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Strabismus is a condition in which the eyes do not point in the same direction. It can also be referred to as a tropia or squint.


Strabismus occurs in 2-5% of all children. About half are born with the condition, which causes one or both eyes to turn:
  • inward (esotropia or "crossed eyes")
  • outward (exotropia or "wall eyes")
  • upward (hypertropia)
  • downward (hypotropia)
Strabismus is equally common in boys and girls. It sometimes runs in families.

Types of strabismus

Esotropia is the most common type of strabismus in infants. Accommodative esotropia develops in children under age two who cross their eyes when focusing on objects nearby. This usually occurs in children who are moderately to highly farsighted (hyperopic).
Another common form of strabismus, exotropia, may only be noticeable when a child looks at far-away objects, daydreams, or is tired or sick.
Sometimes the eye turn is always in the same eye; however sometimes the turn alternates from one eye to the other'.
Most children with strabismus have comitant strabismus. No matter where they look, the degree of deviation does not change. In incomitant strabismus, the amount of misalignment depends upon which direction the eyes are pointed.

False strabismus (pseudostrabismus)

A child may appear to have a turned eye, however this appearance may actually be due to:
  • extra skin that covers the inner corner of the eye
  • a broad, flat nose
  • eyes set unusually close together or far apart
This condition, false strabismus, usually disappears as the child's face grows. An eye doctor needs to determine whether the eyeturn is true or pseudostrabismus.
With normal vision, both eyes send the brain the same message. This binocular fixation (both eyes looking directly at the same object) is necessary to see three-dimensionally and to aid in depth perception. When an eye is misaligned, the brain receives two different images. Young children learn to ignore distorted messages from a misaligned eye, but adults with strabismus often develop double vision (diplopia).
A baby's eyes should be straight and parallel by three or four months of age. A child who develops strabismus after the age of eight or nine years is said to have adult-onset strabismus.

Causes and symptoms

Strabismus can be caused by a defect in muscles or the part of the brain that controls eye movement. It is especially common in children who have:
  • brain tumors
  • cerebral palsy
  • Down syndrome
  • hydrocephalus
  • other disorders that affect the brain
Diseases that cause partial or total blindness can cause strabismus. So can extreme farsightedness, cataracts, eye injury, or having much better vision in one eye than the other.
In adults, strabismus is usually caused by:
  • diabetes
  • head trauma
  • stroke
  • brain tumor
  • other diseases affecting nerves that control eye muscles
The most obvious symptom of strabismus is an eye that isn't always straight. The deviation can vary from day to day or during the day. People who have strabismus often squint in bright sunlight or tilt their heads to focus their eyes.


Every baby's eyes should be examined by the age of six months. A baby whose eyes have not straightened by the age of four months should be examined to rule out serious disease.
A pediatrician, family doctor, ophthalmologist, or optometrist licensed to use diagnostic drugs uses drops that dilate the pupils and temporarily paralyze eye-focusing muscles to evaluate visual status and ocular health. Early diagnosis is important. Some eye turns may be a result of a tumor. Untreated strabismus can damage vision in the unused eye and possibly result in lazy eye (amblyopia).


Preserving or restoring vision and improving appearance may involve one or more of the following:
  • glasses to aid in focusing and straighten the eye(s)
  • patching to force infants and young children to use and straighten the weaker eye
  • eye drops or ointments as a substitute for patching or glasses, or to make glasses more effective
  • surgery to tighten, relax, or reposition eye muscles
  • medication injected into an overactive eye muscle to allow the opposite muscle to straighten the eye
  • vision training (also called eye exercises)


Early consistent treatment usually improves vision and appearance. The most satisfactory results are achieved if the condition is corrected before the age of seven years old.



American Academy of Ophthalmology. 655 Beach Street, P.O. Box 7424, San Francisco, CA 94120-7424.
American Academy of Pediatric Ophthalmology and Strabismus (AAPOS). 〈〉.
American Optometric Association. 243 North Lindbergh Blvd., St. Louis, MO 63141. (314) 991-4100.


deviation of the eye that the patient cannot overcome; the visual axes assume a position relative to each other different from that required by the physiological conditions. Called also squint. adj., adj strabis´mic. The various forms of strabismus are spoken of as tropias, their direction being indicated by the appropriate prefix, as cyclotropia, esotropia, exotropia, hypertropia, and hypotropia.

