Snapshot A 12-month-old girl presents to the pediatrician for a well-baby visit. The child is cooperative and playful. On physical examination, the boy has a head tilt. Deflection is noted on corneal light reflex testing, and cover test shows refixation of the left eye when the other eye is covered. Introduction Abnormal visual development → decreased visual acuity visual stimulation is highly important for maturation of the visual cortex ETIOLOGY Can divided into three etiologies: strabismus (most common) leads to the generation of images that cannot be fused properly image generated by one eye is suppressed by the visual cortex refractive error (second most common) leads to differences in image clarity visual deprivation e.g., cataracts Presentation Depends on the cause strabismus esotropia inwardly deviated "crossed eyes" exotropia outwardly deviated "walled eyes" pseudostrabismus appears to be misaligned by eyes are in correct alignment often due to certain facial features (e.g., wide nose bridge, epicanthal folds) can differentiate from strabismus via the Hirschberg light reflex test (pupilary light reflex will be centered in both eyes) refractive error abnormal vision screening visual deprivation e.g., cataracts lenticular opacity noted on exam Treatment Correct underlying cause is the initial step strabismus eye realignment via glasses or surgery in severe cases refractive error refractive correction with glasses visual deprivation remove insult e.g., surgery to remove cataract Patching or optic penalization patching occluding the "better" eye to encourage use of the amblyopic eye optic penalization atropine, a cycloplegic, is added to the "better" eye both are equally effective