Pseudo/False Strabismus

What is pseudostrabismus?

Pseudostrabismus is the appearance of crossed eyes. When eyes are truly misaligned, the condition is called strabismus. Pseudostrabismus, which is caused by an infant's facial appearance, improves with age as the bridge of the nose narrows, the folds of the eyelid skin disappear and the eyes open wider.

It is common for parents to be concerned about their child's visual development, especially when they notice what appears to be crossed eyes. Misaligned eyes are a true cause for concern. If left untreated, strabismus can quickly lead to poor visual development in one eye.

An infant's eyes may drift in or out at times, but this variable alignment is perfectly normal during the first few months. When a baby begins focusing on the environment, at about four months of age, the eyes should be straight most or all of the time.

A child does not outgrow true crossing of the eyes, a type of strabismus called esotropia. He or she will need ophthalmological treatment to straighten the eyes and allow for normal vision to develop.

Occasionally, a child may have eyes that wander out. This condition is known as exotropia. A form of pseudostrabismus called pseudoexotropia can be a result of widely set eyes and excess skin around the bridge of the nose.

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How can you tell the difference?

To tell the difference between strabismus and pseudostrabismus, shine a flashlight on your child's eyes. When the child is looking at the light, a reflection can be seen on the front surface of the pupil.

If the eyes are properly aligned, the light reflection will be in the same location in each eye. If the child has strabismus and the eyes are not aligned properly, the reflection will appear in a different location in each eye. Because the light is not affected by the width of the nose or folds of the eyelid skin, a child with pseudostrabismus will have a normal reflection. Parents may first notice the abnormal light reflection in flash photos of the child.

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Does your child have strabismus?

Ask your ophthalmologist to examine the child if you have any questions as to whether his or her eyes are straight. Strabismus should not be ignored and a prompt examination may help avoid vision loss. Occasionally, strabismus can be caused by a:

• Cataract;

• Tumor in the eye;

• Neurological problem.

These conditions may require urgent medical attention.

When a child's eyes are actually crossed, he or she will use only one eye at a time to avoid seeing double. The unused or crossed eye may not develop good vision and may become amblyopic ("lazy"). To avoid this condition, the child must be made to use the misaligned eye by patching or covering the good eye. If amblyopia is not treated early in childhood, it persists throughout life.

In some cases, true strabismus may be difficult to detect. The eye may deviate intermittently, or only slightly, and more than one examination may be needed to detect the problem. Over time, pseudostrabismus gets better, whereas true strabismus may get worse.

Older children can be tested for poor vision and amblyopia by using eye charts.

The goals of treating strabismus are:

• Good visual development in both eyes;

• Straight eyes;

• Eyes that work together;

• Detection and treatment of any underlying eye problems.

If you have any questions, please contact your pediatrician, family doctor or ophthalmologist.

This brochure was written in conjunction with the Association for Pediatric Ophthalmology and Strabismus, an organization of pediatric ophthalmologists dedicated to prevention and treatment of eye problems in children and the treatment of strabismus in people of all ages.

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Copyright © American Academy of Ophthalmology