Management of Strabismus in a 2-Month-Old Infant
Intermittent strabismus at 2 months of age is typically normal and requires observation rather than immediate intervention, as most cases resolve spontaneously by 3-4 months of age. 1
Understanding Normal Visual Development
- Some degree of intermittent eye misalignment during the first 3 months of life is considered a normal part of visual development and does not necessarily predict the development of constant strabismus. 1
- Neonates frequently have intermittent exotropia during the first 3-4 months of life, though it rarely persists beyond this period. 2
- If the eye crossing is intermittent and variable at 2 months, continued observation is the appropriate management strategy. 1
When to Escalate Care
Ophthalmological evaluation becomes necessary if any of the following occur: 1
- Strabismus persists beyond 3-4 months of age
- The deviation becomes constant rather than intermittent
- The deviation is present at all times rather than occasionally
- Associated concerns develop (such as abnormal fixation behavior or signs of amblyopia)
Risk Factors Requiring Closer Monitoring
Certain infants warrant more vigilant observation for persistent strabismus: 1
- Family history of strabismus
- Premature birth, especially with birth weight under 2000 grams
- Neurodevelopmental impairment
- Significant hyperopia (farsightedness)
- Low Apgar scores
- Exposure to smoking or alcohol in utero
- Craniofacial or chromosomal anomalies
Screening Recommendations
The USPSTF recommends screening to detect amblyopia, strabismus, and defects in visual acuity in children younger than age 5 years. 2 During the first year of life, strabismus can be assessed by the cover test and the Hirschberg light reflex test. 2
Why Early Intervention Matters (When Indicated)
- Persistent strabismus can lead to amblyopia (lazy eye) if left untreated, as binocular vision can degrade rapidly in young children. 1
- Early treatment promotes binocular vision and improves visual function in each eye. 1
- Proper alignment is important for normal visual development and social interactions. 1
Critical Pitfall to Avoid
Do not rush to treatment at 2 months of age. The key distinction is between normal developmental intermittent misalignment (which resolves spontaneously) and true persistent strabismus (which requires intervention). 1 Conservative management is recommended during the first few months of life, as significant variability in ocular alignment is normal during this period. 3