Strabismus surgery recommended before age six

This laboratory study investigated the social acceptance of children with strabismus by their peers and the age at which the negative impact of strabismus on psychosocial interactions emerges. The results indicate that children aged six years and older with strabismus appear to be less likely to be accepted by their peers.

The authors, who were based in Switzerland, digitally altered pictures of six children to create pairs of twins that were identical except for the position of the eyes (orthotropic, exotropic and exotropic) and the color of the shirt worn. They asked 118 children between ages 3 and 12 years to choose which twin to invite to their birthday party.

Children younger than six years did not make any significant distinctions between orthotropic and strabismic children. However, children aged six years and older chose to invite children with a squint to their birthday parties significantly less often than orthotropic children. Gender, shirt color or type of strabismus did not have any impact. Although children between ages four and six were often aware of a difference between an aligned and squinting eye, this difference was not valued negatively.

The authors found that the percentage of children who made specific comments about the eyes increased with age. When asked if they had noticed anything in particular regarding the twins, approximately 19 percent of children aged four to six years commented on eye alignment without being asked to pay attention to the eyes. After being asked to do so, the number of children saying something concerning the eyes increased to 39 percent. For children aged six to eight years, these percentages increased to 48 percent and 77 percent, respectively, and for those aged 8 to 10 years, to 83 percent and 91 percent, respectively. Their comments included that the eyes were crossed, strange, turned, squinting, looking in different directions, like chameleons, different from each other or not straight.

The authors say that the differences in the perception of strabismus between age groups can be explained by child development studies on the recognition of faces and facial features. These studies show that children older than age six mostly process faces holistically, like adults. Children younger than four years use part-based processing, categorizing faces in terms of piecemeal characteristics. Therefore, they may not be able to realize that two eyes are not aligned.