Squint & Lazy Eyes

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Refer urgently children with:

  • a white pupillary reflex (leukocoria). Pay attention to parents reporting an odd appearance in their child’s eye
  • a new squint or change in visual acuity if cancer is suspected. (Refer non-urgently if cancer is not suspected.)
  • a family history of retinoblastoma and visual problems. (Screening should be offered soon after birth.)

Refer non urgently a case of squint in following circumstances :

  • intermittent deviation of the eyes is a quite common finding in healthy neonates and should not cause undue concern
    • normal binocular coordination becomes evident at about three months and strabismus (squint) after this age is significant.
  • constant squint is generally recognised early by the family, health visitor or general practitioner. A positive family history of squint or amblyopia should alert those in primary care when carrying out routine checks or immunisations
  • strabismus is often found in association with neurological disease such as in cerebral palsy and in craniofacial developmental anomalies
  • strabismus, amblyopia and refractive error are much more common in children with treated or regressed retinopathy of prematurity (ROP) Premature infants with a history of stage III ROP or worse should be followed up after the neonatal period to screen for these complications
  • if squint or amblyopia is suspected in the primary care setting, it is appropriate for local protocols to provide for direct referral to an Eye Care Specialist to exclude refractive error and strabismus. If no abnormality is detected, such patients may be discharged
    • cases with intermittent or constant manifest squint should be referred to an Pediatric Ophthalmologist/Neuro - Ophthalmologist/Strabismologist without delay. In all children referred with strabismus or amblyopia the possibility must be considered that this is the presenting feature of a serious ophthalmic or systemic disease requiring urgent management
    • It is suggested that a within 2 week referral is indicated if a new squint or change in visual acuity and cancer is suspected.

How do eyes work?

When light enters the eye through the pupil, the muscles inside the eye squeeze or relax to help the lens focus the image on to the retina.

Your eyes are controlled by muscles that allow you to look up and down and from side to side without moving your head.

Normally, both eyes work together to form a picture on the retina, which is then interpreted by the brain. As each eye sees a slightly different picture, the resulting image is three-dimensional (binocular vision). This allows us to work out whether objects are near or further away (depth of vision).



BewiseHealthwise: Squint

A squint is a condition where one eye turns inwards, outwards, upwards or downwards while the other eye looks forwards. The misalignment of the eye is caused by an incorrect balance of the eye muscles. The medical name is strabismus.

Squints are common and affect about one in 20 children. They usually develop during the first three years of life, but can appear later. A squint is often spotted in early childhood, sometimes within weeks of a baby being born.

Types of squint

There are four different types of squint. They are classified according to the direction in which the eye turns.

  • Esotropia: the eye turns inwards.
  • Exotropia: the eye turns outwards.
  • Hypertropia: the eye turns upwards.
  • Hypotropia: the eye turns downwards.

Hypertropia and hypotropia are less common than esotropia and exotropia.

Squints can also be:

  • constant, apparent at all times, or
  • intermittent, only apparent at certain times.

The cause, severity and direction of a squint vary from person to person.

How does a squint affect vision?

It is very important that a squint is picked up and treated as early as possible to avoid vision problems developing. If a squint is identified when a child is young, there is a good chance it will be successfully treated.

In young children, a squint can mean binocular vision fails to develop (see the box, left). This may result in a ‘lazy eye’ (amblyopia). To avoid double vision, the child’s brain ignores the signals from the eye with the squint and only recognises images from the normal eye. As the squinting eye is not being used, it eventually becomes ‘lazy’.

In older children, a squint may cause double vision but not result in a lazy eye. This is because their vision has fully developed and their brain is unable to ignore signals from the eye with the squint.

If the vision in a child’s squinting eye is poor, they may have to wear a patch over their other eye to encourage the vision in the squinting eye to develop.

Can adults develop a squint?

Occasionally, squints that have been corrected during childhood reappear in adulthood. Squints that affect adults may cause double vision as the brain has been trained to collect images from both eyes.
 
If you develop a new squint, visit your GP as soon as possible. They may refer you to an ophthalmologist (an eye care specialist) who will carry out an examination to identify the cause.

Squints may cause a cosmetic problem in adults whose squint was not treated when they were young.  In such cases, the appearance of a squint my lead to low self esteem.

A squint is a condition where one eye turns inwards, outwards, upwards or downwards while the other eye looks forwards. The misalignment of the eye is caused by an incorrect balance of the eye muscles. The medical name is strabismus.

Squints are common and affect about one in 20 children. They usually develop during the first three years of life, but can appear later. A squint is often spotted in early childhood, sometimes within weeks of a baby being born.

