Persistent strabismus after six months of age

Specialty: Pediatrics.

• Children's eye deviation
• loss of ocular alignment
• pediatric strabismus

Why it occurs

• Accommodative strabismus due to severe refractive errors (uncorrected high hyperopia that requires excessive accommodation effort causing ocular convergence)
• Congenital idiopathic strabismus or infantile esotropia/exotropia (primary imbalance of extraocular muscle forces without apparent cause)
• Amblyopia or "lazy eye" (unilateral visual sensory deprivation that causes the brain to ignore the signal from the deviated eye, perpetuating the deviation)
• Congenital cataract or retinoblastoma (serious intraocular pathologies that prevent the fixation of light on the retina, causing secondary deviation due to vision loss, "sensory strabismus")
• Cranial nerve palsy (III, IV or VI nerve, due to intracranial expansive processes, hydrocephalus or orbital trauma)

Initial workup

Complete pediatric ophthalmological examination that includes: Cover test (alternating viewing to detect manifest or latent deviations), evaluation of corneal light reflexes (Hirschberg test), examination of extrinsic ocular motility in the 9 gaze positions. Visual acuity adapted to age (children's optotypes or preferential gaze test). Refraction under cycloplegia (using cyclopentolate or atropine drops to relax accommodation and measure the real refractive error). Fundus examination under mydriasis to rule out retinoblastoma, TORCH chorioretinitis, or papilla malformations.

Standard management

• 1% cyclopentolate in eye drops — cycloplegic and mydriatic anticholinergic agent used for ocular diagnosis and refraction; 1 drop in each eye, repeatable after 5-10 minutes, with maximum effect after 30-40 minutes
• Atropine 0.5% or 1% in eye drops or ophthalmic ointment — used under strict indication for optical penalization of the healthy eye in the treatment of amblyopia, forcing the use of the deviated eye; monitor systemic side effects such as flushing, mucosal dryness, or tachycardia
• Ocular occlusive patches (non-pharmacological treatment of choice for amblyopia, applied to the eye with the best visual acuity according to a strict time schedule).