Optometry & Visual Performance 289 Volume 13 | Issue 4 | December 2025 Differential Diagnosis (Prevents misattribution using step-by-step algorithm) Common Mimics & Differentiation Mimic Hallmark Differentiation Pseudostrabismus Apparent esotropia from epicanthal folds, wide nasal bridge, or positive angle kappa (light reflex off-center). No true deviation on unilateral cover test; common in infants (resolves with growth by about age 5). Symmetric Hirschberg; normal UCT/ACT (no refixation); normal motility/stereopsis. Latent Phorias/Decompensated Phorias Hidden deviations unmasked by stress; no manifest tropia. ACT shows phoria only; good fusion on Worth 4-dot; low fusional reserves Convergence Insufficiency Near exotropia/esotropia with asthenopia; normal distance alignment. Reduced NPC (>10 cm); fusional reserves low. Divergence Insufficiency Distance esotropia; normal near/motility. No accommodative influence; absence of restriction. Neuromuscular (e.g., Myasthenia Gravis) Variable ptosis/diplopia worsening with fatigue, improved with rest/ice pack; no restriction. Ice pack/Tensilon test positive (80%); negative forced duction. Fatigability. Restrictive (e.g., TED) Proptosis/lid signs; positive forced duction. CT/labs; systemic symptoms (e.g., smoking worsens TED by 20%). Restrictive myopathy with lid retraction/proptosis. Orbital Floor Fracture Post-trauma vertical restriction; hypoesthesia/enophthalmos (2–5mm). “Whiteeyed” in pediatrics. CT entrapment; positive forced duction, hypoesthesia; resolves post-repair. Neurological (e.g., INO in MS) Adduction lag/abducting nystagmus. MRI demyelination; CSF analysis. Adduction deficit with nystagmus in abducting eye. Skew Deviation Supranuclear or infranuclear disruption, not a direct muscle or nerve palsy, causing variable vertical deviation. Hypertropia may alternate or vary with gaze direction. Accompanying nystagmus, ataxia, neurological deficits (e.g., stroke symptoms). MRI; lacks cyclovertical pattern. (+) neurologic signs vs. trochlear palsy. Spasm of Near Reflex Transient esotropia with miosis; resolves with cycloplegia. Young patients; Esotropia with accommodative spasm. Very rare. Age-Specific Manifestations Age Group Manifestations Functional Impact Management Focus Infants (0-4 months) Congenital misalignment with asymmetrical tracking, lack of conjugate gaze; intermittent post-4 months signals accommodative or neurological issues. Congenital strabismus may remain asymptomatic due to early suppression or amblyopia. Detectable deviation, categorized as esotropia, exotropia, hypertropia, or hypotropia. Asymptomatic due to suppression Early screening; rule out neurologic cause; monitor fixation.
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