Learn about Strabismus Disorders, commonly known as crossed eyes. Discover the strabismus definition, how it affects vision, and the importance of early diagnosis.
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Overview and definition
When patients and parents ask what is strabismus, it is essential to understand it as both a neurological and muscular disorder. The formal strabismus definition is a visual defect in which the eyes are misaligned and point in different directions. While one eye looks straight ahead at the object you are viewing, the other eye turns inward (esotropia), outward (exotropia), upward (hypertropia), or downward (hypotropia). Colloquially, the inward-turning variation is often referred to as crossed eyes strabismus. This misalignment can be constant, or it can be intermittent, occurring only when a person is tired, ill, or looking at nearby objects.
To maintain proper alignment and focus both eyes on a single target, all six extraocular muscles surrounding each eye must work together in perfect coordination. The brain controls these muscles via cranial nerves (specifically cranial nerves III, IV, and VI). Therefore, strabismus is frequently a neurological issue, stemming from a miscommunication between the brain and the eye muscles, rather than a primary defect in the muscles themselves.
Symptoms and Causes
The most obvious sign of the condition is the visible misalignment of the eyes. However, the patient’s subjective symptoms can be highly disruptive. If the eyes are not pointed at the same object, the brain receives two different visual images.
In adults or older children who develop the condition suddenly, this results in double vision (diplopia). In young children, whose brains are still developing, the brain often adapts by completely ignoring the image from the misaligned eye to avoid double vision, which leads to a loss of depth perception and stereoscopic vision.
A frequent source of confusion is understanding amblyopia vs strabismus (or strabismus vs amblyopia). They are distinctly different, though closely linked, conditions.
In short, strabismus is often the cause, and amblyopia is the result.
Diagnosis and Tests
Diagnosing the specific type and severity of the ocular misalignment requires a comprehensive eye exam. A pediatric ophthalmologist or neuro-ophthalmologist will typically perform a corneal light reflex test (the Hirschberg test). By shining a small light into the patient’s eyes and observing where the light reflects on the corneas, the doctor can quickly identify an asymmetry.
To measure the exact angle of deviation, the doctor will use the cover-uncover test. While the patient focuses on a target, the examiner covers one eye and watches the uncovered eye for any movement. They then remove the cover and observe how the eyes shift to regain binocular fixation. Prisms are often held over the eyes during this test to quantify the exact degree of the turn, which is crucial for surgical planning.
Treatment and Procedures
Treatment aims to improve eye alignment and restore binocular vision. If the misalignment is caused by an uncorrected refractive error, the first line of treatment is prescribing eyeglasses or contact lenses. Prism lenses can also be prescribed to alter the light entering the eye, helping the patient see a single image without needing to turn their eye. If amblyopia has developed, patching the stronger eye is necessary to force the brain to use the weaker eye. Furthermore, eye exercises for strabismus (vision therapy) are highly effective for specific types of the disorder, particularly convergence insufficiency, where the eyes struggle to turn inward to read. These exercises train the brain and eyes to coordinate better.
When glasses or therapy are insufficient, or the angle of deviation is very large, strabismus surgery is the definitive treatment. This is a day-case procedure performed under general anesthesia. The surgeon makes a small incision in the conjunctiva (the clear membrane over the white of the eye) to access the extraocular muscles. To correct the alignment, the surgeon will either weaken an overactive muscle by detaching it and reattaching it further back on the eye (recession), or strengthen a weak muscle by removing a small section and reattaching it (resection).
Post-Surgery Care
Following surgery, the eyes will be distinctly red, and the patient may experience a scratchy, foreign-body sensation for several days, similar to having an eyelash stuck in the eye. Antibiotic and steroid eye drops are prescribed to prevent infection and manage swelling. The patient can usually return to normal, non-strenuous activities within a few days, though swimming and exposing the eye to dirt or dust must be avoided for a couple of weeks to allow the conjunctival incisions to heal.
Surgery structurally aligns the eyes, but long-term care requires ensuring the brain actually uses them together. Follow-up appointments are critical. Sometimes, the brain needs help adjusting to the new structural alignment, meaning the patient might need to continue wearing prism glasses or performing vision therapy exercises post-operatively. In some complex cases, a single surgery may not perfectly align the eyes, and a secondary adjustment procedure may be required down the road.
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No, a true eye turn will not go away on its own; it requires professional intervention to ensure the brain and eyes develop correctly.
In adults, it often does. In children, the brain often suppresses the image from one eye, so they may not report double vision but will lose depth perception.
No, strabismus is the misalignment, while a lazy eye is the reduced vision that can result from that misalignment.
Yes, misalignment can be treated at any age through various methods to improve alignment and the visual field.
While the turn might only be seen in one eye, the disorder involves the muscle balance of the entire visual system.
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