Childhood Strabismus from A Different Perspective: Examining Its Association with Cognitive Development

Childhood Strabismus from A Different Perspective: Examining Its Association with Cognitive Development | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Childhood Strabismus from A Different Perspective: Examining Its Association with Cognitive Development Yan Yang, Jinen Hou, Hailu Huang, Siyu Tan, Hong Chen, Shihui Ling, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5444829/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background: Previous studies have shown that abnormal visual input and processing possibly impact the cognition development in children. We aimed to investigate the relationship between abnormal visual function associated with strabismus and cognition development in children. Methods: Conducted at Zhongshan Ophthalmic Center, this cross-sectional case-control study involved 201 children aged 4-10 years, including 114 with strabismus and 87 matched controls, between January 2021 and December 2022. Cognitive functions were evaluated using the Wechsler Intelligence Scale for Children—Fourth Edition (WISC-IV) and the Wechsler Preschool and Primary Scale of Intelligence—Fourth Edition (WPPSI-IVR), focusing on the global cognitive score (GCS), verbal comprehension index (VCI), perceptual reasoning index (PRI), working memory index (WMI), and processing speed index (PSI). Results: Children with strabismus showed significantly lower scores in GCS (t=-8.31, p<0.001), VCI (t=-7.81, p<0.001), PRI (t=-6.18, p<0.001), WMI (t=-5.55, p<0.001), and PSI (t=-3.51, p=0.006) compared to controls. The type of strabismus (esotropia or exotropia, intermittent of constant tropia) did not show a significant association with cognitive performance (p>0.05). Spearman’s correlation and multivariate linear regression analyses identified that better fusion ability (p=0.01) and a shorter duration of strabismus (p=0.002) were associated with higher cognitive function. Conclusion: The findings reveal a significant decline in cognitive performance among children with strabismus compared to their non-strabismic peers, regardless of the type of strabismus. The duration of strabismus and impaired near fusion function are associated with cognitive development levels, highlighting the importance of early detection and potential interventions to support better cognitive outcomes. Strabismus Children Cognitive development Binocular Vision Figures Figure 1 Figure 2 Figure 3 1. Introduction Strabismus, affecting 3–5% of children, [ 1 , 2 ] is one of the most prevalent childhood visual abnormalities. This condition leads to several clinical consequences, including amblyopia ("lazy eye"), impaired stereopsis (binocular depth perception), aberrant binocular interaction, diplopia (double vision), and potential psychological effects. [ 3 , 4 ] These clinical manifestations suggest disruptions in both visual input and processing in strabismus. Cognition involves complex mental processes, including perception, attention, memory, reasoning, problem-solving, decision-making, language processing, and learning. [ 5 ] These processes are fundamental to human intelligence, influencing how individuals perceive their environment, tackle challenges, make decisions, and adapt to new situations. Cognitive functions develop progressively and systematically throughout life stages, from infancy through adulthood. [ 6 ] Age 4 to 11 are considered critical for the development of children's cognitive functions, including logical thinking and overcoming egocentrism. [ 7 ] Cognitive development is influenced by biological maturation, environmental experiences, social interactions, and cultural contexts. [ 8 ] The literatures suggests that normal visual experiences play a significant role in cognitive development, especially during early childhood. [ 9 , 10 ] Abnormal visual input and processing associated with strabismus possibly impact the cognition development in children [ 11 ] by disrupting spatial perception, potentially leading to developmental delays and academic, social, and emotional challenges. [ 4 , 12 ] Studies show that school-aged children with strabismus demonstrate lower reading proficiency and impaired academic and athletic achievements. [ 13 , 14 ] There are moderate associations between strabismus severity and attention deficits, as well as learning disorders in children. [ 15 ] Bagheri et al. found that patients with congenital strabismus had lower cognitive scores compared to their peers. [ 16 ] Sun et al. discovered that children with exotropia typically show lower perceptual reasoning index (PRI) scores but higher processing speed index (PSI) scores than children without strabismus, suggesting distinct cognitive profiles. [ 17 ] In contrast, Ghaderpanah et al. found no significant negative impact of strabismus on the cognitive scores in preschool children aged 3–7 years [ 11 ]. These mixed findings highlight the need for further investigation into the relationship between cognitive functions and visual impairments in children with strabismus. In this study, we enrolled patients with varying level of binocular visual function and different durations of strabismus. We compared these patients to a control group to investigate the relationship between strabismus-related visual abnormalities and cognitive development in children, aiming to identify key associated factors. 2. Methods 2.1 Study Design A cross-sectional, case-control study. 2.2Participants The study included a total of 114 children diagnosed with strabismus and 87 typically developing children aged 4 to 10 years who were enrolled at Zhongshan Ophthalmic Center, Sun Yat-sen University, between January 2021 and December 2022. All participating children with strabismus were seeking surgical correction for their condition. Participants were matched for gender and age. All participants were native Chinese speakers. Recruitment announcements were made directly during these clinical visits, and no external advertisements or recruitment from other hospitals were conducted, limiting participation to children visiting Zhongshan Ophthalmic Center. For the children with strabismus, the inclusion criteria were as follows: (1) children aged between 4 to 10 years diagnosed with strabismus who had not yet undergone any strabismus-related surgeries; (2) manifest exotropia or esotropia with a horizontal angle of deviation of at least 15 prism diopters (PD); (3) both eyes measured monocularly LogMAR best-corrected visual acuity (VA) of ≤ 0.1; (4) ability to cooperate for cognitive function test. Exclusion criteria for this group included: (1) any concurrent vertical deviation such as oblique muscle dysfunction, dissociated vertical deviation, or manifest hypertropia; (2) intraocular diseases such as congenital cataract, glaucoma, retinal disease, and optic atrophy; (3) refractive errors exceeding 6 diopters; (4) amblyopia; (5) premature birth (< 32 weeks postmenstrual age); (6) underlying or associated neurologic, paralytic or anatomic disorders; and (7) systemic malformation or psychiatric disorders such as severe developmental delay with scores more than 2 standard deviations below those of normal children, anxiety, autism, and dyslexia. To ensure the appropriate cognitive assessment of the study population, developmental levels were screened before inclusion. Children were evaluated based on their age-proportionate developmental milestones during routine clinical assessments. Only children who demonstrated age-appropriate cognitive functioning were included in the study. For children aged 4 to 6, we acknowledged that conditions such as autism, dyslexia, and other psychiatric disorders may not yet have formal diagnoses. In such cases, children displaying symptoms suggestive of these conditions were also excluded from the study to minimize confounding effects. However, during the study, two children in the strabismus group were observed to score lower in cognitive assessments. These children were evaluated further but did not meet formal diagnostic criteria for developmental delay at the time of inclusion, which may account for their lower cognitive scores. The inclusion criteria for healthy controls were: (1) both eyes measured monocularly LogMAR best-corrected visual acuity (VA) of ≤ 0.1 and absence of any ocular diseases; and (2) no current psychiatric and developmental conditions. 2.3 Main Outcome Measure The Wechsler Intelligence Scale for Children is widely recognized as a primary tool for evaluating cognitive function due to its comprehensive coverage of multiple cognitive domains such as learning ability, language comprehension, memory, perception, and attentional focus. [ 18 ] It provides systematic and detailed information on various aspects of cognitive functioning in individuals. In our study, we utilized specific versions of the Wechsler scales based on the age of the participants. For preschool children aged 4 to 6.5 years, we administered the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-IV). [ 19 ] For children aged 6.6 to 10 years, we used the Wechsler Intelligence Scale for Children–Revised (WISC-IV-R). [ 20 ] These assessments yield a global cognitive score (GCS) that integrates performance across four main indices: the perceptual reasoning index (PRI), verbal comprehension index (VCI), working memory index (WMI), and processing speed index (PSI). Additionally, the General Ability Index (GAI), which combines VCI and PRI scores, and the Cognitive Efficiency Index (CEI), composed of WMI and PSI scores, provide further insights into cognitive abilities. To ensure consistency and accuracy in scoring, preliminary scores were converted to scale scores using the appropriate tables from WPPSI-IV [ 21 ] and WISC-IV-R (Chinese version) manuals. [ 22 ] 2.4 Demographic and Clinical Characteristics All data were collected from strabismus patients prior to any strabismus-related surgeries. We collected comprehensive demographic information, including age, gender, first language, parental educational levels, and residential location, to provide context for our analyses. Each participant underwent a thorough ophthalmic examination to assess various aspects of their visual health. This examination included: Best Corrected Visual Acuity: Subjects viewed one randomly selected Early Treatment Diabetic Retinopathy Study (ETDRS) visual chart. Spherical Equivalent: Determined through cycloplegic refraction in children to assess refractive error. Angle of Deviation: Assessed using the prism and alternate cover test at both distance (6m) and near (33cm). Binocular Visual Function: Worth’s 4-dot test: Used to evaluate sensory fusion at near and distance. A response of 4 dots indicates normal fusion, while other responses (2 or 3 dots for suppression, 5 dots for diplopia) indicate deviations from normal fusion. Stereoacuity: Assessed using the Random Dot Stereoacuity Test at near (40cm) (Vision Assessment Corporation, Elk Grove Village, IL, USA) and the Randot Stereoacuity Test at far distance (3m) (Stereo Optical Inc., Chicago, IL, USA). All children wore polarized glasses during the stereoacuity tests to ensure accurate depth perception measurement. Stereoacuity measures the ability to perceive depth and binocular vision. Participants with strabismus were categorized based on their stereopsis (presence or absence of depth perception) and fusion abilities (with and without). Additionally, we meticulously determined the duration of strabismus through repeated and detailed interviews with children with strabismus and their parents or guardians, ensuring accurate recording of this time-related data. Routine tests such as slit lamp and fundus examinations were also conducted to rule out any concurrent intraocular diseases. 