During the first 3 to 6 months of life, the eyes of infants tend to waver and turn either inward or outward independently of one another; this usually corrects itself. If it persists, or if the eyes are continually crossed in the same way, even if the child is less than 6 months old, it may be a sign of strabismus. Children do not outgrow strabismus. In an older child, a tendency to tilt the head when reading, or to close or rub one eye, may indicate strabismus.

Strabismus almost always appears at an early age. If not corrected, the condition may impair vision in the nonfocusing eye, as well as marring the child's appearance. In the great majority of cases the eyes can be straightened by proper medical treatment at any age, but vision of the malfunctioning eye may remain impaired. If treated early enough, preferably before 6 years, normal vision can usually be restored in the affected eye.
Cause. Strabismus may result from several factors, including a blow on the head, disease, or heredity. Many cases are caused by a malfunction of the muscles that move the eyes. This causes the eyes to focus differently, sending different images to the brain. As the child grows, he or she learns to ignore the image from one eye with the result that it fails to grow as strong as the eye on which he or she is depending.
Treatment. Treatment for strabismus varies with the individual case. A patch may be placed over the child's stronger eye for a period, forcing use of the weaker eye and thus restoring its strength as far as possible, instead of letting it grow worse from lack of use. Eyeglasses or special eye exercises may correct the condition. In some cases, a relatively simple surgical operation on the eye muscles may be necessary. Since these muscles are outside the eye itself, there is no danger to the vision.
comitant strabismus (concomitant strabismus) that in which the angle of deviation of the visual axis of the squinting eye is always the same in relation to the other eye, no matter what the direction of the gaze; due to faulty insertion of the eye muscles.
convergent strabismus esotropia.
divergent strabismus exotropia.
noncomitant strabismus (nonconcomitant strabismus) that in which the amount of deviation of the squinting eye varies according to the direction in which the eyes are turned.
vertical strabismus that in which the visual axis of the squinting eye deviates in the vertical plane; see hypertropia and hypotropia.


(stra-biz'mŭs), [MIM*185100]
A manifest lack of parallelism of the visual axes of the eyes.
[Mod. L., fr. G. strabismos, a squinting]


/stra·bis·mus/ (strah-biz´mus) squint; deviation of the eye which the patient cannot overcome; the visual axes assume a position relative to each other different from that required by the physiological conditions.strabis´mic
concomitant strabismus  that due to faulty insertion of the eye muscles, resulting in the same amount of deviation regardless of the direction of the gaze.
convergent strabismus  esotropia.
divergent strabismus  exotropia.
nonconcomitant strabismus  that in which the amount of deviation of the squinting eye varies according to the direction of gaze.
vertical strabismus  that in which the visual axis of the squinting eye deviates in the vertical plane (hypertropia or hypotropia).


A visual defect in which one eye cannot focus with the other on an object because of imbalance of the eye muscles. Also called squint.

stra·bis′mal (-məl), stra·bis′mic (-mĭk) adj.


Etymology: Gk, strabismos, squint
an abnormal ocular condition in which the visual axes of the eyes are not directed at the same point. There are two kinds of strabismus, paralytic and nonparalytic. Paralytic strabismus results from the inability of the ocular muscles to move the eye because of neurologic deficit or muscular dysfunction. The muscle that is dysfunctional may be identified by watching as the patient attempts to move the eyes to each of the cardinal positions of gaze. If the affected eye cannot be directed to a position, the examiner infers that the associated ocular muscle is the dysfunctional one. Because this kind of strabismus may be caused by tumor, infection, or injury to the brain or the eye, an ophthalmologic examination is recommended. Nonparalytic strabismus is a defect in the position of the two eyes in relation to each other. The condition may be inherited. The person cannot use the two eyes together but has to fixate with one or the other. The eye that looks straight at a given time is the fixing eye. Some people have alternating strabismus, using one eye and then the other; some have monocular strabismus, which affects only one eye. Visual acuity diminishes with diminished use of an eye, and suppression amblyopia may develop. Nonparalytic strabismus and suppression amblyopia are treated most successfully in early childhood. The primary treatment to prevent amblyopia consists mainly of covering the fixing eye, forcing the child to use the deviating eye. The earlier it is begun, the more rapid and effective is the treatment. The eyes might be straightened by surgery, but suppression amblyopia will not be corrected. Also called squint. See also anoopsia, esotropia, exotropia. strabismal, strabismic, strabismical, adj.
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Nonparallel positioning or movement of the eyes—usually of the vertical axis—due to decreased binocular muscle coordination with loss of stereoscopic vision and inability to focus simultaneously on a single point.
Extraocular muscle defects, neurotoxins, blindness, mechanical defects, unilateral vision obstruction in childhood, various brain disorders or systemic diseases, amblyopia, paralytic shellfish poisoning, botulism, haemangioma near eye, Guillain-Barré syndrome, Apert syndrome, Noonan syndrome, Prader-Willi syndrome, trisomy 18, congenital rubella, incontinentia pigmenti, cerebral palsy, Laurence-Moon-Biedl syndrome, pseudohyperparathyroidism.


