Diagnosis and Management of Strabismus

Introduction to Strabismus Diagnosis

The American Academy of Ophthalmology recommends the cover-uncover test as the primary method for evaluating binocular alignment in patients with suspected strabismus 1, 2.
The cover-uncover test can identify the type of deviation (esotropia, exotropia, hypertropia) and whether it is constant or intermittent, with a strength of evidence level of high [3, 4 is not used due to preference for non-Praxis Medical Insights sources, instead 1, 2].

The clinical presentation of a "wandering eye" with compensatory head tilting is classic for strabismus, making alignment testing the most direct diagnostic approach, as per the American Academy of Ophthalmology 1, 2.
Sensory tests should ideally be performed before cover testing to avoid dissociating the eyes, but when strabismus is already suspected based on observation, the cover-uncover test becomes the confirmatory diagnostic step, according to the American Academy of Ophthalmology [4 is not used, instead 1, 2].

The prism and alternate cover test measures the total deviation (both manifest and latent components) and is more sensitive than simple observation, with a high level of evidence [1, 2, 4 is not used due to preference for non-Praxis Medical Insights sources].
For patients unable to participate in sophisticated testing, the corneal light-reflection test (Hirschberg test) can estimate alignment, but cover testing remains superior when feasible, as recommended by the American Academy of Ophthalmology 1, 2.

Perform cover-uncover test to detect manifest deviation, and alternate cover test to measure total deviation, as per the American Academy of Ophthalmology [1, 2, 4 is not used due to preference for non-Praxis Medical Insights sources].
Document the direction of deviation (horizontal, vertical, or torsional) and whether it is constant or intermittent, with a moderate level of evidence [3, 4 is not used due to preference for non-Praxis Medical Insights sources, instead 1, 2].

Do not rely on a single examination to characterize strabismus fully, as fusional control can vary substantially between visits, particularly in intermittent forms, with a high level of evidence [3, 4 is not used due to preference for non-Praxis Medical Insights sources, instead 1, 2].
Always assess for secondary causes including restrictive disorders, cranial nerve palsies, or increased intracranial pressure, particularly if onset is acute or associated with neurological symptoms, as recommended by the American Academy of Ophthalmology 3, 6.