Pediatric Strabismus
Pediatric Strabismus
Strabismus is a misalignment of the eyes where both eyes do not look at the same point simultaneously. It affects approximately 4% of children under age 6 years.
Key Points
- Affects binocular vision development
- Critical period for intervention: first 8-10 years
- Can lead to amblyopia if untreated
- May indicate serious underlying neurological conditions
- Requires comprehensive evaluation and management
Types of Strabismus
1. By Direction
- Horizontal Deviations:
- Esotropia (inward turning)
- Exotropia (outward turning)
- Vertical Deviations:
- Hypertropia (upward turning)
- Hypotropia (downward turning)
- Torsional Deviations:
- Incyclotropia
- Excyclotropia
2. By Onset
- Congenital/Infantile: Present before 6 months
- Acquired: Develops after 6 months
3. By Pattern
- Comitant: Deviation same in all directions
- Incomitant: Varies with direction of gaze
- Pattern Strabismus:
- A-pattern
- V-pattern
- Y-pattern
4. Special Forms
- Duane Retraction Syndrome
- Brown Syndrome
- Möbius Syndrome
- Convergence Insufficiency
Common Presentations
Infantile Esotropia
- Large-angle constant esotropia
- Onset before 6 months
- Cross-fixation
- Latent nystagmus
- Dissociated vertical deviation (DVD)
Accommodative Esotropia
- Onset between 2-3 years
- Associated with hyperopia
- Worse at near fixation
- Improves with glasses
Intermittent Exotropia
- More common in Asian populations
- Worse with fatigue
- Squinting in bright light
- Progressive deterioration
Associated Features
- Abnormal head posture
- Diplopia (older children)
- Poor depth perception
- Asthenopia (eye strain)
- Psychological impacts
Diagnostic Approach
History Taking
- Age of onset
- Family history
- Pattern of deviation
- Associated symptoms
- Developmental history
- Previous treatments
Clinical Examination
- Visual Acuity Assessment:
- Age-appropriate methods
- Cycloplegic refraction
- Ocular Alignment Tests:
- Hirschberg test
- Cover tests
- Krimsky test
- Prism alternate cover test
- Sensory Testing:
- Worth 4-dot test
- Stereopsis testing
- Fusion assessment
- Ocular Motility:
- Versions and ductions
- Convergence ability
- Pattern evaluation
Treatment Strategies
Non-surgical Management
- Optical Correction:
- Spectacles
- Contact lenses
- Bifocals when needed
- Amblyopia Treatment:
- Patching
- Atropine penalization
- Active vision therapy
- Prism Therapy:
- Fresnel prisms
- Ground-in prisms
- Orthoptic Exercises:
- Convergence exercises
- Fusion exercises
Surgical Management
- Timing Considerations:
- Early for infantile strabismus
- After stability in acquired cases
- Emergency in acute cases
- Surgical Procedures:
- Recession
- Resection
- Transposition procedures
- Adjustable sutures
Complications and Prognosis
Visual Impact
- Amblyopia:
- Development of lazy eye
- Reduced visual acuity
- Poor stereopsis
- Binocular Vision:
- Loss of stereopsis
- Abnormal retinal correspondence
- Suppression
Long-term Outcomes
- Functional Impacts:
- Reading difficulties
- Sports performance
- Career limitations
- Psychosocial Effects:
- Self-esteem issues
- Social interactions
- Academic performance
Prognostic Factors
- Age at onset
- Time to treatment
- Type of strabismus
- Compliance with treatment
- Associated conditions
