Pseudostrabismus refers to the appearance of eye misalignment in the absence of true misalignment of the visual axes (Donahue, 2016). The apparent misalignment may result from certain facial morphological features, including the eyelids, inter-pupillary distance, and nasal structure, or from an abnormal angle kappa (Birch, 2012). The appearance of pseudostrabismus can vary depending on the direction and magnitude of the angle kappa (Mandal et al., 2018). Among its various forms, pseudoesotropia—an apparent inward deviation of the eyes—is the most common, followed by pseudoexotropia and pseudohypotropia/pseudohypertropia (American Academy of Ophthalmology [AAO], 2021). Accurate recognition of these variants is essential for differentiating pseudostrabismus from true strabismus and for providing appropriate parental counseling.Causes and Natural History Pseudostrabismus in infants is frequently associated with a broad nasal bridge and the presence of epicanthal folds, which are small folds of skin covering the inner corners of the eyes (Donahue, 2016; Mandal et al., 2018). These features can obscure the medial sclera, creating the optical illusion that the eyes are crossed, although the visual axes remain properly aligned (Birch, 2012). Pseudostrabismus is most commonly observed as pseudoesotropia, but other forms such as pseudoexotropia and pseudohypotropia/pseudohypertropia may also occur (AAO, 2021). As the child grows and facial structures mature, the nasal bridge narrows and the epicanthal folds become less prominent, often resulting in spontaneous resolution of pseudostrabismus without intervention (AAO, 2021). Understanding this natural course is crucial for reassuring parents and avoiding unnecessary medical procedures or anxiety.Diagnosis The diagnosis of pseudostrabismus should only be made after ruling out the presence of true manifest or intermittent strabismus (Donahue, 2016; Birch, 2012). A thorough history is essential, including details about birth weight, gestational age, general health, and any prior procedures to treat retinopathy of prematurity, as these factors may provide diagnostic clues (Mandal et al., 2018). Early photographs of the child can assist in documenting the onset of the apparent misalignment, assessing its stability over time, and supporting the diagnosis of pseudostrabismus. Physical examination should encompass visual and motor evaluation, as well as careful inspection of facial morphology, including the nasal bridge, orbital anatomy, and eyelid configuration (Donahue, 2016). Cycloplegic refraction and a dilated eye examination are recommended in every case. A detailed ocular motility assessment, comprising cover-uncover and alternate cover tests, is considered the gold standard for detecting true strabismus. In uncooperative infants, the Hirschberg light reflex test may be used to estimate ocular alignment (Birch, 2012). Cycloplegic refraction is particularly important in cases of pseudoesotropia to exclude high hyperopia, which may indicate intermittent accommodative esotropia. Once pseudostrabismus is confirmed, parental reassurance and education regarding the signs of true strabismus are crucial. Families should be advised to seek prompt evaluation if any new signs of ocular misalignment develop, as early diagnosis of manifest strabismus is critical and may otherwise be overlooked in children previously diagnosed with pseudostrabismus (AAO, 2021).References American Academy of Ophthalmology. (2021). Pediatric eye disease: Strabismus. https://www.aao.org/eye- health/diseases/strabismus Birch, E. E. (2012). Strabismus and amblyopia in children. Journal of American Association for Pediatric Ophthalmology and Strabismus, 16(1), 1–7. https://doi.org/10.1016/j.jaapos.2011.11.002 Donahue, S. P. (2016). Common pediatric eye disorders. Pediatrics in Review, 37(9), 372–384. https://doi.org/10.1542/pir.2015-0114 Mandal, A., Aggarwal, S., & Sinha, R. (2018). Pseudostrabismus in infants: Clinical significance and parental counseling. University of Al-Mustaqbal – The First and Leading Private University