[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Ophthalmology](https://durgical.com/en/ophthalmology/) › [Paediatric ophthalmology](https://durgical.com/en/ophthalmology/areas/pediatric/) › Strabismus in children: esotropia, exotropia, pseudostrabismus # 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. Updated Nov 5, 2026 **See it in 3D:** [Medial rectus](https://durgical.com/en/anatomy/medial-rectus-muscle/) · [Lateral rectus](https://durgical.com/en/anatomy/lateral-rectus-muscle/) · [Abducens nerve (VI)](https://durgical.com/en/anatomy/abducens-nerve/) ## Key points - Strabismus is not outgrown. - Symmetrical light reflex = pseudostrabismus. - Accommodative esotropia: hyperopia, corrected by glasses. - Every squint needs a fundus exam. ## 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. [Add to my cards (3)](https://durgical.app/estudiar/?add=/en/ophthalmology/strabismus-in-children-esotropia-exotropia-pseudostrabismus/) ## Connections ## See it in 3D 3 The structures of Durgical's 3D anatomy where it is found. - [Medial rectus](https://durgical.com/en/anatomy/medial-rectus-muscle/) - [Lateral rectus](https://durgical.com/en/anatomy/lateral-rectus-muscle/) - [Abducens nerve (VI)](https://durgical.com/en/anatomy/abducens-nerve/) ## Related 5 - [Eye movements and the cover test](https://durgical.com/en/ophthalmology/eye-movements-and-the-cover-test/) - [Amblyopia: the critical period, patching and atropine](https://durgical.com/en/ophthalmology/amblyopia-the-critical-period-patching-and-atropine/) - [Leukocoria: the white pupil](https://durgical.com/en/ophthalmology/leukocoria-the-white-pupil/) - [The red reflex test](https://durgical.com/en/ophthalmology/the-red-reflex-test/) - [Cycloplegic refraction and retinoscopy](https://durgical.com/en/ophthalmology/cycloplegic-refraction-and-retinoscopy/) ## Related conditions 4 - [Strabismus and amblyopia](https://durgical.com/en/conditions/strabismus-and-amblyopia/) - [Retinoblastoma](https://durgical.com/en/conditions/retinoblastoma/) - [Cataract](https://durgical.com/en/conditions/cataract/) - [Raised intracranial pressure and brain herniation](https://durgical.com/en/conditions/raised-intracranial-pressure-and-brain-herniation/) [← All of ophthalmology](https://durgical.com/en/ophthalmology/) 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](https://www.ncbi.nlm.nih.gov/books/NBK560782/) (StatPearls Publishing (NCBI Bookshelf), 2026); [Esotropia](https://www.ncbi.nlm.nih.gov/books/NBK578207/) (StatPearls Publishing (NCBI Bookshelf), 2023); [Intermittent Exotropia](https://www.ncbi.nlm.nih.gov/books/NBK574514/) (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. --- Source: https://durgical.com/en/ophthalmology/strabismus-in-children-esotropia-exotropia-pseudostrabismus/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/ophthalmology/strabismus-in-children-esotropia-exotropia-pseudostrabismus/