Strabismus

Dr. Burke is one of Cincinnati's most trusted resources concerning strabismus treatment in children and in adults.

What is Strabismus?

Strabismus is the encyclopedic word that describes a problem in which the eyes are not properly aligned with each other. The eyes are not properly aligned and do not focus on one object together at the same time. An eye may be misaligned all of the time (constant) or only some of the time (intermittent). The common types of horizontal strabismus are esotropia and exotropia. When the eyes are vertically misaligned, this is referred to as hypertropia.

What causes Strabismus?

The eyes move faster and more precisely than any other part of our body. The eye muscles are controlled through nerves from the brain. Strabismus is caused when these neural connections that control the eye muscles are out of balance.

What are the risk factors for Strabismus?

One of the highest risk factors for strabismus is having a family history of strabismus. Significant prematurity, cerebral palsy and other neurological problems, and genetic disorders also increase the risk of eye misalignment.

If you suspect your child has Strabismus, what should you do?

Besides parents, a pediatrician or family doctor is often the first person to suspect strabismus. Any baby whose eyes do not appear straight by the age of 3-4 months should have a thorough pediatric ophthalmologic exam. Strabismus that is not treated early in the child's life may cause amblyopia (poor visual development in one or both eyes). As soon as a child is suspected of having a misaligned eye (Strabismus), a complete exam with a Pediatric Ophthalmologist is necessary to determine if there is an eye problem.

If I just wait, will my child’s misaligned eyes get better by themselves?

No. Children do not outgrow strabismus. Treatment for strabismus is required. These treatments may include glasses, amblyopic therapy (patching or eye drops), and eye muscle surgery.

Who specializes in the treatment of Strabismus?

The American Association for Pediatric Ophthalmology and Strabismus is an organization of pediatric ophthalmologists dedicated to the prevention and treatment of eye problems in children and the treatment of strabismus in people of all ages.

What are the symptoms of strabismus in children?

For most children, there are no symptoms from strabismus. However, the most common sign of strabismus is that the eyes are not straight. Parents might also notice the child squint or close one eye in bright sunlight, close or put one hand over an eye while watching television or reading a book, or they may have an unusual head tilt or head turn while attempting to look closely at a target.

What are the symptoms of strabismus in adults?

Strabismus often causes complaints in adults. They may complain of double vision (diplopia), visual confusion, loss of binocular (3-D) vision, partial loss of peripheral visual field, and awareness of or neck pain caused by a compensatory head position (head tilt or head turn). Many adults project upon themselves a decreased self-image because they are aware of the negative impact that misaligned eyes (strabismus) causes in many social and vocational settings.

What is double vision?

Diplopia, the medical term for double vision, is the perception of the same image in two different visual locations. The brain attempts to deal with double vision by attempting to ignore or suppress one of these 2 different images. If this neural adjustment is unsuccessful, closing one eye or covering one side with an eye patch may be necessary.

What is visual confusion?

Visual confusion is the perception of two different images superimposed onto the same space. One of the most common examples of visual confusion that is particularly dangerous and often debilitating occurs when driving. Adults with visual confusion may describe cars going in the opposite direction crossing over the center line and coming straight at them. This visual confusion is caused by the brain shifting the image of the oncoming car and superimposing it on the road straight ahead.

How is strabismus diagnosed?

Pediatric ophthalmologists are experts in the examination techniques to confirm the diagnosis of strabismus. Most patients are referred to pediatric ophthalmologists by pediatricians, family doctors, and other ophthalmologists and optometrists because on their examinations an eye misalignment problem is suspected.

What is pseudo-esotropia?

Pseudo-esotropia is the illusion that the eyes are crossed where indeed they are straight and properly aligned. The eyes of infant often seem to be crossed. Infants and young children often have a wide and flat nasal bridge causing the folds of skin at the inner corners of the eyelids to partially cover the inner corners of each eye giving the illusion that the eyes are crossed. This is particularly noticeable when the child is looking to either side. Photographs often catch a child in these positions causing many parents to suspect the child may have crossed eyes. This illusion of strabismus improves as the child's face grows and, in most children, is no longer noticeable by the age of 5.

Why is it important to have strabismus treated?

The most important reasons to treat eye misalignment problems (strabismus) are first to straighten the eyes and second to restore binocular (3-D) vision. In children it is particularly important to treat eye misalignment problems (strabismus) to preserve normal visual development or assist in the therapy of and the stability of amblyopic therapy.

What are the common types of strabismus?

