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Eye squint (Strabismus) in children

The brain normally combines the slightly different images from each to give a 3-D picture of the world. When a squint is present (strabismus) the eyes point in different directions and the brain is no longer able to do this.

  • The brain then ignores the image from one eye and the vision in this eye

    may deteriorate (amblyopia). When an eye is turned in the squint is said to be convergent (esotropia) and when turned out it is divergent (exotropia). Some patients may also have a vertical squint, where one eye is higher than the other. The squint may be present all or only part of the time (constant or intermittent) and may appear to affect only one eye or alternate between the eyes.

    The most obvious sign of a squint is one eye that does not look straight ahead but turns inwards, outwards, upwards or downwards.

    Minor squints may be less obvious.

    Babies and young children
    It is quite normal for the eyes of newborn babies to ‘cross’ occasionally, particularly when they are tired. Speak to your GP if you notice this happening to your child after the age of three months.
    If your child looks at you with one eye closed or with their head turned to one side, it may mean that they are experiencing double vision and could be a sign that they have a squint. See your GP as soon as possible if this happens repeatedly.

    Lazy eye
    If a squint is left untreated, lazy eye (amblyopia) can develop. The vision in the affected eye gradually deteriorates because the brain ignores the weaker message being sent from that eye. It is not usually possible to correct amblyopia after the age of about 7 years, which is why it is so important to treat a squint as soon as possible.

  • There are a number of causes. The main ones are:

    • Refractive error (focusing abnormality, particularly uncorrected long-sight)
    • Eye muscle imbalance

    These separately or together cause squint.

    • It can run in families
    • Illness – can make it obvious
    • Injury
    • Rarely, it can be due to other diseases or illness

    Some babies may appear to have a squint when they do not in fact have a true squint. This is because some small children have a wide bridge to their nose, which makes the eyes appear to be turning in. This is sometimes termed ‘epicanthus’. Epicanthus does not exclude the possibility of a squint being present and so you should always seek an expert opinion if you are concerned.

  • How will the squint be managed?
    The first step is to give glasses if there is a significant refractive error and this may also improve the squint. Patching or atropine drops are used to treat amblyopia if present Squint surgery can be used to improve the appearance of the eyes and in some children can restore some binocular function if done early.

    REFRACTIVE ABNORMALITY AND SPECTACLES
    The main refractive (focussing) error to be the cause or part of the cause of convergent squint is Hypermetropia (long sight).

    Will my child need to wear glasses?
    This is decided by the Ophthalmologist (the eye surgeon responsible for the management of your child’s squint) after refraction.

    Refraction involves your child first having some drops or ointment to both eyes to dilate the pupils (make them bigger) and stabilise the focussing. Then the doctor measures what lens is needed by shining a special light into the eye and seeing how its reflection is changed. Appropriate lenses are put into a (trial) frame and older children will read the test chart.

    Do the glasses have to be worn all the time?
    Yes, unless advised otherwise.

    How do we obtain the glasses?
    You will be given a prescription for glasses which you can take to your own optician or you can visit the spectacle department on the ground floor of the Richard Desmond Centre where they specialise in children’s care and hold a good selection of frames at competitive prices. The prescription issued after a private consultation is not an NHS voucher.

    What do we do if the glasses break?
    These days all children have glasses with plastic lenses. These are lighter in weight and less likely to break.

    EYE MUSCLE IMBALANCE AND OCCLUSION (PATCHING)
    In order to focus both eyes on an object all the eye muscles of each eye must be balanced and work together. When one eye turns that eye is not focused properly and the vision can deteriorate in the squinting eye. An orthoptist carries out a series of eye tests to determine the presence of a squint and measure vision. In some children who develop a squint patching or using Atropine to the good eye will make the lazy eye work harder and therefore improve the vision.

    How does a patch affect the squint?
    Patching purely improves vision by making the brain use the amblyopic eye. The unpatched eye will appear to be straight while the patch is worn. Sometimes when the patch is removed the squint may be temporarily more noticeable, but later returns to the pre-patching position.

    Will my child need to wear a patch?
    Possibly, if your child is less than about 8 years and if the vision in one eye is reduced because of the squint. This will mean regular follow up visits.

    Which eye does the patch need to be put on?
    On the straight eye so that the eye with the poorer vision is used on its own for some part every day. It is a very effective way of improving vision.

    Does my child wear his glasses with the patch?
    Yes, the patch should be worn on the face. It is made from non-irritating material to prevent rashes. Spectacles are worn over the patch.

    How long should the patch be worn?
    This varies according to the child’s need and may be from less than 1 hour to a day to all day. Close work activities such as colouring, reading or schoolwork should be undertaken during patching. It can be useful to negotiate this with your child’s teacher. It is important that the child is involved in some near vision activity during patching. This will achieve maximum effect and help the child comply with patching because it distracts attention from the patch. Perseverance with patching is vital.

    Atropine
    Another way of getting a lazy eye to work is putting Atropine into the good eye to blur the vision and make the weaker eye work harder.

    Can exercises cure the squint?
    They can hep to control some intermittent squints in older children.

    OPERATION

    Will an operation help?
    Many children with squints do need an operation as well as glasses or patching. The operation is confined entirely to the surface of the eye. The muscles which are attached to the outside of the eye are moved to a new position on the surface of the eye. Usually the muscles of the squinting eye are operated upon, but sometimes it may be necessary to operate on the muscles of the other eye as well, as this may give better results. Often one operation is effective but some children will need further operations. Even an operation cannot ensure perfect alignment afterwards. In any squint surgery the focusing parts of the eye are never operated on and there is no significant risk of your child’s sight being damaged by the operation. For any eye operation the eye is NEVER brought onto the cheek for surgery.

    Can you tell us about the hospital stay?
    You may wish to visit the Childrens ward before the hospital admission. On the day of admission your child will be seen by the your surgeon and the anaesthetist (the doctor who puts your child to sleep for the operation). One parent is allowed into the anaesthetic room until the child is fully asleep.

    Before returning home, the nurse will clean around the child’s eye and instil drops. The doctor will see your child and ensure they are fit for discharge. An appointment will be made for follow up after this. Usually drops will need to be used at home. The nursing staff will show you how to instil drops.

  • Is squint common?
    About 2-3% of the population have a squint.

    Is my child too young to start treatment?
    No, the earlier the better.

    Does it matter if the squint is not treated?

    Yes:

    • If at some later point the sight in the better eye is lost e.g. by accident, the squinting eye could not compensate and your child would be visually handicapped.
    • Your child will NOT grow out of the squint
    • Sight will get worse in the affected eye
    • Your child may be teased about their appearance
    • Your child may be precluded from some jobs later if they have a lazy eye


    Should other children be checked for squint?

    Yes, because squint can run in families.

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