Squint & lazy eye

My baby looks cross-eyed in photos: when it is the nose bridge, not a squint

The photo makes your baby's eyes look crossed and a relative says squint. Often the eyes are straight and the shape of the nose bridge is doing the trick, but one check is still worth having.

by Dr Chan Li Yen · MBBS, MOphth (UM), Fellowship in Paediatric Ophthalmology & Strabismus

Dr Chan Li Yen, consultant paediatric ophthalmologist, MMC 43128, NSR 132980 · Eagle Eye Centre Kuala Lumpur, Petaling Jaya

11 min read · 1,965 words

Key takeaways

A flat nose bridge and small skin folds at the inner corners of the eyes can make straight eyes look crossed, most of all in photos and side glances.
This look is called pseudostrabismus. It needs no treatment, and it often fades as the face grows.
In a photo, look at where the flash reflection sits in each pupil. The same place in both is a good sign, but a photo is not a diagnosis.
A true squint can appear later in children first labelled pseudostrabismus. Studies put it between about 5% and 12%, so one check is worthwhile.
A clear result means the eyes are aligned that day. Ask when to come back, and book sooner if an eye starts to turn and stay turned.

You open a photo from the weekend and your baby's eyes look crossed. A relative looks over your shoulder and says "squint", and now you cannot stop seeing it. Everything here is about the baby or toddler past the newborn weeks, the one whose eyes were never described as drifting, just look odd in some pictures. Very often the eyes are straight and the face is doing the trick. Here is how to look at it calmly, and why I would still book one check.

Why does my baby look cross eyed in photos when the eyes seem fine in real life?

Usually because of the shape of the nose bridge, not the aim of the eyes. A flat nasal bridge and small folds of skin at the inner corners of the eyes, called epicanthal folds, change how the inner corner of each eye looks, and the eyes can look pulled inwards. The name for this is pseudostrabismus, or a pseudo-squint: eyes that look crooked but are not.

AAPOS, the American association for paediatric eye doctors, notes that the look is more noticeable in pictures when the child glances to the side and the eye sits closer to the fold. That explains your camera roll. A photo freezes the one half second when your baby looked at the fairy lights, and the fold does the rest. The AAO describes the same picture: a wide, flat nose or a fold of skin at the inner eyelid.

Is this the same as the eye drifting I read about in newborns?

No. Newborn drift is about eyes that really do move out of line in the first weeks while the brain learns to team them, and it has its own timetable, which I set out in cross eyed baby: what is normal, and when to have it checked. This page is for the baby who is well past that stage, or the toddler, whose eyes look inward mostly in pictures and when glancing sideways.

The AAO says that when children are under a year old their eyes may look crossed when they really are not, and that a child can outgrow pseudostrabismus but not strabismus. As the face grows and the bridge of the nose builds up, the look often fades. AAPOS says pseudostrabismus needs no treatment and often gets better as the face changes. The look fading is not the same as proof that it was never a squint, so the next sections matter.

My mother in law says it is a squint. Who is right?

Neither of you can be sure from a photo, and that is fine. Relatives who say "squint" are describing what they see, and what they see is real: the eyes do look inward. What they cannot see is whether the eyes are actually pointing in different directions.

What I would ask everyone at the table to agree on is this: looks are not evidence either way. A true squint, one eye pointing somewhere different from the other, is not outgrown, and it can affect how the sight in the turned eye develops. That is a lazy eye, which I explain in how to spot the drift. So the honest answer to "who is right" is a short examination, not a family vote.

What can I look at in a photo to see if the eyes are straight?

Look at the tiny bright spot of flash reflected on each pupil. If the spot sits in the same place in both pupils, the eyes are pointing the same way. This is the idea behind the light test I use in the room: AAPOS says that if the eyes are aligned the light should be in the centre of each pupil, and the AAO says the reflection is in the same place in both eyes. If the spot sits off to one side in one eye only, that is a reason to book.

This is something to look at, not a diagnosis. It only helps when your baby is facing the camera with the head straight and the eyes on the lens, because a tilted head or a sideways glance moves the reflection. A photo cannot rule a squint in or out. Take a few, straight on, with the flash on, and bring them. If the flash makes a pupil look white or golden rather than red, that is a different question, and the white glow in photos covers it.

Look at where the flash spot sits in each pupil. Same place in both is a good sign. It is not a diagnosis.

If it is just the nose bridge, why bother having it checked?

Because a true squint can hide behind the look. AAPOS states that a baby with pseudostrabismus may get true strabismus as they get older. Three studies of children first labelled with pseudostrabismus show how often, and they do not agree exactly.

Mayo Clinic, Minnesota. Of 184 infants diagnosed with pseudostrabismus in their first year, nine (4.9%) were later diagnosed with strabismus, on average at 4.5 years. The authors found this similar to the rate in the general population there. Only about half had an ophthalmology follow-up visit.
Silbert and colleagues, Pennsylvania. One paediatric ophthalmologist followed children under three with a look of inward turn and normal eyes on first examination. Of 201 who returned, 20 (10%) later had strabismus, and 5 (2%) had a significant focusing error with mild lazy eye. They found this higher than expected in the general population.
A second Silbert review. Of 207 children first seen under 36 months, 22 (11%) later had strabismus. Mild long-sightedness on the first visit did not make the risk lower.