2.5 Statistical Analysis Statistical analysis was conducted using SPSS software (version 25, SPSS Inc.). Continuous data were presented as mean with standard deviation (M[SD]) or median with interquartile range (M[IQR]), while categorical data were summarized as counts and percentages. The Shapiro-Wilk test and the normal probability plot were utilized to assess the normality of data distribution. Comparisons between patients and control groups for continuous variables utilized Mann–Whitney U tests and unpaired t-tests, and for categorical variables, Fisher's exact tests were used. Simple correlation and multiple regression analyses were conducted to determine the relationship between clinical factors and cognition. Significant factors ( p ≤ 0.05) identified in Spearman correlation analysis were included in a multivariate model with collinearity diagnostics. Results were reported as regression coefficients (β) with 95% confidence intervals (CIs), standard error (SE), adjusted R-squared (R²), and variance inflation factor (VIF). The adjusted R-squared indicates the proportion of variance in the dependent variable explained by the independent variables. A VIF value greater than 10 typically indicates high multicollinearity, potentially affecting the stability and interpretability of regression coefficients. Statistical significance was defined as a two-sided p -value ≤ 0.05. 3. Results 3.1 Demographic and Clinical Characteristics We enrolled 114 children diagnosed with strabismus and 87 age- and gender-matched normal control children in this study. All participants were born at full term without a history of oxygen supplementation or birth asphyxia. In the strabismus group, comprising 46 girls (40.4%) and 68 boys (59.6%), the mean age was 7.02 ± 1.88 years. Similarly, in the control group, which included 34 girls (39.1%) and 53 boys (60.9%), the mean age was 7.44 ± 1.81 years. There were no significant differences in gender ratio (ꭓ2 = 0.33, p = 0.86) or age (t=-1.60, p = 0.11) between the two groups. Compared to the control group, the strabismus group exhibited significantly poorer near (z=-7.88, p < 0.001) and distance stereoacuity (z=-12.22, p < 0.001), as well as impaired near (ꭓ2 = 54.78, p < 0.001) and distance fusion function (ꭓ 2 =106.07, p < 0.001) (Table 1 ). Table 1 Demographic Information and Cognitive Function Strabismus (n = 114) Control (n = 87) t/z/ꭓ 2 P Age(year) M ± SD 7.02 ± 1.88 7.44 ± 1.80 -1.60 0.11 a Female n (%) 46(40.4) 34(39.10) 0.033 0.86 b Onset age(year) M (QIR) 3 (2, 5) Duration(year) M (QIR) 3 (2, 5) d_deviation(PD) M ± SD 30 (25, 40) n_deviation(PD) M ± SD 35 (30, 42.5) Lg(d_stereo) M (QIR) 3.30 (2.60, 3.30) 1.78 (1.65, 1.78) -12.22 < 0.001 a ** Lg(n_stereo) M (QIR) 3.30 (2.60, 3.30) 1.84 (1.79, 2.02) -7.87 < 0.001 a ** d_ fusion n(%) fusion 29(25.4) 87(100) 112.40 < 0.001 b ** none fusion 85(74.6) 0(0) n_ fusion n(%) fusion 64(56.1) 87(100) 50.79 < 0.001 b * none fusion 54(43.9) 0(0) Cognitive score M ± SD GCS 99.79 ± 13.11 116.45 ± 15.28 -8.31 < 0.001 c *** GAI 102.09 ± 16.20 119.36 ± 15.96 -7.54 < 0.001 c *** CEI 93.75 ± 14.96 107.69 ± 15.95 --6.36 < 0.001 c *** VCI 100.92 ± 14.67 117.86 ± 15.97 -7.81 < 0.001 c *** PRI 103.68 ± 13.67 115.24 ± 12.39 -6.18 < 0.001 c *** PSI 92.82 ± 11.37 105.7 ± 17.42 -3.51 0.006 c ** WMI 97.92 ± 13.98 105.85 ± 19.54 -5.55 < 0.001 c *** Distribution of GCS Score Retarded n(%) < 70 2(1.0) 0(0) 50.64 < 0.001 b ** Borderline n(%) 70–79 5(2.5) 0(0) Subaverage n(%) 80–89 17(9.5) 2(2.3) Normal n(%) 90–109 64(45.3) 27(31.0) Bright n(%) 110–119 19(21.4) 24(27.6) Superior n(%) 120–129 1(9.0) 17(19.5) Very superior n(%) > 130 6(11.4) 17(19.5) The strabismus group exhibited poorer near and distance stereoacuity as well as fusion function compared to the control group. Despite this, cognitive levels in the strabismus group were significantly lower than those in the control group, indicating a notable disparity in cognitive proficiency between the two groups. M ± SD, mean ± standard deviation; d_deviation, distance angle of deviation; n_deviation, near deviation; Lg (n_stereo), the logarithm of the near stereoacuity value (in arc seconds); Lg (d_stereo), the logarithm of the near stereoacuity value (in arc seconds); d_fusion, distance fusion for Worth’s 4 dot test; n_fusion, near fusion for Worth’s 4 dot test. GCS, global cognitive score; GAI, general ability index; CEI, cognitive efficiency index; VCI, verbal comprehension index; WMI, working memory index; PSI, processing speed index; PRI, perceptual reasoning index. a, Mann–Whitney U test; b, Chi-Squared test or Fisher's exact test, c, independent t-test. * p < 0.05, ** p < 0.01, *** p < 0.001. 3.2 Comparison of Cognitive Function Between Children with Strabismus and Controls The GCS in the strabismus group was significantly lower compared to the control group (t=-8.31, p < 0.001). Following a previous study [ 16 ], we categorized the GCS into seven levels. Figure 1 A illustrates a significant difference in the distribution of GCS levels between the two groups (ꭓ 2 =50.64, p < 0.001), indicating a notably higher prevalence of impaired cognitive function in the strabismus group. Subsequent analysis of the subtest scores revealed that the strabismus group performed significantly poorer across various domains: VCI (t=-7.81, p < 0.001), PRI (t=-6.18, p < 0.001), WMI (t=-5.55, p < 0.001) and PSI values (t =-3.51, p = 0.006) (Table 1 , Fig. 1 B). 3.3 Correlation between Visual function and Global Cognitive Function in Children with Strabismus Patients with exotropia (n = 80) or esotropia (n = 34), as well as those with intermittent (n = 61) or constant strabismus (n = 53) demonstrated comparable cognitive performance (Fig. 2 A, B). Moreover, children with strabismus who demonstrated superior stereopsis and intact fusion abilities displayed enhanced cognitive function (Fig. 2 C, D, E, F). Spearman correlation analysis revealed negative associations between the GCS and both near fusion ability and duration of strabismus ( p < 0.05). The better (finer) the fusion ability, the better the GCS is. The longer the duration of strabismus, the poorer the GCS is. Additionally, we observed negative correlations of VCI and PRI values with both near and distance fusion functions ( p < 0.05). This suggests that abnormal binocular visual experiences (poorer fusion ability and stereopsis) are associated with impairments in children’s cognitive capabilities, particularly in verbal comprehension and visual perceptual reasoning domains. Notably, WMI and PSI values showed no significant correlations with visual parameters associated with strabismus, indicating that working memory and processing speed were not significantly associated with these visual function abnormalities (Table 2 ). Table 2 The Correlation Between Cognition and Clinical Factors in Children with Strabismus GCS GAI CEI VCI WMI PSI PRI age r -0.14 -0.08 -0.10 -0.03 -0.17 -0.06 -0.02 p 0.14 0.39 0.32 0.76 0.065 0.56 0.86 Onset age r 0.12 0.17 -0.05 0.17 -0.04 -0.02 0.23 p 0.19 0.06 0.59 0.07 0.70 0.82 0.02* duration time r -0.28 -0.28 -0.06 -0.24 -0.16 -0.03 -0.3 p 0.002** 0.003** 0.51 0.01* 0.093 0.80 0.002** n_deviation r -0.04 -0.03 0.09 -0.12 0.10 -0.01 -0.03 p 0.67 0.72 0.35 0.21 0.31 0.96 0.75 d_deviation r -0.10 -0.07 -0.06 -0.13 0.00 -0.11 -0.01 p 0.28 0.48 0.56 0.18 0.97 0.24 0.89 Strabismus Constancy (constant and intermittent) r -0.01 -0.05 0.01 -0.03 0.05 0.02 0.06 p 0.91 0.62 0.92 0.77 0.58 0.82 0.54 Strabismus Classification (esotropia and exotropia) r 0.00 0.00 0.07 -0.08 0.09 0.01 -0.09 p 0.99 0.99 0.48 0.39 0.33 0.95 0.37 n_ fusion r 0.25 0.28 0.12 0.28 0.09 0.04 0.26 p 0.008** 0.003** 0.21 0.002** 0.36 0.70 0.004** d_ fusion r 0.14 0.17 0.02 0.15 0.10 -0.03 0.21 p 0.15 0.08 0.81 0.11 0.32 0.78 0.02* Lg (n_ stereo) r -0.15 -0.17 -0.03 -0.23 0.03 -0.03 -0.22 p 0.10 0.06 0.76 0.01* 0.76 0.73 0.02* Lg (d_ stereo) r -0.09 -0.10 -0.04 -0.02 0.06 -0.07 -0.18 p 0.35 0.28 0.70 0.84 0.50 0.49 0.05* Spearman correlation. The correlation between cognitive scores and clinical factors such as the duration of strabismus, near fusion, distance fusion and near stereopsis was significant. GCS, global cognitive score; GAI, general ability index; CEI, cognitive efficiency index; VCI, verbal comprehension index; WMI, working memory index; PSI, processing speed index; PRI, perceptual reasoning index. Strabismus Classification, esotropia and exotropia; d_deviation, distance angle of deviation; n_deviation, near deviation; d_fusion, distance fusion for Worth’s 4 dot test; n_fusion, near fusion for Worth’s 4 dot test; Lg (n_stereo), the logarithm of the near stereoacuity value (in arc seconds); Lg (d_stereo), the logarithm of the near stereoacuity value (in arc seconds). * p < 0.05, ** p < 0.01, *** p < 0.001. A multivariate linear regression model, including variables identified through Spearman correlation ( p < 0.05), highlighted near fusion function as an independent predictor of the GCS ( p = 0.01), GAI ( p = 0.002), VCI ( p = 0.06) and PRI values ( p = 0.01) (Table 3 ). Table 3 Multivariate Linear Regression of Clinical Characteristics and Cognition Variables B S.E 95% CI t p VIF Adjusted R2 F GCS norm 100.61 2.79 95.08ཞ106.13 36.10 < 0.001 0.12 7.4 duration time -1.23 0.54 -0.206 -2.30ཞ-0.15 -2.27 0.03 1.04 n_ fusion 6.18 2.40 0.235 1.44ཞ10.93 2.58 0.01 1.04 GAI norm 100.61 3.43 93.82 ~ 107.40 29.363 < 0.001 0.13 8.1 duration time -1.11 0.67 -0.15 -2.43 ~ 0.21 -1.666 0.098 1.04 n_ fusion 9.53 2.94 0.29 3.70 ~ 15.36 3.236 0.002 1.04 VCI norm 110.67 7.12 96.55 ~ 124.78 15.54 < 0.001 0.14 6.06 duration time -1.23 0.60 -0.18 -2.42~-0.04 -2.04 0.04 1.05 n_ fusion 5.66 3.02 0.19 -0.33 ~ 11.65 1.87 0.06 1.35 Lg (n_ stereo) -3.23 2.04 -0.16 -7.28 ~ 0.82 -1.58 0.12 1.30 PRI norm 103.94 4.96 94.12 ~ 113.77 20.96 < 0.001 0.10 4.19 onset age -0.12 0.69 -0.02 -1.48 ~ 1.24 -0.18 0.86 1.91 duration time -1.06 0.76 -0.17 -2.57 ~ 0.46 -1.39 0.17 1.87 n_ fusion 6.91 2.56 0.25 1.82 ~ 11.99 2.69 0.01 1.07 GCS, global cognitive score; GAI, general ability index; CEI, cognitive efficiency index; VCI, verbal comprehension index; WMI, working memory index; PSI, processing speed index; PRI, perceptual reasoning index. Incorporate variables with p < 0.05 from the univariate linear regression model into the multivariate regression model, * p < 0.0 3.4 Correlation Between Duration of Strabismus and Global Cognitive Function in Children with Strabismus Age-adjusted standard scores were used to ensure comparability across different age groups and durations. Due to a relatively small sample size (11 cases) in the 7–9 years durations group, analysis focused on cases with strabismus durations ranging from 0.5 to 6 years (103 cases). Analysis of the GCS indicated a significant difference among these groups (F = 2.22, p = 0.047). Figure 3 A illustrates that increasing strabismus duration correlates with decreases in the GCS (r=-0.28, p = 0.002). Similarly, declines were observed in both VCI (r=-0.24, p = 0.01) and PRI values (r=-0.3, p = 0.002) (Fig. 3 B, 3 C). In contrast, working memory and processing speed exhibited relatively consistent cognitive performance across different strabismus durations. This suggests that prolonged periods of strabismus may be associated with cognitive development, particularly in domains related to verbal comprehension and visual perceptual reasoning. Discussion Our study found that children with strabismus exhibited lower global cognitive function compared to the controls across all age groups (4 to 10 years). These deficits were observed in verbal comprehension, processing speed, working memory and perceptual reasoning. Notably, cognitive performance declined with the increasing duration of strabismus. This suggests that strabismus may be associated with the development trajectory of cognitive function. In line with prior research, [ 16 ] we found that 14% of children with strabismus scored below the “normal” cognitive range, while 45% fell within the normal range. Cognitive scores, both globally and subscales were lower in children with strabismus compared to controls. This differs from Sun et al.’s findings, which reported lower PRI and higher PSI scores in children with exotropia. [ 17 ] We hypothesize that these discrepancies could be due to differences in the age and duration of strabismus in our cohort versus Sun et al.’s study. Moreover, we did not observe significant differences between exotropia and esotropia, or between intermittent and constant strabismus, contrary to Bagheri et al’s