Alamo City Eye Physicians
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Strabismus & Amblyopia


Strabismus is a misalignment of the eyes. Usually one eye will appear straight – the eye being used to see – and the other may appear deviated inward, outward, upward, or downward. It may come and go or be constant. Strabismus affects males and females equally and sometimes runs in families. It may occur at any age for various reasons. For the most part, however, it is a problem of childhood. According to the American Academy of Ophthalmology, about 4% of children in the United States have strabismus.

The eye muscles control movement and alignment of the eyes. If any of these muscles, or the neural circuitry that controls them, are not functioning properly then there may be an ocular deviation. In adults this causes double vision. In children, however, the visual centers in the brain have not fully developed. Because of this, instead of seeing two fully developed images, the child begins to favor one eye and the brain simply ignores the image of the other eye. The child may choose one eye exclusively or may alternate between the two.

Some of the more common types of strabismus are esotropia, accommodative esotropia, and exotropia. Esotropia is inward turning of the eyes (crossed eyes). Simple esotropia is the most common type in infants and early surgery to realign the eyes is usually indicated. Accommodative esotropia affects farsighted children. The ability to see up close requires focusing of the lens in the eye (accommodation) as well as convergence, or bringing the eyes together. These two processes are neurologically linked. Since farsighted children expend more effort to accommodate, they may simultaneously overconverge (cross) their eyes. Accommodative esotropia may therefore be relieved by correcting farsightedness (hyperopia) with glasses. Exotropia is an outward turning eye. It may occur when focusing in the distance or when the child is tired or inattentive. Treatment options for exotropia include surgery, eye exercises, or glasses.

The goals of treatment for strabismus are to avoid or reduce amblyopia (see below), straighten the eyes, and improve stereovision. Glasses alone may correct the problem. In other cases surgery may be required. Surgery involves tightening or loosening certain muscles on one or both eyes to bring them back into balance.

The effect of strabismus is much more than cosmetic. Our perception of depth requires that the brain receive two simultaneously equal images, meaning that the eyes must be aligned and focused on the same point in space. This is referred to as stereovision. Strabismus therefore results in poor depth perception. Secondly, because the brain ignores the image of the deviated eye to avoid double vision, the visual potential for that eye doesn’t fully develop. This results in amblyopia – a reduction in the best correctable visual acuity of one or both eyes that is not directly attributable to a structural defect. Amblyopia affects about half of all children with strabismus.


Amblyopia may be treatable if diagnosed early enough. The visual centers of the brain are in development until around the age of 9 years. Up to that point there remains potential to strengthen the weaker eye. This is achieved by patching the better eye, thereby forcing the child to focus with the deviated eye and hence stimulate development of the visual pathways.

It is important to note that there are many other causes of amblyopia beyond strabismus. Anything that prevents the delivery of a clear image onto the retina – cataract, tumor, eye trauma, uncorrected refractive error, etc. – may induce amblyopia. The treatment in these cases involves correcting the underlying cause followed by patching if amblyopia is already present.