Pediatric Ophthalmology and Strabismus
Core concepts
Understand visual development and the critical period for amblyopia. Know the types of amblyopia: refractive, strabismic, and deprivation. Learn the strabismus types: esotropia (infantile, accommodative), exotropia, and vertical deviations. Understand the cover test and the Hirschberg test for measuring deviation. Know the red reflex exam and its role in detecting leukocoria (retinoblastoma, congenital cataract). Recognize congenital glaucoma (buphthalmos, corneal edema, photophobia) and congenital nasolacrimal duct obstruction (epiphora, discharge).
Traps
Do not attribute a white pupillary reflex to a benign cause; leukocoria requires urgent workup. In infantile esotropia, surgery timing matters. Accommodative esotropia responds to hyperopic correction, not surgery first. Amblyopia treatment is most effective early; patching or atropine penalization are options. Distinguish pseudostrabismus (epicanthal folds) from true strabismus.
Rule of thumb
Any child with a new-onset strabismus, leukocoria, or nystagmus needs prompt evaluation. For accommodative esotropia, cycloplegic refraction is essential.
Worked example
A 3-year-old has intermittent inward turning of one eye, worse when looking at near objects, and is hyperopic on cycloplegic refraction. This is accommodative esotropia; prescribe glasses and reassess before considering surgery.