Crossed eyes; exotropia, walleye Ophthalmology Nonparallel position or movement of eyes, due to ↓ muscle coordination between eyes, with loss of stereoscopic vision and inability to focus simultaneously on a single point Etiology Extraocular muscle defects, neurotoxins, blindness, mechanical defects, unilateral vision obstruction in childhood, various brain disorders or systemic diseases, amblyopia, paralytic shellfish poisoning, botulism, hemangioma near eye, Guillain-Barre´ syndrome, Apert syndrome, Noonan syndrome, Prader-Willi syndrome, trisomy 18, congenital rubella, incontinentia pigmenti, cerebral palsy, Laurence-Moon-Biedl syndrome, pseudohyperparathyroidism. See Farsightedness, Myopia.


A manifest lack of parallelism of the visual axes of the eyes.
Synonym(s): crossed eyes, cross-eye, heterotropia, heterotropy, squint (1) .
[Mod. L., fr. G. strabismos, a squinting]


Squint. The condition in which only one eye is aligned on the object of interest. The other eye may be directed too far inward (convergent strabismus), too far outward (divergent squint), or upward or downward (vertical squint). Squint in childhood, or any squint of recent onset, requires urgent treatment. Untreated childhood squint often leads to AMBLYOPIA. New squints in adults usually imply a disorder of the nervous system.

