Pediatric Strabismus: A Parent’s Guide to Crossed Eyes in Children
What Is Pediatric Strabismus?
Strabismus means the eyes do not line up in the same direction at the same time. Understanding what it is, how it develops, and what it looks like helps parents recognize when it is time to seek care.
In a child with strabismus, one eye may turn inward, outward, upward, or downward while the other looks straight ahead. Both eyes are not pointing at the same target at the same time, which prevents the brain from combining the two images into one clear picture.
When the brain receives two different images, it often responds by ignoring the image from the misaligned eye. Over time, this suppression can weaken vision in that eye, leading to a condition called amblyopia, which is commonly known as lazy eye.
In the first few weeks of life, a newborn's eyes may wander occasionally as the visual system is still maturing. By three to four months of age, most babies can focus both eyes on the same target consistently. Stable, steady eye alignment is typically expected by six months of age.
If crossing or drifting continues after four months, or if you notice constant misalignment at any point, a prompt eye exam is the right next step. The early years are the most critical period for vision development, and timely treatment can make a lasting difference.
The two most common types in children are esotropia, where one or both eyes turn inward toward the nose, and exotropia, where an eye drifts outward away from the nose. Eyes can also turn upward or downward, and the misalignment may be present all the time or only appear in certain situations.
Some children have constant strabismus, meaning the misalignment is always visible. Others have intermittent strabismus, where the eyes appear aligned most of the time but drift when the child is tired, daydreaming, or concentrating on something nearby.
Pediatric strabismus includes several distinct patterns, each with its own cause and treatment approach. Recognizing these patterns helps guide diagnosis and care planning.
- Infantile esotropia: a large inward turn that appears before six months of age
- Accommodative esotropia: eyes cross when the child tries to focus, often linked to uncorrected farsightedness
- Intermittent exotropia: an outward drift that comes and goes, often when the child is tired or daydreaming
- Fourth nerve palsy: vertical misalignment that often causes a child to tilt the head to compensate
- Duane retraction syndrome: limited eye movement with a narrowing of the eyelid in certain gaze positions
- Dissociated vertical deviation: one eye drifts upward when the other is being used
The most visible sign is an eye that appears to point in a different direction than the other. This may be noticeable all the time or only during certain activities such as reading, watching television, or looking into the distance.
- One eye turning in, out, up, or down
- Eyes that do not move together smoothly
- Tilting or turning the head to see better
- Squinting or closing one eye, especially in bright light
- Frequent bumping into objects on one side
- Complaints of headaches, eye strain, or double vision
Younger children may not be able to describe their symptoms. Instead, look for behavioral signs such as holding books very close, sitting too near the television, or appearing clumsy when reaching for or catching objects.
Some babies appear to have crossed eyes because of the shape of their face or a wide nasal bridge, a harmless appearance called pseudostrabismus. Extra skin near the inner corners of the eyes can cover part of the white of the eye and create the illusion that the eyes are turning inward when they are actually aligned correctly.
A simple in-office check called the corneal light reflex test allows us to tell the difference between true strabismus and pseudostrabismus right away. If you have any concern about your baby's eye alignment, an evaluation offers both clarity and peace of mind.
What Causes Strabismus in Children?
Strabismus has several possible causes, and in many cases more than one factor is involved. Understanding these causes helps explain why early and complete evaluation matters.
Each eye is controlled by six muscles that must work together with great precision. When one or more muscles are too strong, too weak, or do not receive the correct signals from the brain, the eyes will not point in the same direction. This muscle imbalance is the most common underlying cause of strabismus.
The nerves controlling these muscles originate in the brain, so any disruption along those nerve pathways can also affect alignment. In many children, the specific reason for the imbalance is not identified, and the strabismus is classified as congenital or infantile when it appears early in life.
Uncorrected farsightedness, a condition where nearby objects are blurry, can trigger a type of strabismus called accommodative esotropia. When a child works very hard to focus on close objects, that extra effort can cause the eyes to cross inward. This pattern often appears between ages two and three.
In these cases, prescribing the correct glasses can dramatically reduce or eliminate the inward turning by relieving the need for excessive focusing effort. Glasses are often the first and most important treatment step for this type of strabismus.
