Strabismus - Symptoms, Causes, Images, and Treatment Options

Diseases

Highlights & Basics

Key Highlights

Strabismus is a condition where there is misalignment of the visual axes of the eyes; it may be latent or manifest and, if manifest, it may be constant or intermittent.
It is a common cause of diplopia and visual confusion (seeing different objects in the same place) in adults.
It is an important cause of amblyopia (decreased vision in an anatomically normal eye caused by suppression) in children.
It may be esthetically obvious to the patient and others, resulting in psychosocial problems.
Evaluation involves a detailed medical history, including a complete ocular history, followed by thorough neurologic and ophthalmic examinations.

Esotropia: left eye fixating (note decentered light reflection on right cornea)

From the collection of Dr Daniel J. Salchow; used with permission

Quick Reference

History & Exam
- Key Factors
- Other Factors
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Diagnostics Tests
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Treatment Options
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Definition

Epidemiology

Etiology

Pathophysiology

Images

Esotropia: left eye fixating (note decentered light reflection on right cornea)
Exotropia: left eye fixating (note decentered light reflection in right eye)
Right hypertropia: left eye fixating (note inferior scleral show and decentered light reflection in right eye)

Citations

Key Articles

US Preventive Services Task Force. Vision in children ages 6 months to 5 years: screening. Sep 2017 [internet publication].[Full Text]
Sprunger DT, Lambert SR, Hercinovic A, et al. Esotropia and exotropia preferred practice pattern®. Ophthalmology. 2023 Mar;130(3):P179-221.[Abstract][Full Text]
Hutchinson AK, Morse CL, Hercinovic A, et al. Pediatric eye evaluations preferred practice pattern. Ophthalmology. 2023 Mar;130(3):P222-70.[Abstract][Full Text]
Dagi LR, Velez FG, Holmes JM, et al. Adult strabismus preferred practice pattern®. Ophthalmology. 2024 Apr;131(4):P306-403.[Full Text]
Cruz OA, Repka MX, Hercinovic A, et al. Amblyopia preferred practice pattern. Ophthalmology. 2023 Mar;130(3):P136-78.[Abstract][Full Text]

Other Online Resources

JAMA Network: What is strabismus?

