Official reprint from UpToDate®
www.uptodate.com ©2018 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Evaluation and management of strabismus in children

David K Coats, MD
Evelyn A Paysse, MD
Section Editor
Richard A Saunders, MD
Deputy Editor
Carrie Armsby, MD, MPH


Strabismus is the condition of misalignment of the eyes. Strabismus can be horizontal, vertical, or torsional.

The evaluation and management of strabismus in children will be reviewed here. The causes of strabismus are discussed separately. (See "Causes of horizontal strabismus in children" and "Causes of vertical strabismus in children".)


The terms used to describe strabismus depend upon the direction of eye deviation, the conditions under which it is present, and whether it changes with the position of gaze.

The prefix of the term describes the direction of eye deviation (figure 1):

"Eso" − The prefix "eso" describes deviation nasally (inward) relative to the fixating eye.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Dec 2017. | This topic last updated: May 30, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2018 UpToDate, Inc.
  1. McManaway JW III, Frankel CA. Strabismus. In: Primary Pediatric Care, Hoekelman RA (Ed), Mosby, St. Louis 2001. p.1253.
  2. Archer SM, Sondhi N, Helveston EM. Strabismus in infancy. Ophthalmology 1989; 96:133.
  3. Ono H, Mapp AP. A restatement and modification of Wells-Hering's laws of visual direction. Perception 1995; 24:237.
  4. Ciuffreda KJ, Stark L. Descartes' law of reciprocal innervation. Am J Optom Physiol Opt 1975; 52:663.
  5. Abrahamsson M, Magnusson G, Sjöstrand J. Inheritance of strabismus and the gain of using heredity to determine populations at risk of developing strabismus. Acta Ophthalmol Scand 1999; 77:653.
  6. Greenberg AE, Mohney BG, Diehl NN, Burke JP. Incidence and types of childhood esotropia: a population-based study. Ophthalmology 2007; 114:170.
  7. Williams C, Northstone K, Howard M, et al. Prevalence and risk factors for common vision problems in children: data from the ALSPAC study. Br J Ophthalmol 2008; 92:959.
  8. O'Connor AR, Stephenson TJ, Johnson A, et al. Strabismus in children of birth weight less than 1701 g. Arch Ophthalmol 2002; 120:767.
  9. Holmström 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; 83:143.
  10. Pennefather PM, Clarke MP, Strong NP, et al. Risk factors for strabismus in children born before 32 weeks' gestation. Br J Ophthalmol 1999; 83:514.
  11. Mohney BG, Erie JC, Hodge DO, Jacobsen SJ. Congenital esotropia in Olmsted County, Minnesota. Ophthalmology 1998; 105:846.
  12. Podgor MJ, Remaley NA, Chew E. Associations between siblings for esotropia and exotropia. Arch Ophthalmol 1996; 114:739.
  13. Aurell E, Norrsell K. A longitudinal study of children with a family history of strabismus: factors determining the incidence of strabismus. Br J Ophthalmol 1990; 74:589.
  14. The eyes. In: Pediatric diagnosis: Interpretation of symptoms and signs in children and adolescents, 6th, Green M (Ed), WB Saunders Company, Philadelphia 1998. p.15.
  15. Weakley DR Jr, Birch E, Kip K. The role of anisometropia in the development of accommodative esotropia. J AAPOS 2001; 5:153.
  16. Abramson DH, Frank CM, Susman M, et al. Presenting signs of retinoblastoma. J Pediatr 1998; 132:505.
  17. Harley RD. Pediatric Ophthalmology, WB Saunders Company, Philadelphia 1983. p.143.
  18. Damms T, Damms C, Schulz E, Haase W. [Pseudo-esotropia caused by nasal dislocation of the macula in patients with high infantile myopia]. Ophthalmologe 1994; 91:77.
  19. Hoyt CS, Good WV. Acute onset concomitant esotropia: when is it a sign of serious neurological disease? Br J Ophthalmol 1995; 79:498.
  20. COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE, SECTION ON OPHTHALMOLOGY, AMERICAN ASSOCIATION OF CERTIFIED ORTHOPTISTS, et al. Visual System Assessment in Infants, Children, and Young Adults by Pediatricians. Pediatrics 2016; 137:1.
  21. Von Noorden GK. Atlas of Strabismus, 4th ed, Mosby, St. Louis 1983.
  22. Arnold RW. Vision screening in Alaska: experience with Enhanced Brückner Test. Alaska Med 1993; 35:212.
  23. American Academy of Pediatrics, Section on Ophthalmology, American Association for Pediatric Ophthalmology And Strabismus, et al. Red reflex examination in neonates, infants, and children. Pediatrics 2008; 122:1401.
  24. Paysse EA, Steele EA, McCreery KM, et al. Age of the emergence of negative attitudes toward strabismus. J AAPOS 2001; 5:361.
  25. Coats DK, Paysse EA, Towler AJ, Dipboye RL. Impact of large angle horizontal strabismus on ability to obtain employment. Ophthalmology 2000; 107:402.
  26. Uretmen O, Egrilmez S, Kose S, et al. Negative social bias against children with strabismus. Acta Ophthalmol Scand 2003; 81:138.
  27. Lukman H, Kiat JE, Ganesan A, et al. Strabismus-related prejudice in 5-6-year-old children. Br J Ophthalmol 2010; 94:1348.
  28. Mojon-Azzi SM, Kunz A, Mojon DS. Strabismus and discrimination in children: are children with strabismus invited to fewer birthday parties? Br J Ophthalmol 2011; 95:473.
  29. Birch E, Stager D, Wright K, Beck R. The natural history of infantile esotropia during the first six months of life. Pediatric Eye Disease Investigator Group. J AAPOS 1998; 2:325.
  30. Donahue SP. Clinical practice. Pediatric strabismus. N Engl J Med 2007; 356:1040.
  31. Joyce KE, Beyer F, Thomson RG, Clarke MP. A systematic review of the effectiveness of treatments in altering the natural history of intermittent exotropia. Br J Ophthalmol 2015; 99:440.