Strabismus tends to run in families, which suggests a genetic contribution. If a parent or sibling had strabismus or wore glasses as a child, your child has a higher likelihood of developing a similar condition. We often see similar patterns of eye misalignment among siblings.
That said, many children with strabismus have no family history of the condition, and having an affected family member does not guarantee a child will develop it.
Certain medical conditions are associated with a higher rate of strabismus. Children with cerebral palsy, Down syndrome, hydrocephalus (excess fluid around the brain), or a history of brain tumors are more likely to have eye alignment problems. Stroke, head injury, or infections affecting the brain can also lead to strabismus.
Eye conditions such as cataracts, retinoblastoma (a type of eye tumor), or a significant difference in vision between the two eyes may also contribute to misalignment. When strabismus appears suddenly or alongside neurological symptoms, we consider neuro-ophthalmic causes and coordinate prompt evaluation with the appropriate specialists.
Babies born prematurely or with low birth weight face a higher risk for several vision problems, including strabismus. Premature infants may have underdeveloped eye muscles or incomplete nerve connections that affect how the eyes coordinate. They may also be at risk for retinopathy of prematurity, a condition affecting the blood vessels of the developing retina.
If your child was born early or spent time in a neonatal intensive care unit, we recommend early and regular eye exams to monitor visual development and catch any problems before they cause lasting harm.
How We Diagnose Pediatric Strabismus
A comprehensive pediatric eye exam involves several tests and observations that are gentle, age-appropriate, and designed to work even with very young children. We create a welcoming environment and adapt every step to your child's age and developmental level.
For infants, we assess vision by watching how they track moving objects, respond to light, and fix their gaze on faces or toys. We may use specially designed picture cards to measure visual responses without requiring any verbal answers. These objective methods give us reliable information even from children who cannot yet speak or follow directions.
Toddlers and preschoolers can often match shapes, identify pictures, or participate in simple games that help us measure how well each eye sees. Instrument-based photoscreening can also detect risk factors for strabismus and amblyopia in young children before a full exam is possible.
We use several methods to evaluate alignment, including the cover test, where we cover and uncover each eye while your child focuses on a target. This helps reveal even subtle misalignments that may not be obvious at first glance. We also observe how smoothly the eyes move together across all directions of gaze.
- Checking whether both eyes point at the same target when one eye is covered
- Measuring the angle of misalignment using prisms or specialized instruments
- Testing eye movements in multiple gaze positions
- Noting any head tilting or unusual head positioning
In infants, light reflex tests such as the Hirschberg and Krimsky tests help us estimate the angle of deviation without requiring cooperation from the child.
Because strabismus so often leads to amblyopia, we test each eye separately to determine whether one eye has reduced vision. Identifying amblyopia early is critical, as treating it alongside the strabismus gives your child the best chance for normal vision development in both eyes.
Early amblyopia treatment tends to be most effective before age seven or eight, though improvement is still possible in older children. We monitor progress closely and adjust the treatment plan as your child grows.
Dilating drops temporarily widen the pupil, allowing us to examine the internal structures of the eye and check for underlying health issues. In children, we use cycloplegic drops, which also relax the focusing muscles, so we can obtain an accurate measurement of any refractive error such as farsightedness, nearsightedness, or astigmatism. This cycloplegic refraction is the standard approach for young children because their eyes can otherwise compensate and mask the true prescription.
The drops take about 20 to 30 minutes to take full effect, and the blurring and light sensitivity they cause typically last several hours. Bringing a pair of sunglasses for your child to wear afterward is a good idea.
Treatment Options for Pediatric Strabismus
There is no single treatment that works for every child with strabismus. The right approach depends on the type and severity of the misalignment, the presence of amblyopia, your child's age, and other individual factors. We create a personalized plan and adjust it as your child grows and responds to treatment.
When a refractive error is contributing to strabismus, prescription glasses are typically the first treatment we recommend. For children with accommodative esotropia caused by uncorrected farsightedness, the right glasses can straighten the eyes by reducing the excessive focusing effort that causes them to cross. In some children, glasses alone resolve the misalignment entirely.
