Strabismus is a misalignment of the eyes, so they do not point at the same target. In children it can cause amblyopia (lazy eye) if not treated early, while new strabismus in an adult often signals a nerve, muscle or brain problem.
Key symptoms
- One eye turns in, out, up or down
- Double vision, mostly in adults
- Squinting or closing one eye in bright light
- Head tilt or turn
- Parents notice the eyes do not move together
What you find on exam
- Corneal light reflex (Hirschberg test): uneven reflection
- Cover-uncover and alternate cover tests
- Eye movements in all directions
- Visual acuity in each eye to detect amblyopia
- Red reflex test, pupils and cranial nerves
Tests
- Visual acuity and cycloplegic refraction
- Dilated fundus exam to rule out retinal disease such as retinoblastoma
- Brain MRI for sudden onset in adults or with neurologic signs
- Thyroid or myasthenia gravis testing in adults when suspected
Treatment basics
- Glasses for refractive error
- Patching or atropine drops for amblyopia
- Eye muscle surgery
- Prisms in glasses for adult double vision
- Treat the underlying cause in acquired strabismus
Red flags
- Absent or white red reflex
- Sudden onset with headache or other neurologic signs
- Third nerve palsy with a dilated pupil
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.