strabismus (str·bizˑ·ms),

n a condition wherein the two visual axes of the eyes are not aimed at a single object. In paralytic strabismus the muscles in the eyes are unable to move because of infection, tumor, or injury. In nonparalytic strabismus, there is a defect in the location of the eyes in relationship to their focal point. Also called
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The condition in which the lines of sight of the two eyes are not directed towards the same fixation point when the subject is actively fixating an object. Thus the image of the fixation point is not formed on the fovea of the deviated eye and there may be diplopia, although in most cases the diplopic image is suppressed and vision is essentially monocular. The prevalence of concomitant strabismus in children is 2%-5% and is far more common than paretic strabismus. Management depends on the type of strabismus. However, in all cases the refractive errors must be accurately corrected. If the deviation still prevails, orthoptics and, sometimes, pharmacological (e.g. miotics in accommodative esotropia) treatment is attempted but in many cases surgery is necessary (except where accommodation is faulty or when the deviation is small), usually followed by some orthoptics treatment aimed at developing fusion and stereopsis. Syn. heterotropia; squint (this term is commonly used by the general public); tropia. See angle of anomaly; angle of strabismus; botulinum toxin; chemodenervation; deviating eye; fixating eye; hypertropia; Bruckner's method; Hirschberg's method; Javal's method; Krimsky's method; microtropia; phi movement; zero point; past- pointing; abnormal retinal correspondence; suppression; Apert's syndrome; Brown's superior oblique tendon sheath syndrome; Crouzon's syndrome; Duane's syndrome; Marfan's syndrome; cover test; three-step test; theories of strabismus.
accommodative strabismus Convergent strabismus resulting from abnormal demand on accommodation due to an uncorrected hyperopia accompanied by excessive convergence and insufficient relative fusional divergence. The AC/A ratio (accommodative convergence to accommodation) is normal but the child has high hyperopia (refractive accommodative esotropia). It may also occur in cases in which the AC/A ratio is high and accommodation is accompanied by excessive convergence in a child with a very small amount of hyperopia (non-refractive accommodative esotropia). Accommodative strabismus is usually an acquired deviation first presenting in the first decade of life. Children do not usually notice diplopia, but instead develop suppression and later amblyopia. Management consists of full hyperopic correction and amblyopia treatment. Syn. accommodative esotropia. See cycloplegic refraction; acquired non-accommodative strabismus.
acquired strabismus An abnormal alignment of the visual axes that occurs after the age of six months.
acquired non-accommodative strabismus Convergent strabismus that presents after normal ocular alignment has been established and is not related to a subject's accommodative effort. Treatment is usually surgical. Syn. acquired non-accommodative esotropia.
alternating strabismus Strabismus in which either eye may deviate. See unilateral strabismus.
angle of strabismus See angle of deviation.
apparent strabismus Condition simulating the appearance of strabismus. It may be due to epicanthus, to an abnormally large angle lambda (or kappa), or to the breadth of the nose, etc. It can be distinguished from a real strabismus by noting that the corneal light reflexes are centrally located in relation to the pupils, or by means of the cover test. Syn. pseudostrabismus.
comitant strabismus See concomitant strabismus.
concomitant strabismus Strabismus in which the angle of deviation remains the same whichever eye is fixating and in whichever direction the eyes are looking. Syn. comitant strabismus. See concomitance; incomitant strabismus.
congenital strabismus See infantile strabismus.
consecutive strabismus A deviation of the eye in the opposite direction to what it was previously. This condition may follow surgery although it may occur spontaneously. There are two types: consecutive exotropia in a patient who previously had esotropia or esophoria and consecutive esotropia in a patient who previously had exotropia or exophoria. Syn. postoperative over-correction. See divergent strabismus.
convergent strabismus Strabismus in which the deviating eye turns inward. This is the most common type of strabismus in children. The principal categories are accommodative strabismus and non-accommodative strabismus (Fig. S15). Syn. crossed eyes (colloquial); esotropia (SOT, ET, esoT). See A pattern; V pattern; Swann's syndrome; prism adaptation test.
cyclic strabismus A very rare and unusual form of strabismus occurring on a 48-hour rhythm in which a 24-hour period of normal binocular vision is followed by 24 hours of manifest heterotropia. The condition, which may have started in early infancy, only becomes apparent during early childhood. With time, cyclic heterotropia tends to become constant. Syn. cyclic heterotropia.
deorsumvergens strabismus See hypertropia.
divergent strabismus Strabismus in which the deviating eye turns outward (Fig. S15). Syn. exotropia (XOT; XT; exoT). The principal categories are constant exotropia and intermittent exotropia. Constant exotropia may be congenital which is often associated with an underlying neurological anomaly or basic which appears after six months of age with equal exotropia for near and distance vision. Both types are usually treated surgically. Consecutive strabismus can also be a constant exotropia. Intermittent exotropia is the most common form of exotropia. It begins as an exophoria and breaks down to exotropia presenting in children between two and five years of age. It is characterized by worse exotropia at near (convergence excess) or worse exotropia at distance (divergence excess). Treatment includes spectacle correction, orthoptic exercises or surgery. See A pattern; V pattern.
strabismus fixus A rare, congenital condition in which one or both eyes are firmly fixed in a position of extreme adduction or abduction, although the most common position is adduction (esotropia). It is due to an anatomical anomaly (e.g. anomalous insertion of the medial or lateral rectus muscle), or muscle fibrosis (e.g. of the two medial recti muscle in esotropia). Voluntary movements of duction and version, as well as passive movements as in the forced duction test, are either absent or insignificant. See forced duction test.
incomitant strabismus Strabismus in which the angle of deviation varies with the direction of gaze and with the eye used for fixation. It may be congenital or acquired. The congenital type is due to some developmental anomaly of one or more of the extraocular muscles or of the neural component that serves them. The acquired type may be due to head injury, disease of the oculomotor system, or systemic disease (e.g. multiple sclerosis, myasthenia gravis, thyroid eye disease, aneurysms). The main symptom of incomitant strabismus is diplopia and it suddenly appears in the acquired type. Abnormal head posture and past-pointing may be present. The affected muscle(s) may be detected by the motility test. Treatment is aimed first at the primary cause but, in general, this type of strabismus does not respond well to orthoptic procedures. In large deviation, surgery is usually the only remedy. Syn. nonconcomitant strabismus. See abnormal head posture; incomitance; pointing past-; Hess screen; paralytic strabismus; motility test.
infantile strabismus Strabismus which becomes manifest within the first year of life. It is almost always esotropic in nature: exotropia, which is very rare, is usually associated with some neurological condition. Infantile strabismus is characterized by a large angle of squint, hyperopia, alternate fixation that may become unilateral if amblyopia develops, and nystagmus. Management is essentially surgical after correction of the refractive error. A complication following surgery may be dissociated vertical deviation. Syn. congenital strabismus; infantile esotropia syndrome. See cross-fixation.
intermittent strabismus Strabismus that is not present at all times.
monocular strabismus See unilateral strabismus.
non-accommodative strabismus Convergent strabismus not due to abnormal demands on accommodation. There are several types: infantile strabismus, acquired non-accommodative strabismus, basic esotropia (no significant hyperopia and the deviation is equal for near and distance), microtropia, convergence excess (esotropia for near vision but not for distance), divergence insufficiency (esotropia for distance vision but not for near), consecutive strabismus, sensory strabismus and cyclic esotropia (periodic manifestation of esotropia as for example on alternate days). Treatment of associated amblyopia and correction of hyperopia are often followed by surgery.
nonconcomitant strabismus See incomitant strabismus.
paralytic strabismus Strabismus due to a paralysis of the extraocular muscles. It usually gives rise to incomitance. The paralysis is usually due to a disorder of the third, fourth or sixth cranial nerve. Diplopia is noticed if the paralysis is recent and it is usually accompanied by an abnormal head posture. In most cases there is not a complete loss of action of a muscle but a partial loss and the condition is referred to as paretic strabismus, whether it is congenital or acquired. Orthoptic treatment is very limited in these cases and is not normally appropriate if the deviation was caused by injury or a recent disease. Cosmetic surgery is often necessary. See abnormal head posture; incomitance; paralysis of the fourth nerve; paralysis of the sixth nerve; paralysis of the third nerve; motility test.
periodic strabismus Strabismus in which the deviation occurs only at certain distances or in certain directions of fixation. Syn. relative strabismus.
relative strabismus See periodic strabismus.
secondary s . Strabismus resulting from a sensory deficit, surgical intervention, tumour, trauma or stroke. See consecutive strabismus; sensory strabismus.
sensory strabismus Strabismus caused by a unilateral reduction in visual acuity which disrupts binocular vision, such as unilateral cataract, optic atrophy, uncorrected anisometropia or other unilateral visual impairments.
small angle strabismus See microtropia.
strabismus surgery  See myectomy; myotomy; Faden procedure; tuck procedure; recession; resection; transposition.
sursumvergens strabismus See hypertropia.
unilateral strabismus Strabismus in which the deviating eye is always the same, as distinguished from alternating strabismus. Syn. monocular strabismus.
Fig. S15 A, left convergent strabismus; B, left divergent strabismus; C, left hypertropia; D, left hypotropiaenlarge picture
Fig. S15 A, left convergent strabismus; B, left divergent strabismus; C, left hypertropia; D, left hypotropia