- Bifocal lenses may be prescribed when the eyes cross more at near than at distance
- Prism lenses can relieve double vision or help with small-angle deviations
- Contact lenses may be considered for older children with high refractive errors
Full-time wear is important for glasses to be effective, and we monitor alignment and vision at every follow-up visit to determine whether the prescription needs to be adjusted.
When strabismus has caused amblyopia, patching the stronger eye is a well-established way to strengthen vision in the weaker eye. By covering the dominant eye for a set number of hours each day, the brain is encouraged to rely on and develop the weaker eye. Consistency and following the prescribed schedule closely are essential for good results.
Younger children often resist wearing a patch, and that is completely normal. Scheduling patch time during engaging activities, setting up a small reward system, and offering plenty of praise can help. If skin irritation is a concern, hypoallergenic patches or shields that attach to glasses frames are available options.
Atropine drops placed in the stronger eye blur near vision and encourage the weaker eye to work harder without the need for a physical patch. Research shows this approach can be as effective as patching for treating amblyopia, and many children tolerate it better. Atropine is typically used once or twice weekly, though some treatment plans call for daily use.
Bangerter filters are translucent adhesive films placed over the eyeglass lens in front of the stronger eye to reduce its clarity. They offer another alternative when patching or atropine is not the right fit. We work with each family to find the approach that is practical, comfortable, and most likely to produce results.
Vision therapy uses structured activities and exercises to improve eye coordination, focusing ability, and visual processing. It is most effective for specific conditions such as convergence insufficiency, a condition where the eyes struggle to work together when looking at nearby objects. It is not effective for correcting a constant eye turn on its own.
A typical vision therapy program includes weekly or biweekly sessions in our office combined with daily exercises at home. We regularly assess progress and use vision therapy as part of a broader treatment plan rather than as a standalone solution for most types of strabismus.
In select cases, botulinum toxin injections may be used to temporarily weaken an overactive eye muscle, allowing the opposing muscle to bring the eye into better alignment. This approach may be considered for small-angle strabismus or for children who are not good candidates for surgery at a particular point in their care.
The effects are temporary, typically lasting a few months, and some children may need repeat injections or eventually proceed to surgery. We discuss the benefits, limitations, and potential side effects with you thoroughly before recommending this option.
- Temporary drooping of the eyelid or a vertical shift in eye position
- Overcorrection or undercorrection that usually resolves as the effect fades
- Possible need for repeat injections or follow-up surgery
Eye muscle surgery is a safe and commonly performed treatment for many types of strabismus. During the procedure, we adjust the position or tension of one or more eye muscles to improve alignment. Surgery is typically performed under general anesthesia on an outpatient basis, meaning your child goes home the same day.
- The procedure typically takes one to two hours
- Small incisions are made in the tissue covering the eye to access the muscles
- Most children return to normal activities within about a week
- Some children require more than one surgery to achieve the desired alignment
As with any surgical procedure, there are risks to be aware of. These include residual or recurrent misalignment, temporary double vision as the brain adjusts, infection, bleeding, scarring, and rare complications such as a slipped muscle. Risks related to general anesthesia are also present. We discuss all of these with you in detail before proceeding so you can make an informed decision.
Caring for Your Child During and After Treatment
Treatment for strabismus is often a gradual process that unfolds over months or even years. Knowing what to expect and how to support your child at each stage makes the journey much smoother.
Patching works best when it is consistent and fits naturally into your child's daily routine. Scheduling patch time during screen time, reading, or other engaging activities helps distract from the discomfort of having an eye covered. Setting the patch time at the same part of the day each day builds a familiar routine that children tend to accept more readily.
Let teachers, daycare providers, and caregivers know about the patching schedule so they can offer encouragement and support during the school day. Most children adjust within a few days, and many educators are already familiar with patching as part of eye treatment.
After strabismus surgery, some redness, mild swelling, and a scratchy or uncomfortable feeling are normal and expected. These symptoms typically improve within one to two weeks. Temporary double vision is also common in the days to weeks following surgery as the brain adjusts to the new muscle position. We usually recommend over-the-counter pain relief and may prescribe antibiotic or anti-inflammatory eye drops to use during the healing period.