studies. [ 16 ] Bagheri et al. found that intermittent strabismus was linked to poorer cognitive performance compared to constant strabismus. The greater cognitive deficits in the esotropia group could be due to longer disease duration. These differences might stem from potential compensatory mechanisms at play, although the small sample size in the previous study limited the robustness of these conclusions. Our findings support that disruptions in visual input due to strabismus may be associated with delays in cognitive development. Specifically, poorer near stereopsis and fusion in strabismus were linked to lower cognitive scores. Clinical and animal studies consistently show that strabismus is linked to fewer binocular neurons in the visual cortex. This reduction leads to more monocular connections, disrupting normal binocular vision [ 23 ]. This misdirection in visual cortical development can cascade, disrupting various sensorimotor systems crucial for tasks reliant on vision, such as eye-hand coordination, environment navigation, and reading [ 24 ]. Prolonged strabismus can cause functional and structural changes in the visual system, potentially affecting neural and cognitive development, as studies link abnormal visual experiences with altered cerebral cortex function. [ 25 – 27 ] The correlation between longer strabismus duration and lower cognitive function emphasizes the importance of early intervention. Early intervention aims to minimize the duration of the condition and mitigate its adverse effects on cognitive development. An integrated approach to intervention can significantly promote the concurrent development of vision and cognition in children with strabismus, thereby better supporting their future learning and life outcomes. Aberrant visual perception in patients with strabismus may be associated with atypical cognitive development. Compared to those without strabismus, patients with strabismus consistently exhibit poorer visual perception [ 28 ]. A previous study highlighted decreased form constancy and figure-background perception abilities in children with strabismus, findings correlated with stereopsis [ 28 ]. In line with these findings, our study identified significant correlations among perceptual reasoning, stereoacuity, and fusion ability in children with strabismus. This suggests that disrupted visual perception and information processing associated with strabismus could potentially impede cognitive development. Perceptual deficits in these children may affect their ability to perceive object sizes and real-world scenes, which could impact cognitive processes such as motion perception and language comprehension. Recent research has suggested that perceptual training might alleviate clinical symptoms in post-operative strabismus patients [ 29 ]. presenting a promising approach alongside surgical correction to potentially reconfigure brain function and facilitate cognitive development. Further exploration and investigation of this approach are warranted. Recent research has uncovered central nervous system abnormalities in patients with strabismus, suggesting potential adverse effects on cognitive development. Evidence indicates in recent years, structural and functional aberrations in the cerebral cortex among individuals with strabismus. These abnormalities manifest in altered patterns of brain activity [ 30 ], changes in cortical thickness [ 31 ], and disrupted functional connectivity [ 32 ], which vary depending on the subtype and timing of strabismus onset. Specifically, heightened neural activity has been observed in the lingual gyrus within the visual cortex. This region plays a crucial role in processing pivotal visual attributes such as shape, size, color, contour, and object recognition, influencing visual judgment and attention [ 31 ]. Additionally, alterations have been reported in the frontal and supplementary eye fields, integral for saccadic eye movements as well as in midbrain regions and the cerebellum, impacting balance and postural control [ 33 ]. These findings indicate that beyond the primary visual cortex (V1), regions like the extrastriata cortex (V2-V3a) and the dorsal and ventral pathways are also implicated in functions crucial for memory, attention, and learning [ 34 ]. The brain processes retinal images following transmission of visual signals from the eyes [ 35 ], suggesting that strabismus may have abnormal higher-level information processing and potentially lead to cognitive development abnormalities. While the cognitive deficits observed in this study are significant, it is possible that these deficits are not directly caused by the strabismus itself. Instead, strabismus could serve as an outward manifestation of neurodevelopmental issues that affect both ocular alignment and cognitive function. This suggests that the cognitive challenges observed in children with strabismus might predate the onset of the ocular condition, possibly linked to early neurodevelopmental factors. Therefore, it is essential to consider that cognitive dysfunctions observed in children with strabismus may not necessarily be a consequence of misalignment but could be part of a broader neurodevelopmental context. This distinction is critical for understanding the multifaceted nature of the condition and for future studies aiming to clarify the relationship between strabismus and cognitive function. While our findings suggest that strabismus may be associated with children's cognitive development, our study faced several limitations. Firstly, participants were children with strabismus seeking surgical correction at our hospital, representing diverse regions across China. This made it challenging to recruit normal control children from various parts of the country. Second, because our study was preliminary, designed to introduce the concept that childhood strabismus may be associated with cognitive development, the sample size of the control group in our study was relatively small. Future studies on this topic should include a larger and more diverse sample to strengthen the robustness and reliability of the findings. Third, due to the cross-sectional nature of this study, we can only infer the relationship between variables without establishing causality. Therefore, the association between childhood strabismus and cognitive development should not be interpreted as a causal relationship. It is possible that childhood strabismus may indicate an underlying neurocognitive issue that contributes to the impaired cognitive function found in this study assessed with the Wechsler tests, rather than the findings of impaired cognitive function being a consequence of strabismus. Our study's results should be interpreted within the context of its limitations. Conclusion The current study found that children aged 4 to 10 years with strabismus exhibited inferior cognitive performance compared to their peers without strabismus. Moreover, a significant association was found between longer duration of strabismus and a decline in cognitive function, potentially impacting developmental trajectories. Future research should focus on establishing causality and exploring potential mechanisms underlying the relationship between strabismus and cognitive function, since cognitive development is integral to academic achievement and virtually all aspects of modern life. Abbreviations WPPSI-IV Wechsler Preschool and Primary Scale of Intelligence WISC-IV-R Wechsler Intelligence Scale for Children–Revised GCS Global cognitive score PRI Perceptual reasoning index VCI Verbal comprehension index WMI Working memory index PSI Processing speed index GAI General Ability Index CEI Cognitive Efficiency Index Declarations Ethics approval and consent to participate All data was collected as part of routine assessments at the first clinic consultation. Written consents to use the collected data for research purposes were obtained from parents. The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the Zhongshan Ophthalmic Center. Consent for publication Not applicable. Availability of data and materials No data are available. Competing interests The authors declare that they have no competing interests. Funding This study was supported by the National Natural Science Foundation of China (No. 82070995) and the Guangdong Provincial Natural Science Foundation of China(2022A1515012101). Authors' contributions Substantial contributions to the conception or design of the work: XY and YY. Contributions to the acquisition, analysis, or interpretation of data: XY, YY, JH, HC, SL, ST and HH. Drafting the work or critically revising it for important intellectual content: XY, SC, YY, and HJ. Final approval of the version published: XY, JY and WY. Acknowledgements The authors are grateful to all study participants. References Chia A, Roy L, Seenyen L. Comitant horizontal strabismus: an Asian perspective. Br J Ophthalmol. 2007;91(10):1337–40. Chen D, Li R, Li X, Huang D, Wang Y, Zhao X, et al. Prevalence, incidence and risk factors of strabismus in a Chinese population-based cohort of preschool children: the Nanjing Eye Study. Br J Ophthalmol. 2021;105(9):1203–10. Sprunger DT, Lambert SR, Hercinovic A, Morse CL, Repka MX, Hutchinson AK, et al. Esotropia and Exotropia Preferred Practice Pattern®. Ophthalmology. 2023;130(3):P179–221. Buffenn AN. The impact of strabismus on psychosocial heath and quality of life: a systematic review. Surv Ophthalmol. 2021;66(6):1051–64. Barack DL, Krakauer JW. Two views on the cognitive brain. Nat Rev Neurosci. 2021;22(6):359–71. Craik FIM, Bialystok E. Cognition through the lifespan: mechanisms of change. Trends Cogn Sci. 2006;10(3):131–8. Wilks T, Gerber RJ, Erdie-Lalena C. Developmental milestones: cognitive development. Pediatr Rev. 2010;31(9):364–7. Mather M. How Do Cognitively Stimulating Activities Affect Cognition and the Brain Throughout Life? Psychological Science in the Public Interest. J Am Psychol Soc. 2020;21(1):1–5. Kaul YF, Rosander K, von Hofsten C, Strand Brodd K, Holmström G, Hellström-Westas L. Visual tracking at 4 months in preterm infants predicts 6.5-year cognition and attention. Pediatr Res. 2022;92(4):1082–9. Barglow P, Sadow L. Visual perception: its development and maturation from birth to adulthood. J Am Psychoanal Assoc. 1971;19(3):433–50. Ghaderpanah M, Farrahi F, Khataminia G, Jahanbakhshi A, Rezaei L, Tashakori A, et al. Comparing Intelligence Quotient (IQ)among 3 to 7-year-old strabismic and nonstrabismic children in an Iranian population. Global J Health Sci. 2015;8(3):26–36. Bhaskaran S, Lawrence L, Flora J, Perumalsamy V. Functional and cognitive vision assessment in children with autism spectrum disorder. J AAPOS: official publication Am Association Pediatr Ophthalmol Strabismus. 2018;22(4):304–8. Kelly KR, Norouzi DM, Nouredanesh M, Jost RM, Cheng-Patel CS, Beauchamp CL, et al. Temporal Eye–Hand Coordination During Visually Guided Reaching in 7- to 12-Year-Old Children With Strabismus. Invest Opthalmology Visual Sci. 2022;63(12):10. Creavin AL, Lingam R, Steer C, Williams C. Ophthalmic abnormalities and reading impairment. Pediatrics. 2015;135(6):1057–65. Lee YH, Repka MX, Borlik MF, Velez FG, Perez C, Yu F, et al. Association of Strabismus With Mood Disorders, Schizophrenia, and Anxiety Disorders Among Children. JAMA Ophthalmol. 2022;140(4):373–81. Bagheri A, Fallahi MR, Tamannaifard S, Vajebmonfared S, Zonozian S. Intelligence Quotient (IQ) in Congenital Strabismus. J Ophthalmic Vis Res. 2013;8(2):139–46. Sun T, Wang Z, Shen T, Yan J, Xie C, Li X. Characterization of Intelligence in Children with Exotropia. Int J Environ Res Public Health. 2019;16(17):3008. Vohr BR, McGowan EC, Bann C, Das A, Higgins R, Hintz S, et al. Association of High Screen-Time Use With School-age Cognitive, Executive Function, and Behavior Outcomes in Extremely Preterm Children. JAMA Pediatr. 2021;175(10):1025–34. Wechsler D. Wechsler preschool and primary scale of intelligence—fourth edition. TX: The Psychological Corporation San Antonio; 2012. Wechsler D. Wechsler intelligence scale for children–Fifth Edition (WISC-V). Bloomington, MN: Pearson; 2014. Chen Y, Chen H, Wechsler D.). Taipei, Taiwan: Chinese Behavioral Science Corporation. 