Referenced Articles

1. US Preventive Services Task Force. Vision in children ages 6 months to 5 years: screening. Sep 2017 [internet publication].[Full Text]
2. Sprunger DT, Lambert SR, Hercinovic A, et al. Esotropia and exotropia preferred practice pattern®. Ophthalmology. 2023 Mar;130(3):P179-221.[Abstract][Full Text]
3. Govindan M, Mohney BG, Diehl NN, et al. Incidence and types of childhood exotropia: a population-based study. Ophthalmology. 2005 Jan;112(1):104-8.[Abstract]
4. Greenberg AE, Mohney BG, Diehl NN, et al. Incidence and types of childhood esotropia: a population-based study. Ophthalmology. 2007 Jan;114(1):170-4.[Abstract]
5. Tollefson MM, Mohney BG, Diehl NN, et al. Incidence and types of childhood hypertropia: a population-based study. Ophthalmology. 2006 Jul;113(7):1142-5.[Abstract]
6. Yu CB, Fan DS, Wong VW, et al. Changing patterns of strabismus: a decade of experience in Hong Kong. Br J Ophthalmol. 2002 Aug;86(8):854-6.[Abstract][Full Text]
7. van Splunder J, Stilma JS, Bernsen RM, et al. Prevalence of ocular diagnoses found on screening 1539 adults with intellectual disabilities. Ophthalmology. 2004 Aug;111(8):1457-63.[Abstract]
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9. Mohney BG. Common forms of childhood strabismus in an incidence cohort. Am J Ophthalmol. 2007 Sep;144(3):465-7.[Abstract]
10. Matsuo T, Matsuo C. The prevalence of strabismus and amblyopia in Japanese elementary school children. Ophthalmic Epidemiol. 2005 Feb;12(1):31-6.[Abstract]
11. Çorak Eroğlu F, Oto S, Şahin Fİ, et al. The role of heredity and the prevalence of strabismus in families with accommodative, partial accommodative, and infantile esotropia. Turk J Ophthalmol. 2020 Jun 27;50(3):143-50.[Abstract][Full Text]
12. Ye XC, Pegado V, Patel MS, et al. Strabismus genetics across a spectrum of eye misalignment disorders. Clin Genet. 2014 Aug;86(2):103-11.[Abstract][Full Text]
13. Paul TO, Hardage LK. The heritability of strabismus. Ophthalmic Genet. 1994 Mar;15(1):1-18.[Abstract]
14. Maconachie GD, Gottlob I, McLean RJ. Risk factors and genetics in common comitant strabismus: a systematic review of the literature. JAMA Ophthalmol. 2013 Sep;131(9):1179-86.[Abstract][Full Text]
15. Kok JH, Prick L, Merckel E, et al. Visual function at 11 years of age in preterm-born children with and without fetal brain sparing. Pediatrics. 2007 Jun;119(6):e1342-50.[Abstract]
16. Holmstrom G, el Azazi M, Kugelberg U. Ophthalmological follow up of preterm infants: a population based, prospective study of visual acuity and strabismus. Br J Ophthalmol. 1999 Feb;83(2):143-50.[Abstract][Full Text]
17. American College of Radiology. ACR appropriateness criteria: orbits, vision and visual loss [internet publication].[Full Text]
18. American Academy of Ophthalmology. Adult strabismus summary benchmarks 2023. Dec 2023 [internet publication].[Full Text]
19. American Academy of Ophthalmology. Pediatric ophthalmology/strabismus summary benchmarks - 2023. Dec 2023 [internet publication].[Full Text]
20. Donahue SP, Baker CN, Committee on Practice and Ambulatory Medicine, American Academy of Pediatrics, et al. Procedures for the evaluation of the visual system by pediatricians. Pediatrics. 2016 Jan;137(1):e20153597.[Abstract][Full Text]
21. Jacobs DS, Afshari NA, Bishop RJ, et al. Refractive errors preferred practice pattern®. Ophthalmology. 2023 Mar;130(3):P1-60.[Abstract][Full Text]
22. Taylor K, Elliott S. Interventions for strabismic amblyopia. Cochrane Database Syst Rev. 2014 Jul 23;(7):CD006461.[Abstract][Full Text]
23. Gov.UK (National Screening Committee). Child screening programme: vision defects. Aug 2019 [internet publication].[Full Text]
24. Public Health England. Child vision screening. Apr 2019 [internet publication].[Full Text]
25. Hutchinson AK, Morse CL, Hercinovic A, et al. Pediatric eye evaluations preferred practice pattern. Ophthalmology. 2023 Mar;130(3):P222-70.[Abstract][Full Text]
26. American Academy of Ophthalmology. Vision Screening for Infants and Children - 2022. Oct 2022 [internet publication].[Full Text]
27. American Academy of Ophthalmology. Referral of persons with possible eye diseases or injury - 2014. Apr 2014 [internet publication].[Full Text]
28. Dagi LR, Velez FG, Holmes JM, et al. Adult strabismus preferred practice pattern®. Ophthalmology. 2024 Apr;131(4):P306-403.[Full Text]
