Childhood Strabismus Increases Risk for Mental Health Disorders


More research is needed to fully understand the associations with different types of strabismus


Kevin Firl, MD

Data presented at the Association for Research in Vision and Ophthalmology (ARVO) Virtual Meeting indicates that childhood diagnosis of strabismus may be associated with subsequent diagnosis of mental health disorders.

Strabismus is characterized by the misalignment of the eyes, thus resulting in what is colloquially considered “crossed eyes.” This failure of the eyes to align with each other is caused by an abnormality in the neuromuscular control of the eyes’ movements.

Current estimates place the prevalence of the often-inherited condition in the United States at 13 million individuals—even more, it may be diagnosed in both pediatric and adult populations.

Led by Kevin Firl, MD, of the George Washington University School of Medicine and Health Sciences, the investigative team performed a large, retrospective cohort study in order to elucidate and characterize the associations between strabismus and mental health.

“As association between childhood diagnosis of strabismus and increased risk of diagnosis of mental health disorders by early adulthood has been demonstrated in previously published literature,” the team wrote. “[H]owever the number and demographics of such studies are limited.”

To conduct their analysis, they used data from TriNetX, a federated electronic health records research network of large health organizations across the US.

The team then used logistic regression to calculate relative risk of diagnosis of mental health disorder in those with previous diagnosis of strabismus compared to those without a previous strabismus diagnosis. They controlled for primary demographic factors—such as age, race, sex, and body mass index (BMI)—and performed propensity score matching using greedy nearest-neighbor matching algorithm.

Overall, they evaluated a total of 131,413 patients diagnosed with strabismus between the ages of 0-15 years. The mean age of the population was 3.7 years old.

As such, they reported that patients with a history of strabismus were more likely to be diagnosed with several mental disorders. Specifically, they found a higher relative risk of generalized anxiety disorder (RR, 1.73; 95%, 1.55-1.93), major depressive disorder (RR, 1.22; 95% CI, 1.10-1.35), and ADHD (RR, 1.57; 95% CI, 1.51-1.64).

Firl and team also noted higher risks for substance use disorder (RR, 1.60; 95% CI, 1.15-2.23), adjustment disorder (RR, 1.78, 95% CI, 1.63-1.95), obsessive-compulsive disorder (RR, 1.63, 95% CI, 1.33-1.99), post-traumatic stress disorder (RR, 1.21, 95% CI, 1.01-1.46)—as well as for anorexia (RR, 1.92, 95% CI, 1.73-2.12), conduct disorders (RR, 1.75, 95% CI, 1.64-1.86), and Tourette’s disorder (RR, 1.34, 95% CI, 1.02-1.77).

Although they acknowledged these associations uncovered in their study, they nonetheless recognized that more work needs to be done for this domain.

“More research with specific strabismus types and more control of confounders is needed and underway in this dataset,” the investigators noted.

The study, “Associations between a Strabismus Diagnosis and Subsequent Mental Health Disorders in Children and Adolescents,” was presented at ARVO 2021.

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