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Crossed Eyes

By Scott Hamilton, MD
April 27, 2023
Hamilton Blog Headshot Updated 12.21.21

This week's guest columnist is Jennie Zheng, M.D., a family practice resident at the Ochsner University Hospital & Clinics here in Lafayette.

“My baby has funny-looking eyes!” exclaimed the mother. Sure enough, her eyes were crossed. A minute later, they uncrossed. This baby was just one-month old, and mom was worried she would have a “lazy eye”. She had read children could lose eyesight with that condition. I reassured her that we had time to diagnose and treat the issue.

If your new baby has an eye that wanders, don't panic. Many babies are still developing eye control in the first few months of life, and occasionally have crossed eyes. However, after three months old, they should stay aligned. If not, a referral to a pediatric eye doctor is in order. There are other reasons for wandering eyes than “lazy eye”, known medically as Strabismus, and more serious possibilities need ruling out.

Strabismus is where weak aligning muscles in one eye stray off, and the brain relies on the stronger eye to see. The problem is the “lazy eye” vision can become permanently weak, or even completely lost, if that eye isn't used. In early brain development, the phrase “use it or lose it” strictly applies! We treat Strabismus by temporarily weakening vision in the “good” eye to make the brain use the weaker eye. Traditionally, this involved patching the good eye for some hours daily. However, little kids often pull patches off. Special glasses are better tolerated, with a lens over the good eye that weakens its vision or using eye drops that temporarily blur vision. Occasionally, kids need surgical fixes: reattaching the weak muscles into better position.

Sometimes crossed eyes aren't from Strabismus, but from other vision-impairing conditions like Cataracts or Retinoblastoma.

In medical school, there's plenty of opportunities to slap your forehead with your palm. I was learning newborn exams and was looking at baby's eyes with the ophthalmoscope. Healthy eyes have the “red reflex” through the scope, those glowing red pupils you get with flash photography. However, I wasn't getting a red reflex for either eye- were they both diseased!!?? I asked my professor to double check my exam, and instead she dimmed the lights in the room and asked, “is that better?” Sheepishly, I re-examined baby's eyes and both pupils glowed red. Oops!

We're careful to make sure newborn babies have clear vision. They can have conditions that impede vision and diagnosing these early is important. Like we said above, if we don't fix young eyes that see poorly, vision weakness or loss can become permanent. One of those problems, Retinoblastoma, can also be deadly.

Retinoblastoma is a rare malignant tumor that grows inside the eyeball. It typically strikes kids five years-old and younger. Babies can even have it at birth. We detect this by looking for the red reflex through the pupil. Retinoblastomas block light reflecting off the blood supply in the back of the eyeball that make it glow red. Instead, the pupil looks white. Other signs are one eyeball larger than the other or crossed eyes. These signs require an ophthalmologist to confirm the diagnosis and begin treatment.

Babies can also have Cataracts, grey patches in the eye's lens behind the pupil. These also block vision and can lead to permanent vision loss if not removed. Sometimes parents detect Cataracts or Retinoblastoma with baby's first photographs. Take pictures with the flash on. If one pupil is white, black, yellow, grey and the other red, see your pediatrician!