The visual abilities of newborns are very limited. With life, the sense of sight gradually strengthens. Just as an infant learns to speak by hearing, their ability to see develops by seeing during the period up to 8 years of age. The ability to see is a skill jointly developed by the eyes and the nervous system. Any eye problem during the newborn and early infancy period will disrupt the development of the sense of sight. Strabismus, or eye misalignment, is one of the common causes of this condition.

Temporary eye misalignments called physiological strabismus can be seen until infants reach 6 months of age. These are short-term, temporary deviations that can occur in any direction. They are considered normal during the developmental process of the nervous system, similar to the infant's inability to hold their head upright. Persistent misalignments occurring after 6 months or becoming permanent earlier than this are not considered normal.

Symptoms of Strabismus in Infants

Strabismus is the loss of parallelism between the two eyes in infants. In other words, strabismus is defined as the inability of both eyes to look at the same point in a straight gaze. The misalignment can occur in any direction: upward, downward, inward, or outward. Eye misalignment can appear in various forms; it may affect only one eye, start in one eye and continue in both, or appear intermittently. Additionally, constant tilting of the head to one side and frequent blinking may also be signs of strabismus.

Regardless, infants should be examined by an eye doctor during their 3rd or 4th month after routine examinations by pediatricians during the newborn period, and a dilated eye examination should definitely be performed.

Pseudo-Strabismus

Sometimes, due to the shape of the bones around the eyes and eyelids, there are clinical situations that give the appearance of strabismus but are not real. An experienced eye doctor can easily identify this condition. It usually arises due to the development of the nasal bridge bones and is commonly seen in certain races (e.g., those of Central Asian origin). In such cases, treatment is not necessary.

Causes of Strabismus

Genetic or hereditary factors are the most common causes of strabismus. Infants with a family history of strabismus have a higher likelihood of developing it than those without such a history. However, a family history is not an absolute requirement for strabismus to occur. Strabismus can also develop sporadically, without a family history.

High refractive errors, especially those with a significant difference in prescription between the two eyes, increase the risk of developing strabismus. Hyperopia (farsightedness) is a particularly high-risk group.

Congenital diseases that impair vision (such as congenital cataracts or glaucoma) can also cause strabismus in the affected eye.

Prematurity, meaning being born prematurely and with low birth weight, is another risk factor. Other factors like systemic diseases in premature babies, being in intensive care, contribute to the development of strabismus.

Neurological and metabolic diseases present in infants. The ability to keep the eyes parallel is achieved with the nervous system. Diseases affecting the brain and nervous system can lead to the development of strabismus.

Traumas experienced during birth can cause strabismus.

High fever illnesses and seizures (convulsions) experienced in early infancy when the nervous system is not yet fully developed can trigger strabismus.

Types and Onset Ages of Strabismus

Eye misalignments in infants can appear at different times and with various clinical findings. It may suddenly appear in one eye or start intermittently in both eyes and then become continuous. Eye misalignments can be vertical (upward-downward), horizontal (left-right), or circular, known as oblique. The onset age and type of strabismus depend on the underlying cause.

Treatment of Strabismus

Once the type of strabismus and the underlying cause are identified in infants, treatment should begin as soon as possible to align the eyes. Treating strabismus in infancy provides not only cosmetic correction but also many functional benefits: during the period up to 8 years of age when the visual ability of the eye and brain develops rapidly, aligning the eyes quickly helps develop skills like visual acuity, 3D vision, depth perception, and prevents amblyopia (lazy eye).

The most common type of strabismus in infancy is inward deviation, and its most common cause is high refractive errors in hyperopia and significant differences in prescription between the two eyes (anisometropia). For these patients, the required prescription is provided, and if necessary, patching therapy for the healthy eye is given to prevent strabismus and amblyopia. This type of strabismus is called accommodative and does not require surgery. A dilated examination is essential to accurately determine the prescription and examine the back of the eye. Surgery is required for types of strabismus caused by abnormalities in muscle structures. In recent years, Botox injections into the eye muscles have become one of the current treatment methods for congenital strabismus instead of surgery.

For strabismus due to neurological, infectious, metabolic, and other systemic diseases, the primary disease should be treated first.

Surgery for Strabismus in Infants and Timing

Strabismus in infancy should be corrected without delay. Waiting for school age or for the child to grow a bit more, or concerns about anesthesia at this young age are not valid reasons for delay. Every day that passes can lead to a deficiency in the development of the eye.

Surgeries are performed under general anesthesia after examinations and approval by a pediatrician and anesthetist. Surgery takes about 1 hour, and the patient is discharged on the same day. The operated eye is kept closed for one night and opened the next day.

Is there scarring after surgery? Is stitchless surgery possible?

Typically, there is no scarring from surgery. During surgery, the conjunctiva, a membrane that covers the eye, is opened, and the location and size of the muscles are adjusted using self-absorbing sutures. These sutures are also used to close the conjunctiva. However, in recent years, tissue adhesives have been used instead of sutures for the conjunctiva, significantly improving postoperative comfort and reducing complaints.