(stră-biz'mŭs) [MIM*185100]
A manifest lack of parallelism of the visual axes of the eyes.
Synonym(s): crossed eyes, heterotropia, squint (1) .
[Mod. L., fr. G. strabismos, a squinting]

strabismus (strəbiz´məs),

n an abnormal ocular condition in which the eyes are crossed.


deviation of the eye that the patient cannot overcome; the visual axes assume a position relative to each other different from that required by the physiological conditions. Called also squint.
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Basic types of strabismus. By permission from Guyton R, Hall JE, Textbook of Medical Physiology, Saunders, 2000

comitant strabismus
extraocular muscles are not paralyzed and the degree of deviation is the same in all directions.
congenital strabismus
medial strabismus is seen in Siamese cats. See convergent strabismus (below).
convergent strabismus
that in which the visual axes converge; esotropia, or cross-eye. A frequent finding in Siamese cats, related to an anomaly of neuronal pathways between the retina and lateral geniculate nucleus in which more neurons project contralaterally rather than ipsilaterally as in other cats.
divergent strabismus
that in which the visual axes diverge; called also exotropia and walleye.
inherited strabismus
see inherited exophthalmos.
noncomitant strabismus
deviation due to paralysis of one or more muscles.
traumatic strabismus
a complication of traumatic prolapse of the eye, due to rupture of extraocular muscles.