Last updated 2026-02-17

Misaligned Eyes (Strabismus) — When Crossed Eyes Need Attention

Misaligned Eyes (Strabismus) — When Crossed Eyes Need Attention

⏱️ Quick Summary (30 seconds)

🟡 Urgency: Mention to your doctor soon. If sudden onset in a previously normal child, see a doctor within days.

What is it? When your child’s eyes don’t point in the same direction — one looks straight while the other turns inward, outward, up, or down. Doctors call this strabismus (struh-BIZ-mus).

Key facts:

• Very common: affects about 2-5% of all children
• Occasional crossing in babies under 3-4 months is normal
• Constant or persistent crossing after 4 months is NOT normal — get it checked
• If untreated, the brain may stop using the misaligned eye, causing permanent vision loss (amblyopia / “lazy eye”)
• Treatment is usually very effective when started early: glasses, patching, and sometimes surgery

What to do: If your child’s eyes don’t consistently line up after 4 months of age, or if you notice a sudden change in eye alignment at any age, see an eye doctor. The earlier treatment begins, the better the outcome.

What is strabismus?

Every eye has six tiny muscles attached to the outside of it, like strings on a puppet. These muscles work together to point the eye in the right direction — up, down, left, right, and all the angles in between. For both eyes to look at the same thing at the same time, all twelve of these muscles (six per eye) need to coordinate perfectly. [Source: src1]

Strabismus is what happens when this coordination breaks down. One eye looks where it should, while the other turns in a different direction. Think of it like two cameras that are supposed to be aimed at the same subject, but one is slightly off-target. [Source: src1]

This misalignment can be:

• Inward (toward the nose) — called esotropia (ess-oh-TROH-pee-ah). This is what people usually mean by “crossed eyes.” It’s the most common type in Western populations, making up about 60-70% of childhood strabismus cases. [Source: src8]
• Outward (toward the ear) — called exotropia (ecks-oh-TROH-pee-ah). Sometimes described as “wall-eyed.” This type is more common in East Asian populations. [Source: src8]
• Upward or downward — called hypertropia (one eye higher than the other). Less common but still important. [Source: src1]

The misalignment might be constant (always there) or intermittent (comes and goes — often worse when the child is tired, sick, or daydreaming). It might always be the same eye, or it might alternate between eyes. [Sources: src1, src2]

Why does it matter so much?

Here’s the really important part that many parents don’t realize: strabismus isn’t just a cosmetic issue. It’s a brain development issue.

When both eyes are aligned and working together, the brain receives two slightly different images (one from each eye) and combines them into a single, clear, three-dimensional picture. This is how we perceive depth — how far away things are, how fast they’re moving toward us, and how to reach for objects accurately. [Source: src1]

When one eye is misaligned, the brain receives two very different images that it can’t combine. In a young child (under about 7-8 years), the brain solves this problem in the simplest way it can: it ignores the signal from the misaligned eye. Over time, the brain gets so good at ignoring that eye that even if the eye is later straightened, the vision in it may not recover. This is amblyopia — commonly called “lazy eye” — and it’s the most important reason to treat strabismus early. [Sources: src1, src5]

Amblyopia affects about 2-5% of all children, and strabismus is one of its leading causes. The window for effective treatment is during childhood, roughly before age 7-8, while the brain is still forming its visual pathways. After that, treatment becomes much less effective. [Sources: src5, src8]

This is not your fault. Strabismus is not caused by anything you did or didn’t do during pregnancy. It’s not caused by letting your child look at screens, or by holding toys too close to their face, or by any parenting choice. The exact cause is unknown in most children — it likely involves a combination of genetics and how the brain develops control over the eye muscles. If other family members have had strabismus, the risk is higher, but many children with strabismus have no family history at all. [Sources: src1, src2]

When is eye crossing normal vs. concerning?

