Strabismus: Implications for Development

I received a beautiful holiday card from a lovely couple showing several pictures of their two young children. The three-year-old boy is playing ball and laughing. The year-old-girl is wearing glasses and staring into space unfocused with her mouth open. I last saw these children about a year ago, when the girl was just an infant; I had not spoken with her parents since.

It appears to me that this little lady has crossed eyes, also known as strabismus. Her development concerns me greatly.  Unknown to me is what treatment she is receiving. I know from experience that strabismus is a serious visual condition that affects the ability of the eyes and the brain to communicate. A strabismus rarely goes away untreated; children generally do NOT outgrow it.

No one knows this better than neuroscientist, Sue Barry, the author of Fixing My Gaze. I just finished reading her remarkable book, and recommend it highly.  You don’t have to be a scientist to understand the impact of going through life with misaligned eyes. 

What happens normally? As we scan our environment, not only must our two eyes simultaneously aim at the same object, but our brains must integrate a message from each eye into a single image. The process of fusion (combining the pictures from each eye into a single picture) enables us to perceive three-dimensional depth and helps us to determine our relationships to objects in our environment. Vision emerges as the primary sense when a typical child integrates it with touch, movement and the other senses.

What goes wrong?  In children with developmental delays, signs of incomplete or inefficient eye teaming (binocularity) usually appear around eighteen months, just when expressive language is emerging. However, later onset is not uncommon. Poor eye teaming can be associated with neurological disturbances related to heavy metal toxicity, high fevers and childhood illnesses such as strep or pneumonia. Dr. Melvin Kaplan found that about half of the children with autism that he examines have an undiagnosed strabismus.

Initially, the inability to efficiently and effectively team the eyes may appear only at times of illness, fatigue or intense concentration. However, frequently, the vulnerable binocularity can worsen; strabismus and amblyopia or a “lazy eye” can result. 

First, Strabismus… In strabismus, one eye accurately aims at the object of regard, while the other eye misses it by aiming above, below or to the left or right of it. Double vision (diplopia) then results. The misalignment may be constant or intermittent, and thus not always noticeable.  Disorganization and confusion follow as the brain struggles to integrate competing messages.

Next, Amblyopia…. In order to minimize the disorganization and confusion, sometimes the unconscious mind adapts to strabismus by suppressing signals from the faulty aiming eye.  Eventually, visual suppression leads to amblyopia or “lazy eye,” in which the nerves that transport and interpret visual information lose some of their ability. The result is poor vision in one eye, due to an interference in the neurological interpretive mechanism. 

In many instances the reduced vision cannot be corrected with glasses or surgery.  With the eyes functioning at less than 100% efficiency, any sustained visual activity such as reading may require extra effort and strain. As in strabismus, the only obvious sign of amblyopia may be an eye turn. However, some people with amblyopia may turn or tilt their heads to see certain things or close one eye when reading.  I diagnosed a possible strabismus in a child after looking at photos in which his head was tilted to the left in each and every one. 

Proper early developmental vision examinations by an optometrist trained to look at the whole child are essential. Eye turns cannot always be observed and require special testing. Untreated binocular vision problems can pose obstacles to development in many areas.

Strabismus & Amblyopia Affect Spatial Relations and Balance Usually, such as in the holiday photo, cosmetic aspect of misalignment is obvious. Even more important are the effects on function and vision, because strabismus disrupts the ability to orient oneself in space.  A good number of the eye’s neural fibers bring information to the body’s balance system. If they deliver inaccurate information, the person’s sense of where he is in space can be compromised.  

The Psychological Effects of Strabismus –  Strabismus and double vision can adversely affect social-emotional development.  A child who is disoriented in space experiences himself and his environment as unstable and unpredictable. He may grow increasingly inward, become belligerent or demonstrate sensory defensiveness, all characteristics of “autism”

Treatment and Referral – Strabismus and amblyopia always require attention. Surgery, even when done when a child is young, may cosmetically straighten the eyes but usually does not improve visual function, especially without pre- and post-surgical vision therapy. Clinical studies indicate that fewer than 20% of patients who undergo strabismic surgery acquire depth perception.  Patching the “strong” eye to force the “lazy” eye to see is also of limited value.  Barry is one of surgery’s failures.

Effective treatment programs using vision therapy combine involve lenses, prisms and motor activity designed to teach the eyes, body and brain to work together.  Research shows that vision therapy can be effective at any age, but more treatment is needed the longer the condition has existed. Barry is one of vision therapy’s most prominent successes. 

At 50 years of age, she danced among falling snowflakes, experienced skyscrapers looming toward her, and tree branches projecting upward and outward, “enclosing and commanding palpable volumes of space” for the first time in her life. 

If you suspect that a child’s eyes don¹t work together, as I do with my friends’ child, go to the vision section in the Practitioner Directory at to find a qualified eye care practitioner in your area. This section lists organizations that train and certify optometrists to work with children and adults with a variety of vision issues. Go either to or For a  complete explanation of this common problem, go also to .


2 Responses to “Strabismus: Implications for Development”

  1. The Role of the Therapist in Vision Therapy: Part 2 « The VisionHelp Blog Says:

    […] as related to visual development, something that Patty Lemer addressed very nicely in her DDR blog. But what about the effects on the patient when unraveling all these developmental adaptations and […]

  2. One last thing… | Being a Vegan on The GAPS Diet Says:

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