The authors aimed to evaluate the incidence of strabismus in children initially diagnosed with pseudostrabismus and identify risk factors for development of strabismus. This was a retrospective review of 65 patients with a diagnosis of pseudostrabismus; two exo and 63 eso appearance. Mean age at initial examination was 29.26±26.68 months; 40% were female. Mean follow-up was 25.2±23.28 months; 7.6% had a family history of strabismus and 9.2% had a history of prematurity; 53.8% had epicanthus, 26.2% with a flat broad nasal bridge, 1.5% with blepharophimosis syndrome, 1.5% with hypertelorism and 1.5% with telecanthus. Average retinoscopy was +1.39±1.37D for the right eye and +1.43±1.43D for the left eye. True strabismus was detected in 12% (eight cases) at an average 12.63±6.35 months. The mean angle was 21.5±10.5PD. Seven were esotropia and one case of exotropia. Refraction was not found to be a risk factor for development of strabismus. Binocular single vision and best corrected visual acuity were the most important risk factors. The authors recommend follow-up in patients with low visual acuity or sub-optimal BSV where pseudostrabismus is initially diagnosed.