Four Ocular Abnormalities Not to Overlook in Children

Brianne N. Hobbs, OD


January 17, 2019

In This Article


An eye turn in a child may occur secondary to a systemic condition, or it may be an isolated finding. An initial step in the evaluation of strabismus is to determine whether it is congenital or acquired. Congenital strabismus is often a cosmetic concern for parents, but the real threat is the lack of bifoveal fixation in a developing visual system. Constant, unilateral strabismus is at highest risk of causing amblyopia, which may permanently reduce visual function in the affected eye (Figure 2).

Figure 2. Left esotropia with mild amblyopia. The eye turn was noticed at approximately 3 years of age. Although not diagnosed in this patient, accommodative esotropia is a common type of strabismus that usually develops between 2 and 3 years of age. In accommodative esotropia, there is no obvious deviation in primary gaze, but the inward deviation becomes apparent when a near stimulus is presented. Image courtesy of Alicia Feis, OD.

Large-angle deviations are more dramatic in presentation, but not necessarily at higher risk for amblyopia development, because even a subtle misalignment can lead to amblyopia. Strabismus warrants a referral to an optometrist or ophthalmologist because surgical alignment of the eyes or correction of refractive error may help prevent the development of amblyopia.

Acute onset of strabismus is the most worrisome, because it may be caused by retinoblastoma, intracranial tumor, meningitis, or intracranial hemorrhage. Esotropia is the second most common presenting sign of retinoblastoma, following leukocoria. Increased intracranial pressure can result in an abducens nerve palsy that manifests as an acute-onset esotropia.

Acute-onset strabismus may also be the result of a decompensating phoria, a misalignment in the resting position of the eyes that the visual system can overcome under normal circumstances. When the visual system is stressed, phorias can transition into constant strabismus that can appear acutely.

One strategy to help differentiate the two types of acquired strabismus is to determine when the patient is symptomatic for diplopia. If the patient only experiences diplopia at near, a decompensating phoria is more common. The presence of additional neurologic symptoms or an afferent pupillary defect is not typical of a decompensating phoria and increases the risk for a more serious etiology.

Key Factors

  • Concerning diagnoses:

    • Acute: retinoblastoma, intracranial tumor, increased intracranial pressure

    • Long-standing: amblyopia

  • History: Age of onset, frequency of deviation, context of diplopia (if present)

  • Examination: Monocular visual acuity, penlight assessment of corneal reflex alignment, assess resistance to occlusion, pupillary assessment

  • Management:

    • Referral to an optometrist or ophthalmologist

      • Acute onset: Perform neuroimaging studies


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