Strabismus is a vision problem where the eyes are not aligned. There are different types of strabismus, but the more common types are what are sometimes referred to as "crossed eyes" or "lazy eye". There are a few associations and direct causes, but often the underlying cause is unknown. The fundamental problem is that the muscles of each eye are not working together to correctly align the eyes and focus the vision. This can be seen on photographs as an asymmetric displacement of the light reflex from a camera flash on each eye. Sometimes children try to compensate by squinting, closing one eye, and/or tilting their heads. This can lead to decreased vision in one or both eyes calls amblyopia and can result in permanent visual impairment if not treated in early childhood. Strabismus and amblyopia occurs in about 4% of children under 6 years old.

A common problem after adoption is that we are often missing information about prenatal exposures and family history. Specifically, alcohol exposure and fetal alcohol syndrome is associated with strabismus and other eye problems in multiple studies1-3. One study in Eastern European adoptees, an area with historically high rates of alcohol exposure, showed that 32% of adoptees had strabismus and 78% had abnormal eye diagnoses4. We are further concerned for children from countries like Korea that have seen a sharp increase in the number of alcohol exposed children. If there is known alcohol exposure, then strabismus may be a marker for alcohol-induced birth defects rather than an isolated pediatric issue.

There are also many syndromes that are associated with strabismus like Albinism, William's syndrome5, fetal valproate exposure6, and Down syndrome7, so it is important to review medical information with an experienced practitioner who can recognize potential associations.

There are several treatment options for strabismus including glasses, eye patching, eye exercises, eye drops, and eye muscle surgery. Each child demands different combinations of these interventions depending on their pattern of strabismus and severity of visual loss. The earlier the child is treated, the better the prognosis for a good visual outcome. Most children with strabismus can read, drive, and do normal daily activities with adequate treatment.

Summary:

*Strabismus is a common pediatric problem that can be treated.
*The child's vision should be tested by a pediatric ophthalmologist after arrival to his/her adoptive home.
*Discovering the underlying reason for strabismus may require screening and later testing for metabolic diseases, prenatal infections, genetic syndromes, etc. A child with strabismus from an area of high alcohol exposure can raise the potential for Fetal Alcohol Spectrum Disorder (FASD).
*A pediatric ophthalmologist can recommend and perform the correct combination of medical and surgical eye therapies as needed for each child's particular strabismus.

References

1. Stromland K. Ocular abnormalities in the fetal alcohol syndrome. Acta Ophthalmol Suppl. 1985; 171:1-50.

2. Hinzpeter EN, Renz S, Loser H. Eye manifestations of fetal alcohol syndrome. Klin Monbl Augenheilkd. 1992;200(1):33-38.

3. Stromland K, Pinazo-Duran MD. Ophthalmic involvement in the fetal alcohol syndrome: clinical and animal model studies. Alcohol and Alcoholism. 2002;37(1):2.

4. Gronlund M, Aring E, Hellstrom A, Landgren M, Stromland K. Visual and ocular findings in children adopted from eastern Europe. Br J Ophthalmol. 2004;88(11):1362.

5. Kapp ME, von Noorden GK, Jenkins R. Strabismus in Williams syndrome. Am J Ophthalmol. 1995;119(3):355-360.

6. DiLiberti JH, Farndon PA, Dennis NR, Curry CJR. The fetal valproate syndrome. Am J Med Genet. 2005;19(3):473-481.

7. Creff M, Woodhouse JM, Stewart RE, et al. Development of refractive error and strabismus in children with Down syndrome. Invest Ophthalmol Vis Sci. 2003;44(3):1023.

This article was generously shared by Dr. Judith Eckerle of the University of Minnesota, Adoption Medicine Clinic. Child referrals are becoming increasingly complex, and adoption medicine professionals are identifying many more children with special needs from all countries that participate in intercountry adoption, as well as from the United States. To help families prepare for these changes, Dr. Eckerle and other medical specialists are writing a book: Health Topics For Preadoptive Families.