Ocular deviation or asymmetry manifested in infants older than six months

Specialty: Pediatrics.

• Children's ocular strabismus
• suspected lazy eye
• loss of visual alignment

Why it occurs

• Childhood idiopathic strabismus (convergent deviation or esotropia, or divergent deviation or exotropia, due to a primary imbalance in the tone of the extraocular muscles without apparent cause)
• Refractive accommodative strabismus (uncorrected moderate-severe hyperopia that forces the infant to make excessive accommodation efforts to focus, triggering a reflex convergence of the visual axes)
• Amblyopia due to deprivation or anisometropia (unilateral decrease in visual acuity secondary to a significant difference in prescription between both eyes, which leads the brain to suppress the visual signal of the most affected eye, causing its deviation)
• Congenital cataract or retinoblastoma (intraocular neoplasms or malformations that obstruct the visual axis, preventing the fixation of light on the macula and causing secondary sensory strabismus, of extreme severity)
• Oculomotor cranial nerve palsy (paralysis of the VI nerve, which prevents ocular abduction, or of the III nerve, due to hydrocephalus, obstetric trauma or intracranial space-occupying processes).

Initial workup

Priority referral to pediatric ophthalmology for a comprehensive ophthalmological examination. Cover Test or monocular occlusion test (to detect manifest deviations -tropias- or latent deviations -phorias- by alternatively covering the eyes). Hirschberg test (evaluation of the symmetry of the light reflection centered in both pupils). Objective refraction under total cycloplegia using cyclopentolate or atropine drops to relax accommodation. Fundus examination by direct or indirect ophthalmoscopy under mydriasis to rule out retinoblastoma, infectious chorioretinitis, colobomas or papillary edema.

Standard management

• 1% cyclopentolate in eye drops — cycloplegic anticholinergic agent used for refraction; 1 drop in each eye, repeatable after 5 minutes, with refractive measurement at 30-45 minutes
• Atropine 0.5% or 1% in eye drops — indicated under the indication of the pediatric ophthalmologist for optical penalty of the non-deviated eye with good vision to force the use of the lazy or amblyopic eye; closely monitor for signs of systemic anticholinergic toxicity: flushing, dryness, fever, or tachycardia
• Occlusion eye patches (first-line therapy for amblyopia, applied directly to the periorbital skin of the healthy eye according to a personalized schedule).