Misalignment of the eyes is one of the most common eye problems encountered in childhood, affecting approximately 4% of children younger than 6 years of age. This condition is usually referred to by the terms, strabismus or abnormal ocular alignment. Misalignment of the eyes may cause vision loss (amblyopia) and result in important and lifelong psychological effects. Misalignment of the eyes involves a number of clinical entities. Orthophoria is the condition of exact ocular balance. A convergent deviation, crossing, or turning in of the eyes is referred to as esotropia. Divergent deviation or turning outward of the eyes is referred to as exotropia. Hyperdeviation or hypodeviation, or hypotropia, refers to an upward or downward misalignment of the eyes, respectively. Misalignment of the eyes may be constant in all fields of gaze (comitant) or may change depending on where the child is looking (incomitant). Misalignments of the eyes prior to 3 months of age may not necessarily indicate an abnormality. However, if a misalignment of the eyes is present beyond 3 months of age, pediatricians must develop the clinical skill to detect the condition and refer the child for further evaluation and treatment. Early detection of a misalignment of the eyes is essential for restoring proper alignment and to prevent vision loss.

• When a parent informs a pediatrician of their concern about the possibility of a misalignment of the eyes of their child, there are a number of important questions to be asked:

  • Is there a family history of strabismus? Strabismus is commonly found in families.

  • How long have the eyes been misaligned? Different types of strabismus tend to occur at different ages. For example, congenital esotropia occurs by 6 months of age.

  • Any history of significant head trauma? Injury to the brain can result in a nerve palsy.

  • In what direction do the eyes appear to deviate? It is important for the parents to note the direction of the strabismus to determine whether it is consistent with the findings of the health care provider.

  • Is the deviation noted intermittently or constantly? Different strabismus conditions may present as a manifest deviation as with congenital esotropia, or as an intermittent deviation as with intermittent exotropia.

  • Does the child commonly close one eye when focusing? Closing one eye may indicate intermittent diplopia, or double vision.

  • Does the child tilt his/her head or assume an abnormal face turn? Strabismus may be incomitant, forcing a child to turn or tilt his/her head to reduce the deviation.

  • Do the eyes appear to move together in all directions of gaze? Asymmetric eye movements may indicate a nerve palsy or a strabismus disorder, such as Brown syndrome.

• Acute onset of a misalignment of the eyes may indicate a more ominous concern such as an intracranial abnormality.

• A variable misalignment of the eyes associated with intermittent ptosis may suggest myasthenia gravis.

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