2013. Zhang H. The revision of WISC-IV Chinese version. Psychol Sci. 2009;32(5):1177–9. Kiorpes L, Kiper DC, O’Keefe LP, Cavanaugh JR, Movshon JA. Neuronal correlates of amblyopia in the visual cortex of macaque monkeys with experimental strabismus and anisometropia. J Neuroscience: Official J Soc Neurosci. 1998;18(16):6411–24. Birch EE, Kelly KR. Amblyopia and the whole child. Prog Retin Eye Res. 2023;93:101168. Castaldi E, Lunghi C, Morrone MC. Neuroplasticity in adult human visual cortex. Neurosci Biobehav Rev. 2020;112:542–52. Ionta S. Visual Neuropsychology in Development: Anatomo-Functional Brain Mechanisms of Action/Perception Binding in Health and Disease. Front Hum Neurosci. 2021;15:689912. Bui Quoc E, Milleret C. Origins of strabismus and loss of binocular vision. Front Integr Neurosci. 2014;8:71. Ibrahimi D, Mendiola-Santibañez JD, Gkaros AP. Analysis of the potential impact of strabismus with and without amblyopia on visual-perceptual and visual-motor skills evaluated using TVPS-3 and VMI-6 tests. J Optometry. 2021;14(2):166–75. Yang X, Fan Y, Chu H, Yan L, Wiederhold BK, Wiederhold M, et al. Preliminary Study of Short-Term Visual Perceptual Training Based on Virtual Reality and Augmented Reality in Postoperative Strabismic Patients. Cyberpsychol Behav Soc Netw. 2022;25(7):465–70. Min YL, Su T, Shu YQ, Liu WF, Chen LL, Shi WQ, et al. Altered spontaneous brain activity patterns in strabismus with amblyopia patients using amplitude of low-frequency fluctuation: a resting-state fMRI study. Neuropsych Dis Treat. 2018;14:2351–9. Huang X, Li HJ, Zhang Y, Peng DC, Hu PH, Zhong YL, et al. Microstructural changes of the whole brain in patients with comitant strabismus: evidence from a diffusion tensor imaging study. Neuropsych Dis Treat. 2016;12:2007–14. Yan X, Wang Y, Xu L, Liu Y, Song S, Ding K, et al. Altered Functional Connectivity of the Primary Visual Cortex in Adult Comitant Strabismus: A Resting-State Functional MRI Study. Curr Eye Res. 2019;44(3):316–23. Zipori AB, Colpa L, Wong AMF, Cushing SL, Gordon KA. Postural stability and visual impairment: Assessing balance in children with strabismus and amblyopia. PLoS ONE. 2018;13(10):e0205857. Joly O, Frankó E. Neuroimaging of amblyopia and binocular vision: a review. Front Integr Neurosci. 2014;8:62. Cavézian C, Vilayphonh M, Vasseur V, Caputo G, Laloum L, Chokron S. Ophthalmic disorder may affect visuo-attentional performance in childhood. Child Neuropsychology: J Normal Abnorm Dev Child Adolescence. 2013;19(3):292–312. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Minor revision 06 May, 2025 Reviewers agreed at journal 03 Feb, 2025 Reviewers invited by journal 18 Nov, 2024 Editor assigned by journal 14 Nov, 2024 First submitted to journal 12 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5444829","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":379629352,"identity":"2dc1b98a-83a5-4a76-ac7e-678db25d491f","order_by":0,"name":"Yan Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIiWNgGAWjYNCCiho7fhD9gIHBgEgtZ44lSzYwMDYkEK2FsYWZccMBYrUYHD97+DVvAxuz8fEe8wcJFTbGDOyHj27Aq+VMXpo17w4ZPrMzZwwbEs6kmTHwpKXdwKvlQI6ZMe8ZNmazGzmGDYlth20YJHjM8Gs5/waopY2ZcfMMorXcyDF+DNKyQQKixYygFskbb8wY5wADWeLMscIZQL8YsxHyC9/5HOMPb0BR2d684cOHChvDfvbDx/BqUTjAwCbFgyzChk85CMg3MDB//EFI1SgYBaNgFIxsAADCO08DAygKagAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0009-0000-5379-018X","institution":"Sun Yat-Sen University","correspondingAuthor":true,"prefix":"","firstName":"Yan","middleName":"","lastName":"Yang","suffix":""},{"id":379629353,"identity":"dc602652-0ee1-44e1-b465-232cd1b718fe","order_by":1,"name":"Jinen Hou","email":"","orcid":"","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":false,"prefix":"","firstName":"Jinen","middleName":"","lastName":"Hou","suffix":""},{"id":379629354,"identity":"ebeb3113-8e8c-4f51-81ab-fb0098853726","order_by":2,"name":"Hailu Huang","email":"","orcid":"","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":false,"prefix":"","firstName":"Hailu","middleName":"","lastName":"Huang","suffix":""},{"id":379629355,"identity":"e7e568b7-b5db-4023-aefe-0f2a796701b1","order_by":3,"name":"Siyu Tan","email":"","orcid":"","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":false,"prefix":"","firstName":"Siyu","middleName":"","lastName":"Tan","suffix":""},{"id":379629356,"identity":"2bda56b9-9c9d-41fc-a9b7-5e4a865eb89e","order_by":4,"name":"Hong Chen","email":"","orcid":"","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":false,"prefix":"","firstName":"Hong","middleName":"","lastName":"Chen","suffix":""},{"id":379629357,"identity":"68fcd636-7bde-47fe-94a0-6947af33ca9f","order_by":5,"name":"Shihui Ling","email":"","orcid":"","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":false,"prefix":"","firstName":"Shihui","middleName":"","lastName":"Ling","suffix":""},{"id":379629358,"identity":"360c4c1d-0add-42a5-96ea-a9ff0b657d0f","order_by":6,"name":"Wenhan Yang","email":"","orcid":"","institution":"Guangdong Pharmaceutical University","correspondingAuthor":false,"prefix":"","firstName":"Wenhan","middleName":"","lastName":"Yang","suffix":""},{"id":379629359,"identity":"1891aec9-5da7-41c8-ba3f-1c256d38f374","order_by":7,"name":"Shuai Chang","email":"","orcid":"","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":false,"prefix":"","firstName":"Shuai","middleName":"","lastName":"Chang","suffix":""},{"id":379629360,"identity":"0f737ed0-b7d5-4cc3-9007-e4b4f0c35ab8","order_by":8,"name":"Xin-Ping Yu","email":"","orcid":"","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":false,"prefix":"","firstName":"Xin-Ping","middleName":"","lastName":"Yu","suffix":""},{"id":379629361,"identity":"50890677-b2de-496a-99e8-3ebce5a21fc7","order_by":9,"name":"Jianhua Yan","email":"","orcid":"","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":false,"prefix":"","firstName":"Jianhua","middleName":"","lastName":"Yan","suffix":""}],"badges":[],"createdAt":"2024-11-13 07:42:01","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5444829/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5444829/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71809805,"identity":"7234d96c-3fd1-413f-91de-80e61fddadae","added_by":"auto","created_at":"2024-12-18 18:08:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":224012,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of Cognitive Function between children with Strabismus and Controls. \u003c/strong\u003e\u0026nbsp;Children with strabismus scored lower than controls on measures including the PRI, VCI, and PSI of the GCS. Approximately 14% of children with strabismus displayed cognitive levels below normal, while around 45% exhibited cognitive function within the normal range. These differences in score distribution between the two groups were statistically significant. GCS, global cognitive score; GAI, general ability index; CEI, cognitive efficiency index; VCI, verbal comprehension index; WMI, working memory index; PSI, processing speed index; PRI, perceptual reasoning index. The error bar stands for standard deviation. * \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05, ** \u003cem\u003ep\u003c/em\u003e\u0026lt; 0.01, *** \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-5444829/v1/254fd83c88c9c100ceab872b.png"},{"id":71809804,"identity":"b2bb99a4-62d8-4342-8a8f-f47959a0d227","added_by":"auto","created_at":"2024-12-18 18:08:54","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1543745,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCognitive Function Scores in Children with Strabismus.\u003c/strong\u003e There was no significant difference in cognitive scores between intermittent and constant strabismus groups, nor between esotropia and exotropia groups. However, children in the strabismus group lacking distance fusion or stereoacuity showed lower scores in multiple areas, including GCS, GAI, VCI, and PRI. Similarly, those without near stereoacuity or near fusion function within the strabismus group exhibited lower GCS, GAI, and PRI scores. GCS, global cognitive score; GAI, general ability index; CEI, cognitive efficiency Index; VCI, verbal comprehension index; WMI, working memory index; PSI, processing speed index; PRI, perceptual reasoning index. Independent t-test, error bar stands for standard deviation, * \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05, ** \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.01, *** \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-5444829/v1/2f13ce770c711ac13c692788.png"},{"id":71809803,"identity":"0ae0fa8d-6df3-4db4-83aa-c386cd31865a","added_by":"auto","created_at":"2024-12-18 18:08:54","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":282592,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eEffect of Duration of Strabismus on Cognitive Function\u003c/strong\u003e. Children with prolonged strabismus duration showed a notable decline in GCS, VCI and PRI scores. Specifically, there was a significant reduction in PRI scores when comparing children with 5 to 6 years of strabismus to those with 1 year. However, the duration of strabismus did not appear to have a significant impact on WMI and PSI. GCS, global cognitive score; VCI, verbal comprehension index; WMI, working memory index; PSI, processing speed index. PRI, perceptual reasoning index. one-way analysis of variance, error bar stands for standard deviation. * \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05, ** \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.01, *** \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-5444829/v1/72a8bf77d0dee4d7b815e9f2.png"},{"id":71809807,"identity":"22d7a48b-ae24-4618-9e5d-7cdf2da97b15","added_by":"auto","created_at":"2024-12-18 18:09:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2328840,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5444829/v1/2f89fd36-195b-47f2-80e7-075cf139d6b3.pdf"}],"financialInterests":"","formattedTitle":"Childhood Strabismus from A Different Perspective: Examining Its Association with Cognitive Development","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eStrabismus, affecting 3\u0026ndash;5% of children, [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] is one of the most prevalent childhood visual abnormalities. This condition leads to several clinical consequences, including amblyopia (\"lazy eye\"), impaired stereopsis (binocular depth perception), aberrant binocular interaction, diplopia (double vision), and potential psychological effects. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] These clinical manifestations suggest disruptions in both visual input and processing in strabismus. Cognition involves complex mental processes, including perception, attention, memory, reasoning, problem-solving, decision-making, language processing, and learning. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] These processes are fundamental to human intelligence, influencing how individuals perceive their environment, tackle challenges, make decisions, and adapt to new situations. Cognitive functions develop progressively and systematically throughout life stages, from infancy through adulthood. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Age 4 to 11 are considered critical for the development of children's cognitive functions, including logical thinking and overcoming egocentrism. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Cognitive development is influenced by biological maturation, environmental experiences, social interactions, and cultural contexts. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] The literatures suggests that normal visual experiences play a significant role in cognitive development, especially during early childhood. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAbnormal visual input and processing associated with strabismus possibly impact the cognition development in children [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] by disrupting spatial perception, potentially leading to developmental delays and academic, social, and emotional challenges. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Studies show that school-aged children with strabismus demonstrate lower reading proficiency and impaired academic and athletic achievements. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] There are moderate associations between strabismus severity and attention deficits, as well as learning disorders in children. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Bagheri et al. found that patients with congenital strabismus had lower cognitive scores compared to their peers. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] Sun et al. discovered that children with exotropia typically show lower perceptual reasoning index (PRI) scores but higher processing speed index (PSI) scores than children without strabismus, suggesting distinct cognitive profiles. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] In contrast, Ghaderpanah et al. found no significant negative impact of strabismus on the cognitive scores in preschool children aged 3\u0026ndash;7 years [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These mixed findings highlight the need for further investigation into the relationship between cognitive functions and visual impairments in children with strabismus.\u003c/p\u003e \u003cp\u003eIn this study, we enrolled patients with varying level of binocular visual function and different durations of strabismus. We compared these patients to a control group to investigate the relationship between strabismus-related visual abnormalities and cognitive development in children, aiming to identify key associated factors.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study Design\u003c/h2\u003e \u003cp\u003eA cross-sectional, case-control study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2Participants\u003c/h2\u003e \u003cp\u003eThe study included a total of 114 children diagnosed with strabismus and 87 typically developing children aged 4 to 10 years who were enrolled at Zhongshan Ophthalmic Center, Sun Yat-sen University, between January 2021 and December 2022. All participating children with strabismus were seeking surgical correction for their condition. Participants were matched for gender and age. All participants were native Chinese speakers. Recruitment announcements were made directly during these clinical visits, and no external advertisements or recruitment from other hospitals were conducted, limiting participation to children visiting Zhongshan Ophthalmic Center.\u003c/p\u003e \u003cp\u003eFor the children with strabismus, the inclusion criteria were as follows: (1) children aged between 4 to 10 years diagnosed with strabismus who had not yet undergone any strabismus-related surgeries; (2) manifest exotropia or esotropia with a horizontal angle of deviation of at least 15 prism diopters (PD); (3) both eyes measured monocularly LogMAR best-corrected visual acuity (VA) of \u0026le;\u0026thinsp;0.1; (4) ability to cooperate for cognitive function test. Exclusion criteria for this group included: (1) any concurrent vertical deviation such as oblique muscle dysfunction, dissociated vertical deviation, or manifest hypertropia; (2) intraocular diseases such as congenital cataract, glaucoma, retinal disease, and optic atrophy; (3) refractive errors exceeding 6 diopters; (4) amblyopia; (5) premature birth (\u0026lt;\u0026thinsp;32 weeks postmenstrual age); (6) underlying or associated neurologic, paralytic or anatomic disorders; and (7) systemic malformation or psychiatric disorders such as severe developmental delay with scores more than 2 standard deviations below those of normal children, anxiety, autism, and dyslexia. To ensure the appropriate cognitive assessment of the study population, developmental levels were screened before inclusion. Children were evaluated based on their age-proportionate developmental milestones during routine clinical assessments. Only children who demonstrated age-appropriate cognitive functioning were included in the study.\u003c/p\u003e \u003cp\u003eFor children aged 4 to 6, we acknowledged that conditions such as autism, dyslexia, and other psychiatric disorders may not yet have formal diagnoses. In such cases, children displaying symptoms suggestive of these conditions were also excluded from the study to minimize confounding effects. However, during the study, two children in the strabismus group were observed to score lower in cognitive assessments. These children were evaluated further but did not meet formal diagnostic criteria for developmental delay at the time of inclusion, which may account for their lower cognitive scores.\u003c/p\u003e \u003cp\u003eThe inclusion criteria for healthy controls were: (1) both eyes measured monocularly LogMAR best-corrected visual acuity (VA) of \u0026le;\u0026thinsp;0.1 and absence of any ocular diseases; and (2) no current psychiatric and developmental conditions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Main Outcome Measure\u003c/h2\u003e \u003cp\u003eThe Wechsler Intelligence Scale for Children is widely recognized as a primary tool for evaluating cognitive function due to its comprehensive coverage of multiple cognitive domains such as learning ability, language comprehension, memory, perception, and attentional focus. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] It provides systematic and detailed information on various aspects of cognitive functioning in individuals.\u003c/p\u003e \u003cp\u003eIn our study, we utilized specific versions of the Wechsler scales based on the age of the participants. For preschool children aged 4 to 6.5 years, we administered the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-IV). [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] For children aged 6.6 to 10 years, we used the Wechsler Intelligence Scale for Children\u0026ndash;Revised (WISC-IV-R). [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] These assessments yield a global cognitive score (GCS) that integrates performance across four main indices: the perceptual reasoning index (PRI), verbal comprehension index (VCI), working memory index (WMI), and processing speed index (PSI). Additionally, the General Ability Index (GAI), which combines VCI and PRI scores, and the Cognitive Efficiency Index (CEI), composed of WMI and PSI scores, provide further insights into cognitive abilities.\u003c/p\u003e \u003cp\u003eTo ensure consistency and accuracy in scoring, preliminary scores were converted to scale scores using the appropriate tables from WPPSI-IV [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and WISC-IV-R (Chinese version) manuals. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Demographic and Clinical Characteristics\u003c/h2\u003e \u003cp\u003eAll data were collected from strabismus patients prior to any strabismus-related surgeries. We collected comprehensive demographic information, including age, gender, first language, parental educational levels, and residential location, to provide context for our analyses.\u003c/p\u003e \u003cp\u003eEach participant underwent a thorough ophthalmic examination to assess various aspects of their visual health. This examination included:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eBest Corrected Visual Acuity: Subjects viewed one randomly selected Early Treatment Diabetic Retinopathy Study (ETDRS) visual chart.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSpherical Equivalent: Determined through cycloplegic refraction in children to assess refractive error.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAngle of Deviation: Assessed using the prism and alternate cover test at both distance (6m) and near (33cm).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eBinocular Visual Function:\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eWorth\u0026rsquo;s 4-dot test: Used to evaluate sensory fusion at near and distance. A response of 4 dots indicates normal fusion, while other responses (2 or 3 dots for suppression, 5 dots for diplopia) indicate deviations from normal fusion.\u003c/p\u003e \u003cp\u003eStereoacuity: Assessed using the Random Dot Stereoacuity Test at near (40cm) (Vision Assessment Corporation, Elk Grove Village, IL, USA) and the Randot Stereoacuity Test at far distance (3m) (Stereo Optical Inc., Chicago, IL, USA). All children wore polarized glasses during the stereoacuity tests to ensure accurate depth perception measurement. Stereoacuity measures the ability to perceive depth and binocular vision.\u003c/p\u003e \u003cp\u003eParticipants with strabismus were categorized based on their stereopsis (presence or absence of depth perception) and fusion abilities (with and without).\u003c/p\u003e \u003cp\u003eAdditionally, we meticulously determined the duration of strabismus through repeated and detailed interviews with children with strabismus and their parents or guardians, ensuring accurate recording of this time-related data.\u003c/p\u003e \u003cp\u003eRoutine tests such as slit lamp and fundus examinations were also conducted to rule out any concurrent intraocular diseases.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Statistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was conducted using SPSS software (version 25, SPSS Inc.). Continuous data were presented as mean with standard deviation (M[SD]) or median with interquartile range (M[IQR]), while categorical data were summarized as counts and percentages. The Shapiro-Wilk test and the normal probability plot were utilized to assess the normality of data distribution.\u003c/p\u003e \u003cp\u003eComparisons between patients and control groups for continuous variables utilized Mann\u0026ndash;Whitney U tests and unpaired t-tests, and for categorical variables, Fisher's exact tests were used. Simple correlation and multiple regression analyses were conducted to determine the relationship between clinical factors and cognition.\u003c/p\u003e \u003cp\u003eSignificant factors (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026le;\u0026thinsp;0.05) identified in Spearman correlation analysis were included in a multivariate model with collinearity diagnostics. Results were reported as regression coefficients (β) with 95% confidence intervals (CIs), standard error (SE), adjusted R-squared (R\u0026sup2;), and variance inflation factor (VIF).\u003c/p\u003e \u003cp\u003eThe adjusted R-squared indicates the proportion of variance in the dependent variable explained by the independent variables. A VIF value greater than 10 typically indicates high multicollinearity, potentially affecting the stability and interpretability of regression coefficients.\u003c/p\u003e \u003cp\u003eStatistical significance was defined as a two-sided \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026le;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Demographic and Clinical Characteristics\u003c/h2\u003e \u003cp\u003eWe enrolled 114 children diagnosed with strabismus and 87 age- and gender-matched normal control children in this study. All participants were born at full term without a history of oxygen supplementation or birth asphyxia. In the strabismus group, comprising 46 girls (40.4%) and 68 boys (59.6%), the mean age was 7.02\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88 years. Similarly, in the control group, which included 34 girls (39.1%) and 53 boys (60.9%), the mean age was 7.44\u0026thinsp;\u0026plusmn;\u0026thinsp;1.81 years. There were no significant differences in gender ratio (ꭓ2\u0026thinsp;=\u0026thinsp;0.33, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.86) or age (t=-1.60, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.11) between the two groups.\u003c/p\u003e \u003cp\u003eCompared to the control group, the strabismus group exhibited significantly poorer near (z=-7.88, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and distance stereoacuity (z=-12.22, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), as well as impaired near (ꭓ2\u0026thinsp;=\u0026thinsp;54.78, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and distance fusion function (ꭓ\u003csup\u003e2\u003c/sup\u003e=106.07, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Information and Cognitive Function\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrabismus (n\u0026thinsp;=\u0026thinsp;114)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl (n\u0026thinsp;=\u0026thinsp;87)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003et/z/ꭓ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge(year)\u003c/b\u003e M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.02\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.44\u0026thinsp;\u0026plusmn;\u0026thinsp;1.