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The Problem
“My baby’s eyes aren’t straight.”
Common Causes
Normal newborn
Pseudostrabismus
Infantile esotropia
Strabismus secondary to decreased vision
Other Causes
Other strabismus (see Chapters 10 and 34)
Duane syndrome
Cranial nerve palsy
Möbius syndrome
KEY FINDINGS
History
Normal newborn
Child otherwise normal
Brief, occasional crossing during first 1 to 2 months
Pseudostrabismus
Occasional appearance of mild crossing
Often noticed in photographs
Worse in side gaze
Infantile esotropia
Prolonged periods of crossing
Worse when tired
May have family history of strabismus
More common in children with neurological problems
Decreased vision
Frequent strabismus
More variable than infantile esotropia
Examination
Normal newborn
Esotropia lasts a few seconds
Child less than 2 months old
Eye examination otherwise normal
Pseudostrabismus
Epicanthal folds/wide nasal bridge
Appears worse in side gaze
Corneal light reflex symmetric
Eyes straight with cover test
Infantile esotropia
Large angle crossing
Asymmetric corneal light reflex
Prolonged or constant crossing
Possible amblyopia
Strabismus secondary to decreased vision
Strabismus usually variable, both in duration and in angle
Possible abnormal red reflex
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If the child is less than 2 months old and the eyes cross occasionally, and there are no visible abnormalities of the eyes, the child should be rechecked after 2 months of age. Patients with constant crossing at any age, or intermittent crossing that persists after 2 months of age, should be referred to a pediatric ophthalmologist.

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What Shouldn’t Be Missed

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Although uncommon, abnormalities of the eye such as cataract or retinoblastoma may initially present with strabismus (secondary to decreased vision). The prognosis for these disorders is greatly improved with prompt treatment. Any child with strabismus and an abnormal red reflex should be referred immediately.

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  • 1. Normal newborn (physiological intermittent strabismus of the newborn). Intermittent eye crossing is relatively common in the first 1 to 2 months of life. The angle of eye crossing may be quite large, but the duration is brief (a few seconds). This resolves in most infants by 2 months of age.
  • 2. Pseudostrabismus. Normal infants have a wider and flatter nasal bridge than adults. When an infant looks to the side, this tissue may block visualization of the white nasal sclera in the eye that is turned toward the nose, while the sclera remains visible in the other eye. This asymmetry creates an optical illusion that makes it appear as if one eye is crossing. Examination of the corneal light reflex reveals that the eyes are straight (Figure 9–1).
  • 3. Infantile esotropia. True eye crossing (esotropia) is usually not present at birth. It most often begins around age 2 months. Initially it may occur intermittently, but usually progresses rapidly to constant crossing. When the infant’s eye crosses, the brain stops paying attention to the visual information from the eye. This may cause amblyopia if one eye is constantly crossed. Some children spontaneously alternate fixation between the eyes (alternate fixation) (...

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