignment.

Esotropia (Eyes Turning Inward)

Esotropia occurs when one or both eyes turn inward toward the nose. It is commonly called crossed eyes. Different forms of esotropia include:

Infantile Esotropia: Infantile esotropia typically develops during the first six months of life and often involves a noticeable inward turning of one or both eyes. Treatment may include eye muscle surgery, along with management of any associated vision problems. Related Post: When Crossed Eyes in Babies Need Treatment

Accommodative Esotropia: Accommodative esotropia is often associated with farsightedness (hyperopia). When a child focuses to see clearly, the eyes may cross inward. Prescription glasses can significantly improve or fully correct the eye alignment in many children. Related Post: Why Do Some Children’s Eyes Cross?

Partially Accommodative Esotropia: Some children experience improvement in eye alignment with glasses but continue to have an inward eye turn even while wearing their prescription. Additional treatment, including surgery, may be recommended.

Other Forms of Esotropia: Esotropia can also develop later in childhood or adulthood and may be associated with changes in binocular vision, reduced vision in one eye, or neurological and other medical conditions.

Exotropia (Eyes Turning Outward)

Exotropia occurs when one or both eyes drift outward, away from the nose.

Intermittent Exotropia: Intermittent exotropia is a common form of childhood strabismus in which an eye drifts outward only some of the time. Parents may notice the eye drifting when their child is tired, daydreaming, looking into the distance, or not paying attention. Some children close or squint one eye in bright sunlight. Not every child with intermittent exotropia requires immediate treatment or surgery. Our physicians and orthoptists carefully evaluate how often the eye drifts, how well the child controls the alignment, and whether binocular vision is being affected. Treatment recommendations depend on the child’s age, symptoms, measurements, and changes over time.

Constant Exotropia: Constant exotropia occurs when an eye remains turned outward most or all of the time. It may develop from intermittent exotropia or be associated with other visual or medical conditions.

Vertical Strabismus (Eyes Turning Upward or Downward)

Vertical strabismus occurs when one eye is positioned higher or lower than the other.

• Hypertropia: One eye turns upward relative to the other.
• Hypotropia: One eye turns downward relative to the other.

Vertical eye misalignment may cause double vision, abnormal head tilting, or difficulty maintaining comfortable binocular vision. Some forms are associated with abnormalities involving the eye muscles or the nerves controlling eye movement.

Other Complex Types of Strabismus

Our pediatric ophthalmologists also evaluate and manage less common and more complex eye movement disorders, including:

• Duane Syndrome: A congenital eye movement disorder involving abnormal nerve development that limits certain eye movements and may cause an unusual head position.
• Brown Syndrome: A condition that restricts eye movement, particularly when attempting to look upward while the eye is turned inward.
• Fourth Nerve (Superior Oblique) Palsy: A condition that can cause vertical eye misalignment, double vision, and a compensatory head tilt.
• Sixth Nerve Palsy: A condition involving weakness of an eye movement nerve that can cause an eye to turn inward and limit outward movement.
• Dissociated Vertical Deviation (DVD): A condition in which an eye may drift upward, often associated with childhood strabismus.

These conditions require specialized evaluation to determine the underlying cause and appropriate treatment.

What Causes Strabismus?

Strabismus can develop for several reasons. In many cases, it results from differences in how the brain controls and coordinates eye movements rather than a problem with the strength of the eye muscles themselves. Possible contributing factors include:

• Family history of strabismus
• Significant farsightedness or other refractive errors
• Differences in visual development
• Premature birth
• Reduced vision in one eye
• Neurological or genetic conditions
• Disorders affecting the eye muscles or nerves
• Previous eye injuries or surgery

In many children, no single cause can be identified.

Can Babies Outgrow Crossed Eyes?

Parents sometimes notice that a newborn’s eyes appear to cross or wander. Brief, occasional eye misalignment can occur in very young infants as their visual system develops. However, constant eye crossing at any age, or eye misalignment that persists beyond approximately four months of age, should be evaluated.

Some babies have pseudostrabismus, a condition in which the eyes appear crossed because of facial features such as a broad nasal bridge or folds of skin near the inner corners of the eyes. Although the eyes may look misaligned, they are actually straight.

A pediatric ophthalmologist can distinguish pseudostrabismus from true strabismus through a comprehensive eye examination. Parents should not assume that a noticeable eye turn is something their child will simply outgrow.

