Strabismus Associated With Mental Illness Among Children

Stacy L. Pineles, MD, MS

New findings suggest a better understanding of the association of mental illness with strabismus in children may improve the diagnosis and management of psychiatric conditions.

In a recent cross-sectional study, a moderate association between strabismus and anxiety disorder, schizophrenia, bipolar disorder, and depressive disorder was observed in children; no association was observed beteen the disorder and substance use disorder.

“Each type of strabismus (esotropia, exotropia, and hypertropia) in this study had an increased association with 4 mental illness subgroups,” wrote study author Stacy L. Pineles, MD, MS, Department of Ophthalmology, Stein Eye Institute, University of California, Los Angeles.

The study investigated the association between strabismus and mental illness disorders using data collected from the OptumLabs Data Warehouse. The database consisted of deidentified, longitudinal health information on enrollees and patients, with a diverse mixture of ages, races and ethnicities, and geographic regions across the United States.

Claims data between January 2007 - December 2017 were used in the study, with eligibility including age younger than 19 years at time of diagnosis, enrollment in the health plan during the study period, and at least 1 strabismus claim based on International Classification of Diseases codes.

Statistical analysis was conducted by investigators from December 2018 - July 2021. Unadjusted odds ratios (ORs) for mental illness were calculated with 95% CIs using univariate logistic regression models, while adjusted effects were estimated using multivariable logistic regression models with potential confounding variables, including race, ethnicity, and income level.

A total of 12,005,189 participants (50.8% male; mean age, 8.0 years) were enrolled in the study. Data show 352,636 children had strabismus, while 11,652,553 children had no eye disease diagnosis (control).

The study evaluated a total of 5 mental illness diagnoses, including anxiety disorder, depressive disorder, substance use or additive disorder, “bipolar disorder,” and “schizophrenia.”

Investigators observed the adjusted ORs were

• 2.01 (95% CI, 1.99 - 2.04; P <.001) for anxiety disorder
• 1.83 (95% CI, 1.76 - 1.90; P <.001) for schizophrenia
• 1.64 (95% CI, 1.59 - 1.70; P <.001) for bipolar disorder
• 1.61 (95% CI, 1.59 - 1.63; P <.001) for depressive disorder

Following adjustment for confounders, the association between substance use disorder and strabismus was not significant (OR, 0.99; 95% CI, 0.97 - 1.02; P = .48).

Then, the association between strabismus and mental illness was studied by stratifying the strabismus group into those with esotropia (52.2%), exotropia (46.3%), and hypertropia (12.5%).

A moderate association with increased odds between each type and anxiety disorder, schizophrenia, bipolar disorder, and depressive disorder was observed. Odds ratios were shown to range from 1.23 (95% CI, 1.17 - 1.29) for the association between esotropia and bipolar disorder to 2.70 (95% CI, 2.66 - 2.74) for the association between exotropia and anxiety disorder.

“These results should alert ophthalmologists and optometrists to counsel children and their caregivers regarding the risk for mental illness,” Pineles concluded. “They should consider incorporating a screening tool for mental health problems for patients with strabismus and referral of pediatric patients with strabismus for mental health evaluation.”

The study, “Association of Strabismus With Mood Disorders, Schizophrenia, and Anxiety Disorders Among Children,” was published in JAMA Ophthalmology.