29. Cruz OA, Repka MX, Hercinovic A, et al. Amblyopia preferred practice pattern. Ophthalmology. 2023 Mar;130(3):P136-78.[Abstract][Full Text]
30. Weakley DR Jr, Holland DR. Effect of ongoing treatment of amblyopia on surgical outcome in esotropia. J Pediatr Ophthalmol Strabismus. 1997 Sep-Oct;34(5):275-8.[Abstract]
31. Pang Y, Gnanaraj L, Gayleard J, et al. Interventions for intermittent exotropia. Cochrane Database Syst Rev. 2021 Sep 13;(9):CD003737.[Abstract][Full Text]
32. Piano M, O'Connor AR. Conservative management of intermittent distance exotropia: a review. Am Orthopt J. 2011;61:103-16.[Abstract]
33. Barrett BT. A critical evaluation of the evidence supporting the practice of behavioural vision therapy. Ophthalmic Physiol Opt. 2009 Jan;29(1):4-25.[Abstract]
34. The Royal College of Ophthalmologists. Strabismus surgery for adults in the United Kingdom: indications, evidence base and benefits. Aug 2017 [internet publication]. [Full Text]
35. American Academy of Ophthalmology. Adjustable sutures in the treatment of strabismus; a report by the American Academy of Ophthalmology. Aug 2021 [internet publication].[Full Text]
36. Mehner L, Ng SM, Singh J. Interventions for infantile esotropia. Cochrane Database Syst Rev. 2023 Jan 16;1(1):CD004917.[Abstract]
37. Bradbury JA, Taylor RH. Severe complications of strabismus surgery. J AAPOS. 2013 Feb;17(1):59-63.[Abstract][Full Text]
38. Bort-Martí AR, Rowe FJ, Ruiz Sifre L, et al. Botulinum toxin for the treatment of strabismus. Cochrane Database Syst Rev. 2023 Mar 14;3(3):CD006499.[Abstract]
39. Gardner R, Dawson EL, Adams GG, et al. Long-term management of strabismus with multiple repeated injections of botulinum toxin. J AAPOS. 2008 Dec;12(6):569-75.[Abstract]
40. Ripley L, Rowe FJ. Use of botulinum toxin in small-angle heterotropia and decompensating heterophoria: a review of the literature. Strabismus. 2007 Jul-Sep;15(3):165-71.[Abstract]
41. Scott AB, Alexander DE, Miller JM. Bupivacaine injection of eye muscles to treat strabismus. Br J Ophthalmol. 2007 Feb;91(2):146-8.[Abstract]
42. Miller JM, Scott AB, Danh KK, et al. Bupivacaine injection remodels extraocular muscles and corrects comitant strabismus. Ophthalmology. 2013 Aug 2;120(12):2733-40.[Abstract]
43. Debert I, Miller JM, Danh KK, et al. Pharmacologic injection treatment of comitant strabismus. J AAPOS. 2016 Apr;20(2):106-11.[Abstract][Full Text]
44. Hopker LM, Modelli R, Allemann N. Bupivacaine injection combined with recession of antagonist rectus muscle to treat sensory strabismus. Strabismus. 2019 Feb 7;27(1):6-10.[Abstract]
45. Fawcett SL, Birch EE. Risk factors for abnormal binocular vision after successful alignment of accommodative esotropia. J AAPOS. 2003 Aug;7(4):256-62.[Abstract]
46. Romanchuk KG, Dotchin SA, Zurevinsky J. The natural history of surgically untreated intermittent exotropia - looking into the distant future. J AAPOS. 2006 Jun;10(3):225-31.[Abstract]
47. Buck D, Powell CJ, Rahi J, et al. The improving outcomes in intermittent exotropia study: outcomes at 2 years after diagnosis in an observational cohort. BMC Ophthalmol. 2012 Jan 18;12:1.[Abstract][Full Text]
48. Baker JD. Twenty-year follow-up of surgery for intermittent exotropia. J AAPOS. 2008 Jun;12(3):227-32.[Abstract]
49. Buck D, Powell CJ, Sloper JJ, et al. Surgical intervention in childhood intermittent exotropia: current practice and clinical outcomes from an observational cohort study. Br J Ophthalmol. 2012 Oct;96(10):1291-5.[Abstract]
50. Schmucker C, Kleijnen J, Grosselfinger R, et al. Effectiveness of early in comparison to late(r) treatment in children with amblyopia or its risk factors: a systematic review. Ophthalmic Epidemiol. 2010 Jan-Feb;17(1):7-17.[Abstract]
51. Jackson S, Harrad RA, Morris M, et al. The psychosocial benefits of corrective surgery for adults with strabismus. Br J Ophthalmol. 2006 Jul;90(7):883-8.[Abstract]
52. Mojon-Azzi SM, Mojon DS. Strabismus and employment: the opinion of headhunters. Acta Ophthalmol. 2009 Nov;87(7):784-8.[Abstract]
53. Mojon-Azzi SM, Potnik W, Mojon DS. Opinions of dating agents about strabismic subjects' ability to find a partner. Br J Ophthalmol. 2008 Jun;92(6):765-9.[Abstract]
54. Mohney BG, McKenzie JA, Capo JA, et al. Mental illness in young adults who had strabismus as children. Pediatrics. 2008 Nov;122(5):1033-8.[Abstract]