Confirm strabismus by performing cover test and eliciting fixational eye movement, or...
Noting if diplopia disappears as patient covers either eye
Understand that strabismus may be hard to diagnose if misalignment is small, patient does not report diplopia, is uncooperative, or cannot properly execute fixation movement on cover test, so...
If you are not sure of your test results or patient reports diplopia...
Refer with urgency that depends on how recently strabismus was noted and on accompanying pertinent findings, because...
Brain aneurysm or other life-threatening conditions could be present
Strabismus in early childhood often accompanied by amblyopia, which must be promptly treated to prevent persistent vision loss
Treatment of strabismus depends on underlying cause
Causes in young children are excessive convergence of brain stem origin ("congenital esotropia"), esotropia of hyperopia ("accommodative esotropia"), impaired vision ("sensory strabismus"), and excessive idiopathic divergence ("exotropia")
Causes in adults are internuclear ophthalmoplegia, skew deviation, cranial nerve palsies, myasthenia gravis, extraocular muscle inflammation, and orbital trauma
Most urgent diagnosis is third cranial nerve palsy because could be caused by brain aneurysm with imminent rupture and death
