Description, Causes and Risk Factors:

The appearance of strabismus caused by epicanthus, abnormality in interorbital distance, or corneal light reflex not corresponding to the center of the pupil.

Pseudostrabismus is a very common diagnosis in a busy pediatric ophthalmology practice although the true prevalence of this entity is unknown. Of note some patients with a diagnosis of pseudostrabismus can present with true misalignment of their eyes in future. The incidence of manifest strabismus following pseudostrabismus diagnosis has been reported as high as 12% in a retrospective review of 83 patients diagnosed with pseudostrabismus.

Pseudostrabismus is usually caused by a distortion in facial morphological features. Prominent folds of skin on top of the inner folds of both eyes are the most common cause of the disease. Other causes include:

    A flat nasal bridge.

  • Either too large or too narrow a distance between both eyes.

  • Different color of both eyes.

  • Abnormality in either the volume or the viscosity of retrobulbar tissue.

  • Facial asymmetry.

  • Chorioretinal infections.

  • Orbital trauma.

  • Orbital tumors.


    Pseudoesotropia: Pseudoesotropia is the most common type of pseudostrabismus and can be seen due to certain facial morphological features such as orientation, shape and size of the orbits, size and shape of globes, volume and viscosity of retrobulbar tissue all of which can create an illusion of misaligned eyes. Most commonly this occurs in infants who have a wide nasal bridge with prominent epicanthal folds (semilunar fold of skin at the medial canthus). Patients with small interpupillary distance may also appear to be esotropic. A negative angle kappa (angle formed by pupillary axis and visual axis at the pupil) where corneal light reflex appears to be on the temporal side of the pupillary center can simulate an esodeviation.

  • Pseudoexotropia: Like pseudoesotropia, certain morphological features of the face can result in a false appearance of eyes to be drifted outwards. Most commonly hypertelorism, which is widely set eyes, can result in pseudoexotropia. Traction of the retina resulting in pathologic ectopia of the macula temporally can cause a positive angle kappa resulting in nasal displacement of the light reflex on the cornea simulating a true exotropia. Pseudoexotropia from positive angle kappa is mostly seen in retinopathy of prematurity which results in temporal dragging of the macula, it can also be seen in ectopic macula resulting from toxocara retinal scars, high myopia or congenital retinal folds.

  • Pseudohypertropia: Facial asymmetry may create an appearance of vertically misaligned eyes where one eye appears to be higher than the other. Certain orbital tumors or trauma to the orbital floor can also in rare occasions create hypoglobus where the entire globe is higher/lower than the other side simulating a vertical misalignment.

It is common for parents to be concerned about their child's eye development, especially when they notice what appear to be crossed eyes. Ask your ophthalmologist to examine the child if you have any questions as to whether his or her eyes are straight. While pseudostrabismus gets better with age, real strabismus should not be ignored and a prompt examination may help avoid vision loss. Occasionally, strabismus can be caused by a cataract, tumor in the eye, or neurological problems. These conditions may require urgent medical attention.


In pseudostrabismus, the eyes appear crossed in but are actually straight. This is common in infants and young children due to their facial structures. The wide bridge of the nose and small folds of eyelid skin on the nasal side of the eye contribute to this appearance by covering the "white" of the eye on that side. This is especially noticed when the infant looks to the right or left. As the child grows, this appearance will improve and disappear.


This basic test can be performed on any child using a penlight. As a child focuses on a penlight, the position of the light reflection from the front surface (cornea) of the eye is observed. The test is accurate only if the child looks directly at the light and not to the side. Normally the corneal light reflex is centered on both pupils. The test is abnormal if the corneal light reflex is "off-center”, or asymmetrical.

To tell the difference between strabismus and pseudostrabismus, shine a flashlight on your child's eyes. When you are certain that your child is looking at the light, observe the light reflection on the surface of the pupil.If both eyes are aligned, the light reflection will appear to be in the center of each pupil. If a child has true strabismus and the eyes are not properly aligned, the reflection will appear in a different location in each eye. Because the light is not affected by the width of the nose or the folds of eyelids skin a child with pseudostrabismus will have a normal reflection.


Pseudostrabismus is common, especially in young babies, and does not require treatment. As facial features mature, the widened nasal bridge tends to narrow, and the appearance tends to improve with time. Asian children may retain a broad nasal bridge into adulthood and this is perfectly normal.

NOTE: The above information is educational purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.


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