Strabismus is commonly designated by the direction of the misaligned eye. The common types of strabismus are esotropia, exotropia, and hypertropia. Esotropia, often called "crossed-eyes", is the most common type of strabismus and refers to an eye that turns inwardly. Exotropia is used to describe an eye that turns outwardly and is often called “wall-eyed”. The most uncommon eye misalignment problem is when one eye is displaced up or down and this type of vertical strabismus is called hypertropia.

What are the common types of esotropia?

There are four types of esotropia. The four types are infantile or congenital esotropia, accommodative esotropia, late onset non-accommodative esotropia, and a combination of accommodative and non-accommodative causes referred to as mixed mechanism esotropia.

What is infantile esotropia?

Congenital or infantile esotropia describes a constantly crossed or turned in eye in an infant less than 12 months old. This type of esotropia occurs in up to 1% of infants. In almost all cases of infantile esotropia, early surgical treatment is necessary to realign their eyes.

What is accommodative esotropia?

Accommodative esotropia is a common form of crossed eyes occurring in up to 2% of children and typically developing after 12 months and before 5 years old. Accommodation refers to the powerful force that allows the eye to focus. When we accommodate on a close target, this powerful focusing force also activates convergence, or the turning inward of the eyes to look at or be aligned upon nearby objects. These two activities (focusing and turning the eyes inward) are both controlled by the same nerve and happen at the same time. This whole process is called accommodative convergence. Most children with accommodative esotropia are farsighted. Farsighted children have to use their focusing mechanism inside their eyes (accommodation) more powerfully than do most children. Because the same nerve controls focusing and turning the eye inward, the farsighted child who is working very hard to focus may cross (over-converge) the eyes at the same time. This is called accommodative esotropia or may also be described as focusing-related-crossing.

How is accommodative esotropia treated?

Most children with focusing-related-crossing, or accommodative esotropia, are treated with eyeglasses. The power of the eyeglasses is determined by performing a refraction. In most cases of accommodative esotropia, the focusing muscles inside the eye must be relaxed with eyedrops (cycloplegia) to accurately measure the full amount of the child's farsightedness (hyperopia). About 75% of children with accommodative esotropia will have straight eyes wearing eyeglasses. Glasses will only help the child if they are prescribed accurately and worn full-time. As soon as the glasses are removed, the eyes will cross again. For this reason your child must wear the glasses during all waking hours. In the remaining 25% of patients, glasses alone may not be enough to straighten your child's eyes. This type of strabismus is referred to as mixed mechanism esotropia. In these cases, eye muscle surgery may be required in addition to glasses. Eye muscle surgery is only used to treat the crossing that is not relaxed by the glasses (the non-accommodative component). That means your child will continue to need glasses to keep their eyes straight even after surgery (for their accommodative component).

What is mixed mechanism esotropia?

When the crossed eyes (esotropia) are caused by both focusing reason (accommodative) and by a muscular reason (non-accommodative), the crossing is referred to as mixed mechanism esotropia. The accommodative component requires to use of glasses. Surgery is often necessary for the muscular imbalance (non-accommodative) part.

What is exotropia?

A child whose eye turns outwardly is said to have a wandering eye or be “wall-eyed”. Exotropia refers to an outwardly drifting eye. About one percent of children have an outwardly wandering eye. The most common presentation in a child is where the eye drifts only part of the time. This is called intermittent exotropia.

What is infantile exotropia?

Congenital or infantile exotropia describes a constantly outwardly deviated eye in an infant less than 12 months old. This type of exotropia is very uncommon. Although it may be no more worrisome than the much more common infantile esotropia (crossed eyes), many with infantile exotropia have some type of neurological insult with developmental delay.

What is intermittent exotropia?

Children with intermittent exotropia have a strong tendency to let an eye turn out, but the eye does not turn outwardly all the time. When the child does control the alignment, the eyes are straight and functional normally together. The most common age of onset is between 2 and 5 years of age. During the early stages, the child has straight eyes looking at anything closer than 3 to 4 feet. The eye will drift or wander outwardly when the child looks at things far away and is especially noticeable when the child is tired, ill, or daydreaming. Parents often notice that the child squints or tries to close one eye in bright sunlight. As time passes, control is gradually lost and the eye will begin to wander more frequently and stay in the outwardly deviated position for a longer period of time. Surgical realignment of the eye muscles will ultimately be necessary in over 90% of patients with intermittent exotropia.

Additional Information:

Strabismus in Children

Strabismus in Adults

Esotropia

Accommodative Esotropia

Exotropia

Examination Techniques for Strabismus

Strabismus Surgery

Anesthesia

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