Strabismus in Infants: Screening in Primary Care

Monte D. Mills, MD


March 12, 2012

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I'm Monte Mills. I'm the Director of the Division of Ophthalmology at Children's Hospital of Philadelphia. I'd like to talk about the topic of recognition and referral of strabismus by primary care pediatricians and family care providers who take care of children and often hear complaints from parents, or even children, that the child's eyes are crossing or wandering.

This is a common problem, occurring in up to 5% of children. It is important to recognize that variable alignment is normal in newborn children up to 2 months after a full-term birth and the equivalent of 2 months in premature children. However, after 2 months of age, the alignment of the eyes should be more stable. Any crossing or drifting should be a reason for referral and complete ophthalmic evaluation.

Strabismus is frequently associated with other ocular abnormalities, including cataracts or retinal or optic nerve problems. It is frequently associated with other systemic conditions, including Down syndrome, prematurity, cerebral palsy, and other neurologic abnormalities.

Frequently there is also a family history. A family history of a sibling or a parent who is affected with strabismus definitely increases the risk to that individual. Early detection and early referral are key to prompt and effective treatment in these children.

There are 3 easy ways that you can, in your office, recognize and diagnose strabismus in children:

  1. The first is the Bruckner test or the Bruckner reflex. Using the direct ophthalmoscope that's available in your office, select the largest spot size and look through the peephole when the spot is shining in both of the child's eyes and the child is looking at the instrument. The quality of the red reflex should be symmetric and should be equally bright in both eyes. An asymmetry of the red reflex from the pupil -- either bright or a brighter color in one eye or the other or darker in one eye than the other -- would indicate possible strabismus or other ocular abnormalities that may need to be evaluated by an ophthalmologist.

  2. The second is the Hirschberg reflex, which requires that the child look at a flashlight. Viewed directly behind the flashlight is the reflection in the cornea centered on the eye, which should be symmetrical between the 2 eyes. An asymmetry or off-centered appearance may indicate strabismus.

  3. The third test is the cover test. This is what we use in our ophthalmology offices frequently. Covering and uncovering the eyes or alternately covering the 2 eyes, determine whether there is a shift in the eyes in order to pick up fixation when the child is looking at a fixed target, and force them to switch fixation between one eye and the other.

All of these tests may be abnormal in strabismus and would indicate that a full ophthalmic examination is necessary. There are surely children with pseudostrabismus -- that is, the appearance of strabismus because of the facial shape and eyelids in children who actually have normal eye alignment. This also would be a reason or an indication for a full ophthalmic evaluation.

Early and prompt treatment as soon as the signs and symptoms are recognized by an appropriate pediatric ophthalmologist or other eyecare professional would be important in insuring the best outcomes in strabismus.

Thank you very much.


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