This is one of the most common questions parents have, and it deserves a clear answer:

Normal (no immediate concern):

• Under 3-4 months of age: A newborn’s eyes may occasionally wander or cross. The eye muscles are immature and still learning to coordinate. This usually resolves on its own. [Source: src2]

Needs attention:

• After 4 months of age: If one eye consistently turns in, out, up, or down, or if the crossing is frequent and obvious, this should be evaluated. [Source: src3]
• At any age: A sudden change in eye alignment in a child whose eyes were previously straight. This is always worth a prompt visit to the eye doctor. [Source: src3]
• At any age: If you’re genuinely not sure whether it’s real — get it checked. Better to be reassured than to miss something. [Source: src4]

“But it looks like my baby is cross-eyed and they’re only 2 months old…”

Many babies look cross-eyed even when their eyes are perfectly aligned. This is called pseudostrabismus (SOO-doh-struh-BIZ-mus) — “false strabismus.” It happens because many babies have a wide, flat bridge of the nose and prominent skin folds at the inner corners of the eyes (called epicanthal folds). These features cover part of the white of the eye near the nose, which makes the eyes look like they’re turning inward — especially when the baby looks to the side. [Source: src2]

As the baby grows and the nose bridge becomes more prominent, the appearance of crossing usually goes away entirely. Your doctor can tell the difference between pseudostrabismus and real strabismus with a quick, simple test using a small light (called the Hirschberg test or corneal light reflex test). [Source: src4]

Pseudostrabismus is especially common in Asian babies due to wider nasal bridges and more prominent epicanthal folds. If you’re a parent of Asian descent and your baby looks cross-eyed, there’s a particularly good chance it’s pseudostrabismus — but please still have it confirmed by a doctor, because real strabismus also occurs and needs treatment. [Source: src2]

The three most common types in children

1. Infantile esotropia (crossing that starts very early)

This appears in the first 6 months of life as a large, obvious inward turn. The angle is usually big enough that you can tell something is off from across the room. These children typically need surgery to align the eye muscles, often performed before age 2. Even with early surgery, some children may need more than one procedure, and they should be monitored closely for amblyopia. [Sources: src2, src3]

2. Accommodative esotropia (crossing caused by farsightedness)

This is the most common type you’ll encounter. It typically appears between ages 1 and 5. The child’s eyes are very farsighted (they naturally have trouble focusing on near objects), so the brain works extra hard to focus — and this overeffort causes the eyes to cross inward. [Source: src2]

The good news: glasses often fix this completely. When the child wears glasses that correct their farsightedness, the brain no longer needs to strain to focus, and the eyes straighten out. Some children may eventually outgrow the need for glasses as their eyes grow and the farsightedness decreases during adolescence. [Source: src2]

“How long will my child need glasses?” This is the most common question parents ask. The honest answer is: it’s hard to predict. Some children can stop wearing glasses as teenagers when their farsightedness decreases with growth. Others will need glasses throughout life. Your eye doctor will monitor this over time and adjust the plan accordingly. [Source: src2]

3. Intermittent exotropia (outward drifting that comes and goes)

This is when one eye occasionally drifts outward — typically when the child is tired, daydreaming, looking at distant objects, or not feeling well. The rest of the time, the eyes look straight. Parents often describe noticing one “lazy” eye that drifts out during certain moments. Many children with this condition will close one eye in bright sunlight. [Source: src2]

If the child is controlling the drift well most of the time (meaning the eyes are straight more often than not), an eye doctor may recommend monitoring rather than immediate treatment. Surgery may be recommended if the drifting becomes more frequent, if the child’s ability to control it worsens, or if depth perception starts to be affected. [Sources: src2, src3]

How is strabismus treated?

Treatment depends on the type, severity, and whether amblyopia has developed. The goals are: (1) protect and develop clear vision in both eyes, (2) align the eyes, and (3) establish or restore the ability to use both eyes together. [Source: src1]

Glasses — For many types of strabismus (especially accommodative esotropia), properly prescribed glasses can reduce or eliminate the misalignment. This is often the first thing tried. [Source: src1]

Patching or eye drops — If amblyopia has developed (the misaligned eye has weaker vision), the stronger eye may need to be patched or blurred with special eye drops (atropine) to force the brain to use the weaker eye. For moderate amblyopia, research has shown that patching for just 2 hours a day is as effective as 6 hours, which is reassuring for families worried about their child wearing a patch all day. [Sources: src1, src5]

Surgery — When glasses and other treatments aren’t enough to straighten the eyes, surgery on the eye muscles may be recommended. This adjusts the tension of one or more of those six muscles we mentioned, pulling the eye into better alignment. [Source: src1]

