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Strabismus was moderately linked with certain mental health disorders in children, according to a cross-sectional study.

In an analysis of medical claims data from a commercial healthcare payer system from 2007 to 2017, strabismus in children was associated with a higher risk for developing mood disorders, schizophrenia, and anxiety compared with those free of any eye disease (all P<0.001):

• Anxiety disorder: adjusted odds ratio (aOR) 2.01 (95% CI 1.99-2.04)
• Schizophrenia: aOR 1.83 (95% CI 1.76-1.90)
• Bipolar disorder: aOR 1.64 (95% CI 1.59-1.70)
• Depressive disorder: aOR 1.61 (95% CI 1.59-1.63)

Each type of strabismus -- esotropia, exotropia, and hypertropia -- was independently tied to these four conditions, but "it is unclear whether the type of strabismus has an association with the magnitude of mental illness risk," noted Stacy Pineles, MD, MS, of the University of California Los Angeles, and colleagues, writing in .

The study found no link between strabismus and substance use disorder.

Strabismus, or crossed eyes, is one of the most common eye diseases in kids, currently affecting between 2% to 5% of U.S. children, said Pineles and coauthors, and research suggests that underrecognition of mental illness in kids results in only a fraction receiving appropriate care.

"These results should alert ophthalmologists and optometrists to counsel children and their caregivers regarding the risk for mental illness," the group 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."

In an , Nathan Congdon, MD, of Queen's University Belfast in Northern Ireland, and colleagues pointed to the growing evidence between strabismus and common psychiatric conditions.

"Longitudinal intervention studies show that surgical correction of ocular misalignments may be associated with reductions in anxiety and depression," they noted, "providing further compelling evidence of this association as well as the potential preventive role of timely surgical intervention."

Due to the perception that corrective procedures of ocular misalignment is simply "cosmetic," health insurance coverage may be limited, even in developed nations, they wrote. "Evidence of the broader association of strabismus with physical and mental health may play an important role in shifting policy to promote insurance coverage for timely strabismus care."

Congdon and his fellow editorialists also noted how the pandemic may have only magnified the relationship between strabismus and the mental health conditions reported in this study.

"With mental health conditions and disorders increasing worldwide, compounded by the stressors from the COVID-19 pandemic, additional studies are needed to explore the causal relationships between ocular and psychiatric phenomena, their treatment, and outcomes," the editorialists concluded.

For their study, Pineles and colleagues examined claims based on ICD-9 and ICD-10 codes for strabismus collected from the OptumLabs Data Warehouse. A total of 12,005,189 participants 18 and younger were enrolled: 352,636 children who had been diagnosed with strabismus and 11,652,553 children who had no eye disease diagnoses. Half were boys and the average age was 8.

Of the strabismus subtypes, esotropia was the most common (n=184,005), followed by exotropia (n=163,439) and hypertropia (n=43,987).

The researchers noted that using data from a commercial health care system likely skewed the results of the study to center children from higher socioeconomic backgrounds, as opposed to kids with no insurance or those on government-funded insurance programs. Another limitation was the study's cross-sectional design, in which causality between strabismus and mental illness cannot be determined.

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