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.11\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemale n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46(40.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34(39.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.033\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.86\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOnset age(year)\u003c/b\u003e M (QIR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration(year)\u003c/b\u003e M (QIR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2, 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ed_deviation(PD)\u003c/b\u003e M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (25, 40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003en_deviation(PD)\u003c/b\u003e M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (30, 42.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLg(d_stereo)\u003c/b\u003e M (QIR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.30 (2.60, 3.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.78 (1.65, 1.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-12.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLg(n_stereo)\u003c/b\u003e M (QIR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.30 (2.60, 3.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.84 (1.79, 2.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-7.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ed_ fusion n(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29(25.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e112.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enone fusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85(74.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003en_ fusion n(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64(56.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enone fusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54(43.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCognitive score\u003c/b\u003e M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99.79\u0026thinsp;\u0026plusmn;\u0026thinsp;13.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e116.45\u0026thinsp;\u0026plusmn;\u0026thinsp;15.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-8.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ec\u003c/sup\u003e***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGAI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102.09\u0026thinsp;\u0026plusmn;\u0026thinsp;16.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e119.36\u0026thinsp;\u0026plusmn;\u0026thinsp;15.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-7.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ec\u003c/sup\u003e***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCEI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93.75\u0026thinsp;\u0026plusmn;\u0026thinsp;14.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e107.69\u0026thinsp;\u0026plusmn;\u0026thinsp;15.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--6.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ec\u003c/sup\u003e***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVCI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.92\u0026thinsp;\u0026plusmn;\u0026thinsp;14.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e117.86\u0026thinsp;\u0026plusmn;\u0026thinsp;15.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-7.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ec\u003c/sup\u003e***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e103.68\u0026thinsp;\u0026plusmn;\u0026thinsp;13.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e115.24\u0026thinsp;\u0026plusmn;\u0026thinsp;12.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-6.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ec\u003c/sup\u003e***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePSI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92.82\u0026thinsp;\u0026plusmn;\u0026thinsp;11.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e105.7\u0026thinsp;\u0026plusmn;\u0026thinsp;17.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-3.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.006\u003csup\u003ec\u003c/sup\u003e**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97.92\u0026thinsp;\u0026plusmn;\u0026thinsp;13.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e105.85\u0026thinsp;\u0026plusmn;\u0026thinsp;19.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-5.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ec\u003c/sup\u003e***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDistribution of GCS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetarded n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003eb\u003c/sup\u003e**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorderline n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70\u0026ndash;79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubaverage n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80\u0026ndash;89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17(9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90\u0026ndash;109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64(45.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27(31.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBright n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110\u0026ndash;119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19(21.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24(27.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuperior n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u0026ndash;129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(9.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17(19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery superior n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17(19.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eThe strabismus group exhibited poorer near and distance stereoacuity as well as fusion function compared to the control group. Despite this, cognitive levels in the strabismus group were significantly lower than those in the control group, indicating a notable disparity in cognitive proficiency between the two groups. M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation; d_deviation, distance angle of deviation; n_deviation, near deviation; Lg (n_stereo), the logarithm of the near stereoacuity value (in arc seconds); Lg (d_stereo), the logarithm of the near stereoacuity value (in arc seconds); d_fusion, distance fusion for Worth\u0026rsquo;s 4 dot test; n_fusion, near fusion for Worth\u0026rsquo;s 4 dot test. GCS, global cognitive score; GAI, general ability index; CEI, cognitive efficiency index; VCI, verbal comprehension index; WMI, working memory index; PSI, processing speed index; PRI, perceptual reasoning index. a, Mann\u0026ndash;Whitney U test; b, Chi-Squared test or Fisher's exact test, c, independent t-test. * \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05, ** \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01, *** \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Comparison of Cognitive Function Between Children with Strabismus and Controls\u003c/h2\u003e \u003cp\u003eThe GCS in the strabismus group was significantly lower compared to the control group (t=-8.31, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Following a previous study [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], we categorized the GCS into seven levels. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA illustrates a significant difference in the distribution of GCS levels between the two groups (ꭓ\u003csup\u003e2\u003c/sup\u003e=50.64, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating a notably higher prevalence of impaired cognitive function in the strabismus group. Subsequent analysis of the subtest scores revealed that the strabismus group performed significantly poorer across various domains: VCI (t=-7.81, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), PRI (t=-6.18, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), WMI (t=-5.55, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and PSI values (t =-3.51, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Correlation between Visual function and Global Cognitive Function in Children with Strabismus\u003c/h2\u003e \u003cp\u003ePatients with exotropia (n\u0026thinsp;=\u0026thinsp;80) or esotropia (n\u0026thinsp;=\u0026thinsp;34), as well as those with intermittent (n\u0026thinsp;=\u0026thinsp;61) or constant strabismus (n\u0026thinsp;=\u0026thinsp;53) demonstrated comparable cognitive performance (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, B). Moreover, children with strabismus who demonstrated superior stereopsis and intact fusion abilities displayed enhanced cognitive function (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC, D, E, F). Spearman correlation analysis revealed negative associations between the GCS and both near fusion ability and duration of strabismus (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The better (finer) the fusion ability, the better the GCS is. The longer the duration of strabismus, the poorer the GCS is. Additionally, we observed negative correlations of VCI and PRI values with both near and distance fusion functions (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This suggests that abnormal binocular visual experiences (poorer fusion ability and stereopsis) are associated with impairments in children\u0026rsquo;s cognitive capabilities, particularly in verbal comprehension and visual perceptual reasoning domains. Notably, WMI and PSI values showed no significant correlations with visual parameters associated with strabismus, indicating that working memory and processing speed were not significantly associated with these visual function abnormalities (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe Correlation Between Cognition and Clinical Factors in Children with Strabismus\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGCS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGAI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCEI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eVCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWMI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePSI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePRI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.065\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnset age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.02*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eduration time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.002**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.003**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.01*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.002**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003en_deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ed_deviation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStrabismus Constancy\u003c/p\u003e \u003cp\u003e(constant and intermittent)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStrabismus Classification\u003c/p\u003e \u003cp\u003e(esotropia and exotropia)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003en_ fusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.008**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.003**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.002**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.004**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ed_ fusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.02*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLg (n_ stereo)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.01*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.02*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLg (d_ stereo)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.05*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003eSpearman correlation. The correlation between cognitive scores and clinical factors such as the duration of strabismus, near fusion, distance fusion and near stereopsis was significant. GCS, global cognitive score; GAI, general ability index; CEI, cognitive efficiency index; VCI, verbal comprehension index; WMI, working memory index; PSI, processing speed index; PRI, perceptual reasoning index. Strabismus Classification, esotropia and exotropia; d_deviation, distance angle of deviation; n_deviation, near deviation; d_fusion, distance fusion for Worth\u0026rsquo;s 4 dot test; n_fusion, near fusion for Worth\u0026rsquo;s 4 dot test; Lg (n_stereo), the logarithm of the near stereoacuity value (in arc seconds); Lg (d_stereo), the logarithm of the near stereoacuity value (in arc seconds). * p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, ** p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, *** p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA multivariate linear regression model, including variables identified through Spearman correlation (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), highlighted near fusion function as an independent predictor of the GCS (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01), GAI (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), VCI (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.06) and PRI values (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eMultivariate Linear Regression of Clinical Characteristics and Cognition\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eS.E\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eVIF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eAdjusted R2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGCS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003enorm\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95.08ཞ106.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e36.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e7.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eduration time\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.30ཞ-0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-2.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en_ fusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.235\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.44ཞ10.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGAI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003enorm\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e93.82\u0026thinsp;~\u0026thinsp;107.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e29.363\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e8.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eduration time\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.43\u0026thinsp;~\u0026thinsp;0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-1.666\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en_ fusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.70\u0026thinsp;~\u0026thinsp;15.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVCI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003enorm\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e110.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e96.55\u0026thinsp;~\u0026thinsp;124.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e6.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eduration time\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.42~-0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-2.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en_ fusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.33\u0026thinsp;~\u0026thinsp;11.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLg (n_ stereo)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-3.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-7.28\u0026thinsp;~\u0026thinsp;0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-1.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePRI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003enorm\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e103.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e94.12\u0026thinsp;~\u0026thinsp;113.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e4.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eonset age\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-1.48\u0026thinsp;~\u0026thinsp;1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eduration time\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.57\u0026thinsp;~\u0026thinsp;0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-1.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en_ fusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.82\u0026thinsp;~\u0026thinsp;11.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003eGCS, global cognitive score; GAI, general ability index; CEI, cognitive efficiency index; VCI, verbal comprehension index; WMI, working memory index; PSI, processing speed index; PRI, perceptual reasoning index. Incorporate variables with p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 from the univariate linear regression model into the multivariate regression model, * p\u0026thinsp;\u0026lt;\u0026thinsp;0.0\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Correlation Between Duration of Strabismus and Global Cognitive Function in Children with Strabismus\u003c/h2\u003e \u003cp\u003eAge-adjusted standard scores were used to ensure comparability across different age groups and durations. Due to a relatively small sample size (11 cases) in the 7\u0026ndash;9 years durations group, analysis focused on cases with strabismus durations ranging from 0.5 to 6 years (103 cases). Analysis of the GCS indicated a significant difference among these groups (F\u0026thinsp;=\u0026thinsp;2.22, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.047). Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA illustrates that increasing strabismus duration correlates with decreases in the GCS (r=-0.28, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). Similarly, declines were observed in both VCI (r=-0.24, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01) and PRI values (r=-0.3, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC). In contrast, working memory and processing speed exhibited relatively consistent cognitive performance across different strabismus durations. This suggests that prolonged periods of strabismus may be associated with cognitive development, particularly in domains related to verbal comprehension and visual perceptual reasoning.\u003c/p\u003e "},{"header":"Discussion","content":" \u003cp\u003eOur study found that children with strabismus exhibited lower global cognitive function compared to the controls across all age groups (4 to 10 years). These deficits were observed in verbal comprehension, processing speed, working memory and perceptual reasoning. Notably, cognitive performance declined with the increasing duration of strabismus. This suggests that strabismus may be associated with the development trajectory of cognitive function.\u003c/p\u003e \u003cp\u003eIn line with prior research, [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] we found that 14% of children with strabismus scored below the \u0026ldquo;normal\u0026rdquo; cognitive range, while 45% fell within the normal range. Cognitive scores, both globally and subscales were lower in children with strabismus compared to controls. This differs from Sun et al.\u0026rsquo;s findings, which reported lower PRI and higher PSI scores in children with exotropia. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] We hypothesize that these discrepancies could be due to differences in the age and duration of strabismus in our cohort versus Sun et al.\u0026rsquo;s study.\u003c/p\u003e \u003cp\u003eMoreover, we did not observe significant differences between exotropia and esotropia, or between intermittent and constant strabismus, contrary to Bagheri et al\u0026rsquo;s studies. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] Bagheri et al. found that intermittent strabismus was linked to poorer cognitive performance compared to constant strabismus. The greater cognitive deficits in the esotropia group could be due to longer disease duration. These differences might stem from potential compensatory mechanisms at play, although the small sample size in the previous study limited the robustness of these conclusions.\u003c/p\u003e \u003cp\u003eOur findings support that disruptions in visual input due to strabismus may be associated with delays in cognitive development. Specifically, poorer near stereopsis and fusion in strabismus were linked to lower cognitive scores. Clinical and animal studies consistently show that strabismus is linked to fewer binocular neurons in the visual cortex. This reduction leads to more monocular connections, disrupting normal binocular vision [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This misdirection in visual cortical development can cascade, disrupting various sensorimotor systems crucial for tasks reliant on vision, such as eye-hand coordination, environment navigation, and reading [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eProlonged strabismus can cause functional and structural changes in the visual system, potentially affecting neural and cognitive development, as studies link abnormal visual experiences with altered cerebral cortex function. [\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] The correlation between longer strabismus duration and lower cognitive function emphasizes the importance of early intervention. Early intervention aims to minimize the duration of the condition and mitigate its adverse effects on cognitive development. An integrated approach to intervention can significantly promote the concurrent development of vision and cognition in children with strabismus, thereby better supporting their future learning and life outcomes.\u003c/p\u003e \u003cp\u003eAberrant visual perception in patients with strabismus may be associated with atypical cognitive development. Compared to those without strabismus, patients with strabismus consistently exhibit poorer visual perception [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. A previous study highlighted decreased form constancy and figure-background perception abilities in children with strabismus, findings correlated with stereopsis [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn line with these findings, our study identified significant correlations among perceptual reasoning, stereoacuity, and fusion ability in children with strabismus. This suggests that disrupted visual perception and information processing associated with strabismus could potentially impede cognitive development. Perceptual deficits in these children may affect their ability to perceive object sizes and real-world scenes, which could impact cognitive processes such as motion perception and language comprehension. Recent research has suggested that perceptual training might alleviate clinical symptoms in post-operative strabismus patients [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. presenting a promising approach alongside surgical correction to potentially reconfigure brain function and facilitate cognitive development. Further exploration and investigation of this approach are warranted.