Treating Latent Strabismus: Causes and Management in 2026

Strabismus is defined as a misalignment of the eyes, where one eye looks in a different direction from the other. In this situation, the brain receives two different images, which leads to visual confusion and double vision. If treatment is delayed or neglected, the condition can progress to serious, chronic problems. That is why early diagnosis and proper treatment of strabismus are essential.

Eye movements are controlled by six extraocular muscles. Strabismus occurs when these muscles are either excessively tight or too weak. Under normal circumstances, both eyes work together and focus on the same point at the same moment. Proper eye alignment is crucial to prevent double vision and is especially important for children in developing accurate visual–cognitive processing. Seeing objects clearly and in three dimensions is necessary to establish a strong connection between what the eyes see and how the brain interprets it. 

If strabismus is not treated, the child may suffer from learning difficulties and an inability to perceive depth properly. Abnormal eye movements may be obvious and constant, or the person may have latent (hidden) strabismus that only appears when binocular vision is disrupted. The type of strabismus also differs depending on the direction in which the affected eye deviates.

Latent Strabismus in Children

Strabismus is commonly noticed, or at least suspected, before the age of three. However, it can also develop in older children and even in adults. Any disease that affects the muscles can interfere with eye alignment and control of eye movements, such as diabetes, head trauma, stroke, and thyroid disease. The most common type of strabismus is exotropia, where one or both eyes drift outward instead of looking straight ahead.

To reduce confusion, the brain begins to adapt by suppressing the image coming from the deviating eye so it does not have to process two different images at the same time. This suppression leads to amblyopia (lazy eye) in the misaligned eye, with a chronic decline in visual acuity that can eventually render that eye functionally useless if left untreated.

There are many types of strabismus, each with different signs, appearance, and appropriate treatment methods. We will explain them in more detail below.

What Is Latent Strabismus? Can It Be Treated?

Latent strabismus, or heterophoria, is characterized by normal eye alignment and normal binocular (stereoscopic) vision when both eyes are open. However, as soon as one eye is disengaged from binocular vision—by covering it, for example—the latent misalignment appears. The visual axis of one eye may deviate inward (esophoria), outward (exophoria), upward (hyperphoria), or downward (hypophoria).

One reported case involved a person who had long‑standing paralysis of the muscles responsible for moving the left eye. He was unable to look to the left because that eye simply could not move in that direction. The other eye, which had been relatively healthy, had become hyperopic (farsighted) with age. He spent months practicing “sunbathing” for the eyes and covering one eye with his hand (occlusion as a functional treatment for strabismus), in addition to training with his index finger. He also underwent treatment to correct his overactive thyroid and associated strabismus.

Perfect muscle balance of both eyes is called orthophoria. Orthophoria provides optimal conditions for binocular fusion of the images from each eye and makes visual tasks easier. In orthophoria, the corneal centers align with the middle of the palpebral fissure, and the visual axes of both eyes are parallel and directed toward optical infinity. 

In practice, heterophoria—an imbalance in the action of the extraocular muscles—occurs more frequently than perfect orthophoria. When heterophoria is present, the continuous effort required to maintain single vision leads to persistent ocular muscle strain, which can be very tiring and bothersome, especially for a child.

Treatment of Latent Strabismus

Latent strabismus has multiple causes. Eye specialists identify several key risk factors that can make a person more likely to develop heterophoria, such as refractive errors, systemic illnesses affecting the muscles or nerves, and sustained visual stress. Treatment is tailored according to the underlying cause, the degree of misalignment, and the patient’s symptoms.

Symptoms of Latent Strabismus

A person usually goes through two stages before the symptoms of latent strabismus and the signs of a hidden eye deviation become noticeable:

1. A compensation phase, during which the eye muscles and brain can still maintain single vision despite the imbalance.

2. A decompensation phase, when this ability is lost and symptoms appear—such as eye strain, headaches, intermittent double vision, difficulty focusing, or reading fatigue—especially after prolonged visual tasks.

Can Adults Develop Latent Strabismus?

Most adults who present with misalignment of the eyes have a prior history of strabismus in childhood. However, several conditions can trigger new‑onset misalignment or decompensate a previously controlled heterophoria, including diabetes, thyroid disorders, autoimmune muscle weakness (such as myasthenia gravis), and brain tumors.