A note about eye muscle surgery: We know the word “surgery” on a child’s eyes sounds terrifying. Here’s what it actually involves: the surgeon adjusts the muscles on the outside of the eyeball — they do not cut into the eye itself, and they do not remove the eye. The surgery is done under general anesthesia (your child is asleep and feels nothing), typically takes less than an hour, and most children go home the same day. The eye may be red and sore for a few days afterward, but children usually recover quickly. About 15-30% of children may need a second surgery to fine-tune the alignment, which is not a sign of failure — it’s a normal part of how strabismus is managed. [Sources: src3, src8]

Vision therapy — For some types of strabismus, especially those involving focusing problems, exercises to improve eye coordination may be recommended alongside other treatments. [Source: src1]

Treating the whole child, not just the eyes

Something that often gets overlooked in discussions about strabismus: children notice when their eyes look different, and so do other children.

Research has shown that children as young as 5 years old can have negative reactions to peers with visible eye misalignment. Older children and teenagers with strabismus may experience teasing, social difficulties, and lower self-esteem. [Source: src8]

This matters because:

Tell your child this is not their fault. Their eyes just need a little help working together, just like some people’s teeth need braces. It doesn’t mean anything is “wrong” with them as a person.

If they need to wear a patch, help them own it. Let them choose colorful patches, decorate them, or wear them as a badge of strength. Many children adapt surprisingly well, especially when the adults around them treat it as normal and not a big deal.

If they need surgery, explain it in simple, age-appropriate terms: “The doctor is going to help your eye muscles work better together, so both your eyes can look at the same thing at the same time. You’ll be asleep and won’t feel anything. When you wake up, your eye might feel a little sore for a few days, but it will get better.”

If other children ask or tease, give your child simple, confident responses they can use: “My eyes just need some help working together. The doctor is fixing it.” Confidence comes from understanding, and understanding comes from honest, calm explanation.

And remember: your calm is your child’s calm. If you treat the diagnosis and treatment as manageable — which it truly is — your child will feel that way too. If you’re anxious and upset, they’ll pick up on it and become anxious and upset themselves. It’s okay to have your own feelings about this — but try to process them away from your child, and present a steady, reassuring front when you’re with them.

When to see a doctor — a simple checklist

• ✅ Your baby’s eyes still cross or wander frequently after 4 months of age
• ✅ One eye consistently turns in, out, up, or down at any age
• ✅ Your child’s eyes were straight before but suddenly start turning
• ✅ Your child tilts their head or turns their face to look at things straight ahead
• ✅ Your child closes one eye in bright sunlight
• ✅ You’re not sure if the crossing is real or just how their face looks — a doctor can check in seconds
• ✅ Anyone in the family has had strabismus, amblyopia, or childhood eye surgery

Don’t wait. The earlier strabismus is addressed, the better the chance of developing normal vision in both eyes and strong depth perception. Treatment that starts early in life can truly change outcomes for the better. [Sources: src3, src5]

⚕️ Medical Disclaimer: This article is for educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. If you have concerns about your child’s eye alignment, please consult a qualified eye care professional. Early evaluation is always better than waiting.

Sources

1. American Academy of Ophthalmology (AAO). “Strabismus in Children.” 2025. https://www.aao.org/eye-health/diseases/strabismus-in-children
2. “Common types of strabismus.” Canadian Journal of Ophthalmology / PMC, 2010. https://pmc.ncbi.nlm.nih.gov/articles/PMC2830773/
3. American Academy of Ophthalmology (AAO). “Esotropia and Exotropia Preferred Practice Pattern.” PMC, 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC10655158/
4. “Pediatric Vision Screening.” Pediatrics in Review, 2018. https://pmc.ncbi.nlm.nih.gov/articles/PMC6317790/
5. “Amblyopia: Detection and Treatment.” American Family Physician, 2019. https://www.aafp.org/pubs/afp/issues/2019/1215/p745.html
6. “Amblyopia in children (aged 7 years or less).” BMJ Clinical Evidence / PMC, 2016. https://pmc.ncbi.nlm.nih.gov/articles/PMC4701128/
7. 国家卫生健康委. “0～6岁儿童眼保健核心知识问答.” 2021.
8. The London Squint Clinic. “Esotropia vs Exotropia.” 2025. https://www.londonsquintclinic.com/esotropia-vs-exotropia-inward-vs-outward-squint-in-children/