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Bulgarian Review of Ophthalmology

Pseudostrabismus, masking manifest strabismus

O. Mladenov, G. Dimitrova


Introduction: The diagnosis strabismus is often "written on the face", especially in cases with large angle of deviation. Nevertheless, the diagnostic dilemma with a risk of hyperdiagnosis is present, especially in children with epicanthus, telecanthus, positive or negative kappa angle. Conversely, in some cases without a cosmetic appearance of squinting, there is a severe impairment of binocular vision (abnormal retinal correspondence, amblyopia, central scotoma, reduced stereo vision) - microstrabismus. Pseudostrabismus may coexist with real strabismus, cosmetically neutralizing it, exaggerating it or even creating an illusion of squinting in the opposite direction.

Objective: To report interesting cases with pseudostrabismus, coexisting with real manifest strabismus.

Material and Methods: We present two clinical cases of children with cicatricial retinopathy of prematurity (ROP) and positive angle kappa, resulting from ectopia of the macula. We use ophthalmic and ortoptic methods.

Results: In one case the existing real esotropia is fully cosmetically compensated by pseudoexotropia. The other case has cosmetic appearance of exotropia, while a large angle of esotropic deviation is present on cover/uncover test.

Conclusion: Decentration of the corneo-foveal reflex (Hirshberg) does not diagnose strabismus, nor it measures the angle of deviation. Diagnosis for real heterotropia or heterophoria is done only after cover/uncover test. Thus, we may encounter significant differences between visible and real squinting. Correct diagnosis of strabismus is important for the right ortoptic and surgical treatment.


cicatricial retinopathy of prematurity; pseudostrabismus; angle kappa; ectopia of the macula

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About The Authors

O. Mladenov
Department of Ophthalmology, Medical University - Sofia, University Hospital "Aleksandrovska" - Sofia

G. Dimitrova
Department of Ophthalmology, Medical University - Sofia, University Hospital "Aleksandrovska" - Sofia