Strabismus may also occur as a complication of intraocular or periocular surgery, such as retinal procedures or cataract surgery, when the extraocular muscles are inadvertently affected. Treating latent strabismus in adults often requires more time and effort, particularly because symptoms may be associated with other medical conditions. It is therefore important to correct eye alignment while also addressing the underlying systemic cause.

What Are the Treatment Options for Latent Strabismus?

Available treatments range from prescription eyeglasses (one of the non‑surgical options) to strabismus surgery. Vision therapy and eye exercises are increasingly used to improve eye alignment and focusing in modern strabismus management programs.

Although exercises can be effective in strengthening eye muscles and improving coordination, they cannot always be relied upon as a stand‑alone, definitive treatment. Their success depends largely on the severity of the strabismus, the underlying cause, visual acuity in each eye, and how intensive, consistent, and appropriate the exercise program is for the particular type and degree of deviation.

Can Intermittent Exotropia Be Treated Without Surgery?

Comprehensive management of strabismus is built on three main components that must all be addressed to achieve satisfactory results:

1. Correcting any refractive errors (with glasses or contact lenses).

2. Treating amblyopia (lazy eye) if present.

3. Correcting the eye misalignment itself (with non‑surgical methods and/or surgery).

What Is a Lazy Eye and How Is It Treated?

When strabismus is present, the brain begins to ignore visual information coming from the deviating eye. As a result, vision in that eye deteriorates because it is no longer being used effectively. To reverse this, the healthy eye must be covered so the brain is forced to use the weaker eye and strengthen the visual pathway from that eye.

Amblyopia (lazy eye) cannot be corrected solely by prescribing glasses or performing muscle surgery. Regardless of the original cause of the strabismus, those factors are separate from amblyopia itself. The brain’s way of coping with strabismus—by suppressing input from the misaligned eye—leads directly to the development of lazy eye. The primary goal in treating amblyopia is to make the affected eye function normally, even if it still has a tendency to deviate.

This problem must be treated in children with strabismus before the age of eight; otherwise, the visual deficit becomes permanent and essentially impossible to reverse.

The cornerstone of amblyopia treatment is patching the stronger eye and forcing reliance on the weaker one. This helps the weaker eye to work, and it is crucial to begin this approach early in childhood. In general, vision improves gradually, and consistent therapy can restore normal sight. The length of treatment varies according to the severity of amblyopia and the child’s age.

Patching is done with an eye patch over the stronger eye to block vision. The patch may be worn for a specific number of hours per week or for most of the day. Treatment continues until vision becomes normal, which typically occurs within weeks to months. Regular follow‑up is necessary to ensure the amblyopia does not recur. In some cases, the child may need additional periods of patching even after initial improvement.

The purpose of amblyopia treatment is to restore visual acuity and clarity in the affected eye. Amblyopia is the most serious long‑term complication of strabismus, but amblyopia therapy alone does not correct eye alignment.

Are Glasses an Effective Treatment for Latent Strabismus in Children?

Glasses are usually the first line of treatment and may, in some cases, be sufficient to correct the misalignment without surgery. Correcting refractive errors—even if present in only one eye—can significantly improve eye position. Wearing prescription glasses helps treat hyperopia (farsightedness) and myopia (nearsightedness), stabilizing focus and directing the eyes straight ahead. You may notice that the strabismus decreases or disappears when the child is wearing glasses, only to reappear when they are removed. Lenses are designed to reduce double vision, so children are generally advised to wear their glasses full‑time.

These glasses are made with lenses of varying thickness, often thicker in front of the affected eye. The thickness helps control how much light is refracted through the lens, which aids in producing a single, unified image and reduces double vision in mild to moderate cases.

In intermittent exotropia—where one eye occasionally drifts outward and then returns to its normal position—glasses are often the main treatment used to correct the visual pathway. Correcting refractive errors like myopia with glasses can improve eye alignment and, in some patients, eliminate the need for surgery.