I would not pick one number and hold it up. The Mayo study covered a whole county, and the Silbert studies are one practice, counting children who came back. What they share is that a squint did appear in some of these children. One visit to show the eyes are aligned now, and a second look if anything changes, is a small price for catching it early.

What happens at the check, and what should I bring?

A light, a cover test and a look at how the eyes move. I shine a light at both eyes and check that the reflection is in the same place in each. Then I cover one eye at a time and watch whether the other eye moves to take up the view. Your baby does not have to name a picture or say a word; how we test children's eyes goes through what is done instead. A baby's first eye check uses the same steps.

Bring the photographs that worry you, with dates if you have them. Tell me if a squint or lazy eye runs in the family, and whether the look is worse when your baby is tired or looking at something close.

The NHS gives two lines worth knowing. Get advice if a child has a squint all the time, or is older than three months and has a squint that comes and goes. The NHS also lists a baby who regularly turns their head to one side, or keeps one eye closed when looking at things. Any of those is an appointment rather than more watching.

What do I do after I am told the eyes are straight?

Enjoy it, and keep looking in the ordinary way you already do. A clear result tells you the eyes are aligned on that day. It is not a lifelong all clear, which is why AAPOS advises regular check-ups. Ask me when to come back. If an eye starts to turn in or out and stays turned, a sudden squint in a toddler explains what is urgent and what can wait for a normal appointment.

The photo that worried you is probably a nose bridge caught at a bad angle. One short visit will tell you which it is.

Don't wait for a check-up if…

One eye turns in or out and stays turned, in real life and not only in photos.
The flash reflection sits in a different place in one pupil than the other, photo after photo.
Your baby regularly turns their head to one side or keeps one eye closed.
An eye that was straight before starts to turn suddenly.

Common questions

Why does my baby look cross eyed in photos?

Usually because of the face, not the eyes. A flat nasal bridge and small folds of skin at the inner corners of the eyes can make straight eyes look crossed, and it shows most in pictures when the child looks to the side. This is called pseudostrabismus. An eye examination is what confirms it.

What is pseudostrabismus?

It is when the eyes look as though they are not straight but actually are. AAPOS says it is often caused by a flat nasal bridge and epicanthal folds, the small skin folds near the inner corners of the eyes. It needs no treatment and often gets better as the child grows and the face changes.

Does a flat nose bridge cause a squint?

No. A flat nose bridge can make the eyes look crossed when they are straight, which is pseudostrabismus. A true squint is a difference in where the two eyes point, and it is a separate problem. A baby with a flat bridge can still develop a true squint later, so the eyes are worth having checked.

Will my baby grow out of looking cross eyed?

The look often fades as the face grows. The AAO says a child can outgrow pseudostrabismus but not strabismus. Because you cannot tell which one you are seeing from a photo, an eye examination is what settles it.

Can I tell from a photo whether my baby has a squint?

Not for certain. You can look at where the flash reflection sits in each pupil. If it is in the same place in both, that is a good sign, and if it is off centre in one eye only, book a check. The face needs to be straight on and the eyes on the camera, and even then a photo is not a diagnosis.

How likely is a true squint later in a child who was told it was pseudostrabismus?

The studies differ. A Mayo Clinic population study found 9 of 184 infants (4.9%) were later diagnosed with strabismus. Reports from one Pennsylvania practice found about 10 to 11% of the children who returned for follow-up did. None of this predicts your child, which is why one check and a second look if anything changes is sensible.

My mother in law says my baby has a squint. Should I worry?

Take it as a reason for a check, not as a diagnosis. Relatives are describing a real look, but only an examination shows whether the eyes point the same way. The NHS advises getting advice if a child has a squint all the time, or is older than three months and has one that comes and goes.

What happens at the check for a baby who looks cross eyed?

A light is shone at both eyes to see whether the reflection sits in the same place in each, then each eye is covered in turn to watch for movement. Your baby does not need to name a picture or say a word. Bring the photographs that worry you.

References

AAPOS · Pseudostrabismus · aapos.org
American Academy of Ophthalmology · Strabismus in children · www.aao.org
NHS · Squint · www.nhs.uk
Xu et al., Mayo Clinic · Pseudostrabismus in the first year of life and the subsequent diagnosis of strabismus, Am J Ophthalmol 2020 · pubmed.ncbi.nlm.nih.gov
Silbert et al. · Incidence of strabismus and amblyopia in preverbal children previously diagnosed with pseudoesotropia, J AAPOS 2012 · pubmed.ncbi.nlm.nih.gov
Silbert et al. · Pseudoesotropia follow-up by age and hyperopia, Am Orthopt J 2013 · pubmed.ncbi.nlm.nih.gov
All About Vision · Corneal light reflex testing · www.allaboutvision.com

By Dr Chan Li Yen. General information only. It does not replace a consultation. If you are worried about your child's eyes or vision, please see an eye doctor.