\u003c/p\u003e \u003cp\u003eRecent research has uncovered central nervous system abnormalities in patients with strabismus, suggesting potential adverse effects on cognitive development. Evidence indicates in recent years, structural and functional aberrations in the cerebral cortex among individuals with strabismus. These abnormalities manifest in altered patterns of brain activity [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], changes in cortical thickness [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], and disrupted functional connectivity [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], which vary depending on the subtype and timing of strabismus onset. Specifically, heightened neural activity has been observed in the lingual gyrus within the visual cortex. This region plays a crucial role in processing pivotal visual attributes such as shape, size, color, contour, and object recognition, influencing visual judgment and attention [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Additionally, alterations have been reported in the frontal and supplementary eye fields, integral for saccadic eye movements as well as in midbrain regions and the cerebellum, impacting balance and postural control [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. These findings indicate that beyond the primary visual cortex (V1), regions like the extrastriata cortex (V2-V3a) and the dorsal and ventral pathways are also implicated in functions crucial for memory, attention, and learning [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The brain processes retinal images following transmission of visual signals from the eyes [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], suggesting that strabismus may have abnormal higher-level information processing and potentially lead to cognitive development abnormalities.\u003c/p\u003e \u003cp\u003eWhile the cognitive deficits observed in this study are significant, it is possible that these deficits are not directly caused by the strabismus itself. Instead, strabismus could serve as an outward manifestation of neurodevelopmental issues that affect both ocular alignment and cognitive function. This suggests that the cognitive challenges observed in children with strabismus might predate the onset of the ocular condition, possibly linked to early neurodevelopmental factors. Therefore, it is essential to consider that cognitive dysfunctions observed in children with strabismus may not necessarily be a consequence of misalignment but could be part of a broader neurodevelopmental context. This distinction is critical for understanding the multifaceted nature of the condition and for future studies aiming to clarify the relationship between strabismus and cognitive function.\u003c/p\u003e \u003cp\u003eWhile our findings suggest that strabismus may be associated with children's cognitive development, our study faced several limitations. Firstly, participants were children with strabismus seeking surgical correction at our hospital, representing diverse regions across China. This made it challenging to recruit normal control children from various parts of the country. Second, because our study was preliminary, designed to introduce the concept that childhood strabismus may be associated with cognitive development, the sample size of the control group in our study was relatively small. Future studies on this topic should include a larger and more diverse sample to strengthen the robustness and reliability of the findings. Third, due to the cross-sectional nature of this study, we can only infer the relationship between variables without establishing causality. Therefore, the association between childhood strabismus and cognitive development should not be interpreted as a causal relationship. It is possible that childhood strabismus may indicate an underlying neurocognitive issue that contributes to the impaired cognitive function found in this study assessed with the Wechsler tests, rather than the findings of impaired cognitive function being a consequence of strabismus. Our study's results should be interpreted within the context of its limitations.\u003c/p\u003e "},{"header":"Conclusion","content":"\u003cp\u003eThe current study found that children aged 4 to 10 years with strabismus exhibited inferior cognitive performance compared to their peers without strabismus. Moreover, a significant association was found between longer duration of strabismus and a decline in cognitive function, potentially impacting developmental trajectories. Future research should focus on establishing causality and exploring potential mechanisms underlying the relationship between strabismus and cognitive function, since cognitive development is integral to academic achievement and virtually all aspects of modern life.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eWPPSI-IV Wechsler Preschool and Primary Scale of Intelligence\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWISC-IV-R Wechsler Intelligence Scale for Children\u0026ndash;Revised\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGCS Global cognitive score\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePRI Perceptual reasoning index\u003c/p\u003e\n\u003cp\u003eVCI Verbal comprehension index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWMI Working memory index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePSI Processing speed index\u003c/p\u003e\n\u003cp\u003eGAI General Ability Index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCEI Cognitive Efficiency Index\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data was collected as part of routine assessments at the first clinic consultation. Written consents to use the collected data for research purposes were obtained from parents. The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the Zhongshan Ophthalmic Center.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo data are available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the National Natural Science Foundation of China (No. 82070995) and the Guangdong Provincial Natural Science Foundation of China(2022A1515012101).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSubstantial contributions to the conception or design of the work: XY and YY. Contributions to the acquisition, analysis, or interpretation of data: XY, YY, JH, HC, SL, ST and HH. Drafting the work or critically revising it for important intellectual content: XY, SC, YY, and HJ. Final approval of the version published: XY, JY and WY.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are grateful to all study participants.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eChia A, Roy L, Seenyen L. Comitant horizontal strabismus: an Asian perspective. Br J Ophthalmol. 2007;91(10):1337\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen D, Li R, Li X, Huang D, Wang Y, Zhao X, et al. Prevalence, incidence and risk factors of strabismus in a Chinese population-based cohort of preschool children: the Nanjing Eye Study. 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Altered spontaneous brain activity patterns in strabismus with amblyopia patients using amplitude of low-frequency fluctuation: a resting-state fMRI study. Neuropsych Dis Treat. 2018;14:2351\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang X, Li HJ, Zhang Y, Peng DC, Hu PH, Zhong YL, et al. Microstructural changes of the whole brain in patients with comitant strabismus: evidence from a diffusion tensor imaging study. Neuropsych Dis Treat. 2016;12:2007\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYan X, Wang Y, Xu L, Liu Y, Song S, Ding K, et al. Altered Functional Connectivity of the Primary Visual Cortex in Adult Comitant Strabismus: A Resting-State Functional MRI Study. Curr Eye Res. 2019;44(3):316\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZipori AB, Colpa L, Wong AMF, Cushing SL, Gordon KA. Postural stability and visual impairment: Assessing balance in children with strabismus and amblyopia. PLoS ONE. 2018;13(10):e0205857.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoly O, Frank\u0026oacute; E. Neuroimaging of amblyopia and binocular vision: a review. Front Integr Neurosci. 2014;8:62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCav\u0026eacute;zian C, Vilayphonh M, Vasseur V, Caputo G, Laloum L, Chokron S. Ophthalmic disorder may affect visuo-attentional performance in childhood. Child Neuropsychology: J Normal Abnorm Dev Child Adolescence. 2013;19(3):292\u0026ndash;312.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"italian-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"itjp","sideBox":"Learn more about [Italian Journal of Pediatrics](http://ijponline.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ITJP/default.aspx","title":"Italian Journal of Pediatrics","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Strabismus, Children, Cognitive development, Binocular Vision","lastPublishedDoi":"10.21203/rs.3.rs-5444829/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5444829/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Previous studies have shown that abnormal visual input and processing possibly impact the cognition development in children. We aimed to investigate the relationship between abnormal visual function associated with strabismus and cognition development in children.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eConducted at Zhongshan Ophthalmic Center, this cross-sectional case-control study involved 201 children aged 4-10 years, including 114 with strabismus and 87 matched controls, between January 2021 and December 2022. Cognitive functions were evaluated using the Wechsler Intelligence Scale for Children—Fourth Edition (WISC-IV) and the Wechsler Preschool and Primary Scale of Intelligence—Fourth Edition (WPPSI-IVR), focusing on the global cognitive score (GCS), verbal comprehension index (VCI), perceptual reasoning index (PRI), working memory index (WMI), and processing speed index (PSI).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eChildren with strabismus showed significantly lower scores in GCS (t=-8.31, p\u0026lt;0.001), VCI (t=-7.81, p\u0026lt;0.001), PRI (t=-6.18, p\u0026lt;0.001), WMI (t=-5.55, p\u0026lt;0.001), and PSI (t=-3.51, p=0.006) compared to controls. The type of strabismus (esotropia or exotropia, intermittent of constant tropia) did not show a significant association with cognitive performance (p\u0026gt;0.05). Spearman’s correlation and multivariate linear regression analyses identified that better fusion ability (p=0.01) and a shorter duration of strabismus (p=0.002) were associated with higher cognitive function.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe findings reveal a significant decline in cognitive performance among children with strabismus compared to their non-strabismic peers, regardless of the type of strabismus. The duration of strabismus and impaired near fusion function are associated with cognitive development levels, highlighting the importance of early detection and potential interventions to support better cognitive outcomes.\u003c/p\u003e","manuscriptTitle":"Childhood Strabismus from A Different Perspective: Examining Its Association with Cognitive Development","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-18 18:08:48","doi":"10.21203/rs.3.rs-5444829/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2025-05-06T04:48:59+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-02-03T18:29:10+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-18T18:11:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-14T05:24:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"Italian Journal of Pediatrics","date":"2024-11-13T02:40:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"italian-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"itjp","sideBox":"Learn more about [Italian Journal of Pediatrics](http://ijponline.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ITJP/default.aspx","title":"Italian Journal of Pediatrics","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ca820225-5a02-494f-841e-bcfaaa9e2da7","owner":[],"postedDate":"December 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-11T08:28:52+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-18 18:08:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5444829","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5444829","identity":"rs-5444829","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}