Strabismus in children: esotropia, exotropia, pseudostrabismus
- Topic
A squint in a child is never outgrown and can hide a tumour or cataract. Some just look crossed (pseudostrabismus); a true squint is referred.
See it in 3D: Medial rectus · Lateral rectus · Abducens nerve (VI)
What it is
Strabismus is a misalignment of the eyes. In children it matters for three reasons: it causes amblyopia, it can be the first sign of a serious eye disease (retinoblastoma, cataract), and it can signal neurological disease. Many infants look cross-eyed because of a wide nasal bridge (pseudostrabismus), but true strabismus does not resolve with age and needs an eye exam.
Key facts
- Pseudostrabismus: wide nasal bridge and epicanthal folds, symmetrical corneal light reflexes, normal cover test.
- Infantile esotropia: a large inward turn starting before about 6 months.
- Accommodative esotropia: starts around 2 to 3 years, with long-sightedness; glasses straighten the eyes.
- Intermittent exotropia: an eye drifts out when tired or daydreaming; the child closes one eye in bright light.
- Sixth nerve palsy in a child: after a viral illness, or from raised intracranial pressure or a tumour.
In clinical practice
- Intermittent misalignment in the first months of life is normal; a constant deviation at any age, or any deviation after about 4 months, is not.
- Every child with strabismus needs a red reflex test and a dilated fundus exam to exclude retinoblastoma and cataract.
- Treatment combines glasses, amblyopia treatment and, when needed, surgery on the eye muscles.
Next step / Initial management
- Any constant strabismus, or strabismus after about 4 months: paediatric ophthalmology, with cycloplegic refraction and fundus exam.
- Strabismus with an abnormal red reflex or leukocoria: urgent referral (retinoblastoma).
- New strabismus with headache, vomiting or other neurological signs: urgent brain imaging.
- Pseudostrabismus with a normal light reflex and cover test: reassure and recheck at the next well-child visit.
Test yourself
Think of the answer, then tap the question to see it.
How is pseudostrabismus recognised?
By symmetrical corneal light reflexes and a normal cover test in a child with a wide nasal bridge or epicanthal folds.
What characterises accommodative esotropia?
An inward turn starting around 2 to 3 years in a long-sighted child, corrected by glasses for the hyperopia.
Why does every child with strabismus need a fundus exam?
Because strabismus can be the first sign of retinoblastoma or a cataract.
Connections
See it in 3D3
The structures of Durgical's 3D anatomy where it is found.
Educational content; not a clinical guideline and no substitute for assessment by a health professional. For sudden visual loss, severe eye pain, a chemical burn or an eye injury, go to an emergency department at once.
Sources: Strabismus (StatPearls Publishing (NCBI Bookshelf), 2026); Esotropia (StatPearls Publishing (NCBI Bookshelf), 2023); Intermittent Exotropia (StatPearls Publishing (NCBI Bookshelf), 2025).
Spotted a mistake?We are always improving for the community. Tell us what is wrong and our team will review it.Report a mistake
Representative model, for educational purposes only.