How Is Strabismus Diagnosed?

A comprehensive strabismus evaluation involves much more than determining whether the eyes look straight. Our pediatric ophthalmologists and certified orthoptists perform specialized examinations to assess:

• Vision in each eye
• Eye alignment at distance and near
• Eye movements and muscle function
• The size and direction of eye misalignment
• Whether the eye turn is constant or intermittent
• Binocular vision and depth perception
• The presence of amblyopia
• Refractive errors that may contribute to the misalignment
• Signs of other eye or medical conditions

For children, a dilated eye examination is often an important part of the initial evaluation to assess eye health and determine whether prescription glasses may improve alignment. These detailed measurements help our physicians develop individualized treatment plans and monitor changes over time.

Strabismus Treatment Options

Treatment depends on the type and severity of strabismus, the patient’s age, vision, symptoms, and ability to use both eyes together. Not every patient requires surgery, and there is no single treatment that is appropriate for every form of strabismus.

Prescription Glasses: Some types of strabismus, particularly accommodative esotropia, can improve significantly with the appropriate glasses prescription. Glasses may be the primary treatment or may be used along with other treatments.

Amblyopia Treatment: Children with strabismus may also develop amblyopia (lazy eye), a condition in which vision does not develop normally in one eye. Treatment may include prescription glasses, patching or other physician-directed therapies. Amblyopia treatment is important for improving vision but does not necessarily straighten the eyes.

Monitoring and Orthoptic Follow-Up: Some children may benefit from careful observation rather than immediate intervention. Our certified orthoptists work closely with our physicians to monitor eye alignment, binocular vision, and response to treatment. Depending on the condition and physician’s treatment plan, some follow-up visits may be scheduled directly with an orthoptist.

Prism Glasses: Prism lenses may help some patients with strabismus-related double vision by changing how light enters the eyes. Prisms can be useful in selected patients with diplopia, although they are not appropriate for every type or degree of misalignment.

Strabismus Surgery: When glasses or other treatments cannot adequately improve eye alignment, surgery may be recommended. Strabismus surgery involves adjusting the position or tension of the muscles that control eye movement to improve alignment. Surgery may be performed on one or both eyes, depending on the type of strabismus and the measurements obtained during the examination. Our pediatric ophthalmologists have specialized surgical training in treating eye misalignment in children and adults, including complex cases and patients who have undergone previous strabismus surgery. The goal of surgery is to improve eye alignment and, when possible, binocular vision and visual comfort. Some patients may require additional treatment or surgery over time.

Adult Strabismus and Double Vision

Although pediatric ophthalmologists specialize in children’s eye conditions, their advanced training in eye alignment also makes them specialists in treating strabismus in adults. Adult strabismus may be present since childhood or develop later in life. Some adults experience worsening of a previously controlled eye turn, while others develop misalignment following illness, injury, or other medical conditions. Symptoms may include:

• Double vision (diplopia)
• Eyes that appear crossed or misaligned
• Difficulty with depth perception
• Eye strain or visual discomfort
• Abnormal head positioning
• Difficulty reading or performing daily activities

Treatment may include prism glasses, observation, or strabismus surgery.

Adult strabismus surgery is not simply cosmetic. Improving eye alignment may help reduce double vision, improve visual function, and positively affect quality of life. New or sudden-onset double vision or eye misalignment, particularly when accompanied by headache, drooping eyelid, weakness, or other neurological symptoms, requires prompt medical evaluation.

Why Choose Children’s Eye Care for Strabismus?

Fellowship-Trained Pediatric Ophthalmologists

Our physicians have completed advanced fellowship training in pediatric ophthalmology and strabismus, including specialized medical and surgical management of eye alignment disorders in children and adults. Strabismus is a core part of our practice, from evaluating a young child with intermittent eye drifting to managing complex eye muscle disorders and performing strabismus surgery.

Certified Orthoptists: Specialized Eye Alignment Expertise

One of the distinguishing strengths of Children’s Eye Care is our team of certified orthoptists. Orthoptists are highly trained eye care professionals who specialize in eye movements, strabismus, amblyopia, double vision, and binocular vision disorders. Our orthoptists work closely with our physicians in evaluating patients, performing detailed measurements, monitoring treatment, and providing specialized follow-up care. Their expertise is particularly valuable for patients requiring ongoing monitoring of intermittent exotropia, amblyopia, prism treatment, and other eye alignment conditions.