|“My baby’s eyes aren’t straight.”|
|Strabismus secondary to decreased vision|
|Other strabismus (see Chapters 10 and 34)|
|Cranial nerve palsy|
|Child otherwise normal|
|Brief, occasional crossing during first 1 to
|Occasional appearance of mild crossing|
|Often noticed in photographs|
|Worse in side gaze|
|Prolonged periods of crossing|
|Worse when tired|
|May have family history of strabismus|
|More common in children with neurological problems|
|More variable than infantile esotropia|
|Esotropia lasts a few seconds|
|Child less than 2 months old|
|Eye examination otherwise normal|
|Epicanthal folds/wide nasal bridge|
|Appears worse in side gaze|
|Corneal light reflex symmetric|
|Eyes straight with cover test|
|Large angle crossing|
|Asymmetric corneal light reflex|
|Prolonged or constant crossing|
|Strabismus secondary to decreased vision|
|Strabismus usually variable, both in duration
and in angle|
|Possible abnormal red reflex|
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
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.
- 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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