Strabismus, affecting an estimated 3–5% of children globally, is a common eye disorder defined by ocular misalignment.

This misalignment can significantly interfere with normal vision development, leading to a range of complications including impaired binocular vision, amblyopia (commonly known as lazy eye), and psychosocial difficulties.

Pathophysiology and Causes of Strabismus in Children

The exact mechanisms behind pediatric strabismus are complex and multifactorial. Proper eye movement relies on the precise coordination controlled by the central nervous system, particularly the brain's control over the extraocular muscles that govern eye positioning. In children, the nervous system is still developing, which can lead to inadequate control of these muscles and subsequent misalignment of the eyes.

Additionally, refractive errors such as hyperopia (farsightedness) can contribute to strabismus. When one eye experiences blurred vision due to a refractive error, the brain may suppress signals from that eye to avoid double vision, leading to muscular imbalance and strabismus over time.

Other contributing factors include congenital anomalies, neurological disorders including cerebral palsy, and physical trauma affecting ocular muscles or their nerve supply. Genetic predisposition and prenatal exposures also play a role in some cases, especially in infants under six months where familial history, genetic syndromes, and perinatal conditions increase risk.

Clinical Manifestations and Complications

The hallmark sign of strabismus is the visible deviation of one or both eyes in different directions. Common symptoms include problems with focusing, visual fatigue, headaches, and diplopia (double vision). One of the most serious outcomes is amblyopia, where the brain favors the stronger eye and suppresses signals from the weaker, misaligned eye, resulting in decreased vision in that eye.

This suppression disrupts the development of binocular vision—the ability to perceive depth and three-dimensional space—crucial for many daily activities.

Beyond physical symptoms, strabismus can negatively impact a child's psychological well-being. Appearance concerns may affect self-esteem and social interactions, compounding the overall burden of the disorder.

Diagnosis and Assessment

Comprehensive eye examinations conducted by pediatric ophthalmologists are critical to assess the degree of eye deviation, ocular motility, refractive status, and retinal health. Such evaluations help differentiate strabismus from other ocular conditions and tailor an effective treatment plan.

Treatment Approaches

Current treatment paradigms for strabismus in children incorporate both non-surgical and surgical options. Treatment often begins with the correction of refractive errors using glasses or contact lenses, which may in some instances fully align the eyes. Amblyopia is frequently addressed with occlusion therapy, where the stronger eye is patched to promote visual development in the weaker one.

Surgical intervention is considered when the misalignment persists despite correction of refractive errors and amblyopia treatment. Strabismus surgery entails repositioning or modifying the tension of the extraocular muscles to achieve ocular realignment.

Non-surgical modalities have advanced significantly, with visual training exercises, neurotrophic medications, and innovative therapies aimed at enhancing central nervous system control and binocular coordination gaining attention. These modalities are particularly important for younger patients who may have limited surgical tolerance.

Dr. Leila M. Khazaeni, a respected pediatric ophthalmologist, underscores the importance of timely intervention "Strabismus, if left untreated, leads not only to vision loss but also challenges in depth perception and coordination that can affect a child's overall development. Early recognition combined with comprehensive treatment is crucial to maximize both visual and developmental progress."

Strabismus in children represents a complicated visual disorder that goes beyond aesthetics, with significant effects on visual ability and daily life. Understanding its multifactorial causes, recognizing its potentially severe complications such as amblyopia, and employing a multifaceted approach to treatment are essential.

Timely intervention with corrective eyewear, therapeutic exercises, and, if needed, surgery, plays a critical role in improving outcomes and supporting proper visual development. Continued research and advancements in non-surgical treatments promise to broaden therapeutic options, giving children affected by strabismus a better chance at optimal vision and well-being.