Optometry & Visual Performance 281 Volume 13 | Issue 4 | December 2025 activities like chalkboard exercises, balance rails, and crawling are incorporated in management plans. Retained primitive reflexes, lack of body midline awareness, and postural imbalances, such as gait abnormalities or sway, are common in deviations. Long-term non-parallel alignments may lead to skeletal issues like scoliosis, requiring interdisciplinary care such as physical therapy or chiropractic care. Strabismus is a condition characterized by misalignment of the eyes, resulting from multifactorial disruptions in the coordinated control of the six extraocular muscles and their neural pathways. It affects binocular vision, stereopsis, depth perception, and psychosocial well-being, with global prevalence of 2-5% in children and 0.5-1% in adults. Environmental modifiers (e.g., prolonged screen time disrupting fusional vergence) and comorbidities (e.g., thyroid dysfunction in 15% of acquired cases) exacerbate pathology. Classification of Strabismus Dimension Subcategory Description / Details Clinical Implications & Notes Age of Onset Congenital / Infantile From birth to six months. Early developmental dysinnervation or congenital anomalies. Early intervention is critical; monitor developmental milestones. High risk of suppression, amblyopia, and abnormal binocular development. Screen siblings (10-15% risk). Early-Onset Six to 36 months. Emerges during early visual maturation, often linked to refractive or neurological factors. Often accommodative; monitor for decompensation into constant deviation. Later-Onset After 36 months. Typically acquired, related to trauma, disease, or decompensation of latent deviations. Detailed history and consideration of imaging for acquired causes. Red flags: older age, large angle (>40Δ), neuro signs ---> urgent neuroimaging. Direction Esotropia Horizontal inward deviation with varied etiologies; accommodative types linked to hyperopia and high AC/A ratio. Horizontal misalignment due to medial rectus overaction or lateral rectus underaction. 36% fully accommodative, 17% non-accommodative, 10% partially accommodative, 8% congenital/infantile, 6.5% paralytic, 2% cyclic, 1% sensory. Most common in pediatric strabismus (60% pediatric) Exotropia Horizontal outward deviation; intermittent often decompensates under stress. Horizontal misalignment from lateral rectus overaction or medial rectus underaction. 60% intermittent, 40% constant. Strabismus control score assessment should be performed if intermittent. 30% of cases; worsens with distance, fatigue, bright light; good initial control in intermittent form. Vertical One eye turns upward (hypertropia) or downward (hypotropia), often non-comitant. Vertical misalignment often involves superior / inferior obliques or superior / inferior recti. Evaluate cyclovertical muscles and check for restrictive etiology. Upward deviation, often cyclovertical muscle-related. 10% of cases; noncomitant in palsy/ restriction; comitant in skew. Early detection and precise classification are essential, as treatment efficacy declines after the critical period of visual plasticity (typically before age 7-8 years), although treatment well into geriatric age is still effective. In children, esotropia is more prevalent, while exotropia is more common in the adult population. Differential diagnosis prevents misattribution, using a step-by-step algorithm to exclude mimics based on history (onset), exam (comitancy), and tests (restriction vs. paresis). Classification of Strabismus Classification systems are essential for etiological inference, diagnostic precision, and management planning. They are multidimensional, allowing for overlapping categories (e.g., a patient may have comitant, intermittent, partially accommodative esotropia with V-pattern, inferior oblique overaction, and DVD). Use this framework to structure history, examination, and diagnostic testing.
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