Strabismus Surgery

The primary goal of strabismus surgery is to correct the visible deviation and align both eyes straight ahead. Surgery also helps restore depth perception and three‑dimensional vision. It is usually considered when glasses and non‑surgical approaches fail to adequately correct the misalignment.

Strabismus surgery is one of the most common and effective treatments, during which the surgeon adjusts the position or tension of the eye muscles to suit the patient’s condition. Some patients may require more than one operation.

In intermittent exotropia, surgery is often recommended when the person spends more than half of the day with the eye drifting outward. Patients typically experience fatigue, eye pain, burning, and dryness, and it can become difficult to function with such symptoms.

Strabismus surgery is usually performed as day‑surgery under general or local anesthesia. The ophthalmologist makes a small incision on the white part of the eye (conjunctiva) to access the extraocular muscles, then changes their position or tightness to correct the deviation. The eye itself is not removed from its socket; only the muscles are repositioned, tightened, or relaxed and then secured in their new location with sutures. Altering muscle insertion points changes the position and movement of the eye as a whole.

Postoperative Instructions After Latent Strabismus Surgery

Strabismus surgery carries potential risks such as infection inside the eye, bleeding, and temporary blurred vision, especially in the early postoperative period. These complications can be minimized by reducing the risk of infection and protecting the operated eye. Important recommendations include:

– Using prescribed antibiotic and anti‑inflammatory eye drops exactly as directed.  

– Avoiding rubbing or pressing on the eye.  

– Keeping water, dust, and foreign bodies away from the eye during the healing period.  

– Attending all follow‑up appointments so the doctor can monitor alignment and healing.  

Botox Injections

Botulinum toxin injections into specific eye muscles can be used to treat certain types of strabismus, especially esotropia (inward deviation of the eye). The toxin temporarily weakens or paralyzes the injected muscle. One or more muscles may be injected, but the effect is temporary and does not last indefinitely. Botox is usually considered when multiple surgeries have failed to achieve satisfactory alignment.

The effect of botulinum toxin typically lasts for a few months, after which the injection can be repeated if necessary. In children, this approach is not commonly the first choice due to the temporary nature of its effect, but in adults, it can sometimes provide long‑term improvement in alignment and symptoms.

Treating Intermittent Exotropia With Exercises

Intermittent exotropia in adults and its management is a significant issue. Eye exercises are one of the non‑surgical approaches to treatment. Ophthalmologists may design a comprehensive therapy plan and teach patients exercises that improve eye alignment and the ability to maintain focus straight ahead.

Exercises are widely used in treating pediatric strabismus, but they do not replace medical or surgical treatments. They also often require a long time to achieve results. Their success depends on how strictly the patient follows the program and performs the exercises correctly and consistently.

Some activities may be used alone or combined with occlusion (patching the stronger eye) to strengthen the weaker eye and enhance coordination between the deviating eye and the brain—an important aspect of non‑surgical treatment of exotropia in children. The core problem in strabismus is not only in the muscles but also in the coordination between brain signals and eye movements. Therefore, surgical correction should ideally be combined with visual training and intensive depth‑perception exercises to help the brain adapt after alignment is restored.

These activities commonly focus on:  

– Convergence training (bringing the eyes together and maintaining a single image at near).  

– Improving sustained focus and accommodation.  

– Practicing accurate fixation and eye‑movement control.  

The advantage of these exercises is that they are generally easy to learn and can be performed at home.

What Are the Risks of Neglecting Strabismus Treatment?

Strabismus should not be ignored once a child is older than three months. Neglecting treatment can lead to more serious and sometimes irreversible complications, including:

– Amblyopia (permanent reduction in vision in the affected eye).  

– Loss or reduction of depth perception and 3D vision.  

– Persistent cosmetic misalignment and psychological impact on the child’s self‑image.  

– Ongoing eye strain, headaches, and visual fatigue.  

If you have visual problems, difficulty seeing clearly, or suspect that misalignment of your eyes is affecting your vision, you should not delay seeking professional help. Schedule an appointment so the condition can be treated at the appropriate time. You can also consult an eye specialist whenever you notice new or worsening symptoms.

Strabismus cannot always be prevented, but in most cases it can be successfully treated and its complications avoided. Early detection is the key. All children should have their eyes examined between the ages of 6 months and 3 years old.