Most children can return to school within a few days. We advise avoiding swimming, contact sports, and rough physical activity for about two weeks. The eye alignment continues to settle over several weeks to months, and we schedule follow-up visits to track progress and make any needed adjustments.
Follow-up visits are an essential part of strabismus care at every stage. The frequency of these visits depends on your child's age, the type of strabismus, and how they are responding to treatment. Infants and toddlers may need exams every few months, while older children with stable alignment may be seen less frequently.
At each visit, we reassess eye alignment, measure vision in each eye separately, and evaluate how well the eyes are working together. We may update glasses prescriptions, modify patching schedules, or recommend changes to the overall plan based on what we observe.
While most children move through strabismus treatment without serious complications, certain symptoms call for immediate contact with our office or urgent care. Do not wait for a scheduled visit if any of the following occur.
- Sudden change in eye alignment or a new eye turn
- New onset of double vision, especially in an older child
- Sudden drooping of an eyelid
- Pupils that are different sizes
- Severe eye pain that does not improve with recommended pain relief
- Fever combined with eye redness after surgery
- A white pupil or white reflection in flash photographs
- New severe headache, vomiting, or other neurological symptoms alongside eye misalignment
Children with strabismus may have difficulty judging distances, which can affect activities like catching a ball, pouring liquids, or navigating stairs. This is because depth perception relies on both eyes working together, a skill called binocular vision. As alignment improves with treatment, depth perception often improves as well.
Encouraging activities that involve hand-eye coordination helps support skill development. Some children go on to develop excellent binocular vision after treatment, while others may have subtle differences in depth perception but function very well in everyday life.
Frequently Asked Questions
Here are answers to questions we hear most often from parents whose children have been diagnosed with or are being evaluated for strabismus.
True strabismus does not resolve without treatment. While occasional eye wandering in the first few months of life may naturally settle as the visual system matures, consistent misalignment after six months of age requires professional evaluation. Waiting too long can allow amblyopia to develop and become harder to treat. Seeking an evaluation as soon as you notice a concern is always the right call.
Yes, if strabismus is left untreated, the brain can permanently suppress vision in the misaligned eye, resulting in amblyopia that may not fully respond to treatment later in life. The earlier treatment begins, the greater the chance of preserving or restoring good vision in both eyes. This is why we encourage parents not to delay a first evaluation even if the problem seems mild or intermittent.
No. Many children with strabismus achieve good alignment through non-surgical approaches such as glasses, patching, or atropine drops. Surgery is recommended when non-surgical treatments are not sufficient to align the eyes, or when the type of strabismus is unlikely to respond to other methods. We always explore non-surgical options first where appropriate and discuss the reasoning behind any surgical recommendation in detail.
For children older than six months, any consistent crossing or drifting of an eye should be evaluated promptly rather than monitored at home. Sudden onset of eye crossing or double vision at any age should be treated as urgent and evaluated as soon as possible, as it can occasionally signal an underlying neurological issue. For babies under six months, occasional wandering is expected, but constant misalignment at any age warrants earlier evaluation.
Screen time and reading do not cause strabismus. The underlying muscle imbalance or nerve control issue is present regardless of how much near work a child does. That said, extended near work can make an existing intermittent strabismus more noticeable and may contribute to eye strain. Reducing screen time will not fix strabismus, but regular breaks and proper viewing distances are good habits for all children.
Yes. Strabismus can be treated at any age, and adults often seek care for strabismus that was not fully corrected in childhood or that develops later in life. Dr. John Donahue provides adult strabismus care in addition to pediatric treatment. Surgery, prism glasses, and other options can improve alignment and reduce double vision in adults, and outcomes are often very good with the right approach.
Schedule a Pediatric Eye Evaluation at Rhode Island Eye Institute
If you have noticed any signs of eye misalignment in your child, or if you simply want peace of mind about their vision development, our team is here to help. Dr. John Donahue brings fellowship-trained expertise, a background in pediatric and neuro-ophthalmic conditions, and a patient-centered approach to every visit. We welcome families from across Rhode Island and southeastern Massachusetts and look forward to providing the thorough, compassionate care your child deserves.