Types of squint

There are four different types of squint. They are classified according to the direction in which the eye turns.

  • Esotropia: the eye turns inwards.
  • Exotropia: the eye turns outwards.
  • Hypertropia: the eye turns upwards.
  • Hypotropia: the eye turns downwards.

Hypertropia and hypotropia are less common than esotropia and exotropia.

Squints can also be:

  • constant, apparent at all times, or
  • intermittent, only apparent at certain times.

The cause, severity and direction of a squint vary from person to person.

How does a squint affect vision?

It is very important that a squint is picked up and treated as early as possible to avoid vision problems developing. If a squint is identified when a child is young, there is a good chance it will be successfully treated.

In young children, a squint can mean binocular vision fails to develop (see the box, left). This may result in a ‘lazy eye’ (amblyopia). To avoid double vision, the child’s brain ignores the signals from the eye with the squint and only recognises images from the normal eye. As the squinting eye is not being used, it eventually becomes ‘lazy’.

In older children, a squint may cause double vision but not result in a lazy eye. This is because their vision has fully developed and their brain is unable to ignore signals from the eye with the squint.

If the vision in a child’s squinting eye is poor, they may have to wear a patch over their other eye to encourage the vision in the squinting eye to develop.

Can adults develop a squint?

Occasionally, squints that have been corrected during childhood reappear in adulthood. Squints that affect adults may cause double vision as the brain has been trained to collect images from both eyes.
 
If you develop a new squint, visit your GP as soon as possible. They may refer you to an ophthalmologist (an eye care specialist) who will carry out an examination to identify the cause.

Squints may cause a cosmetic problem in adults whose squint was not treated when they were young.  In such cases, the appearance of a squint my lead to low self esteem.

Symptoms to look for 

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 possible to correct damage once it has occurred, which is why it is so important to treat a squint as soon as possible.

See Useful links for more information about lazy eye.

The cause of a squint is not always known. Squints sometimes run in families and a baby can be born with the condition (congenital squint).

Squints are also sometimes the result of childhood illnesses or other sight-related problems, such as long-sightedness (hypermetropia).

Congenital squints

A child is either born with a squint or develops one during the first six months of life.

Sometimes other family members have a squint, which suggests it can be genetic.

In most cases of congenital squint, the eye turns inwards (congenital esotropia). It is also possible (although rarer) for the eye to turn outwards (congenital exotropia).

Refractive errors

Squints are sometimes caused by the eye’s inability to focus the light that passes through the lens. This is known as a refractive error, and is also the cause of conditions such as short-sightedness (myopia), long-sightedness (hypermetropia) and astigmatism (where the cornea at the front of the eye is unevenly curved).

See Useful links for more information about these other conditions.

If a child has a refractive error, their eye may turn inwards as it attempts to focus. Squints caused by refractive errors usually develop in children who are two or older and tend to be most common in children who are long-sighted.

Other causes

Most squints are congenital or caused by refractive errors. Occasionally, squints can be the result of:

  • childhood illnesses, such as viral infections like measles,
  • some genetic conditions, such as Noonan syndrome, or
  • a brain condition, such as hydrocephalus where there is too much cerebrospinal fluid (CSF) in the ventricles (cavities) of the brain.

Treating a squint 

It is very important that a squint is treated as soon as possible after being detected. If it is not treated, vision problems, such as those caused by a lazy eye (amblyopia), are likely to get worse or could become permanent.

Treatment is most effective in very young children.

Types of treatment

Several types of treatment are available for squints:

  • glasses,
  • eye patch,
  • botulinum toxin injection,
  • eye drops, and
  • corrective surgery.

Glasses

If your child is long-sighted (hypermetropia), they may be prescribed glasses which can often correct both the vision problem and the squint.

Eye patch

A patch may need to be worn over the ‘good eye’ to encourage the eye with the squint to work harder and train it to work properly.

Botulinum toxin injection

Botulinum toxin (botox) is injected into one of the muscles on the eye’s surface. This may be recommended if a squint develops suddenly and no underlying cause can be found.

In children, a botox injection will usually be given under general anaesthetic. The injection temporarily weakens the injected muscle, allowing the eyes to realign.

Eye drops and eye exercises

In some cases, it may be possible to treat a squint using special eye drops or eye exercises.

Surgery

If none of the above treatments work, surgery may be needed. Surgery has two main benefits:

  • it can improve the alignment of the eyes, and
  • it can get the eyes working together (binocular vision).

The procedure

Surgery to correct a squint involves moving the muscles attached to the outside of the eye to a new position. It may be necessary to operate on both eyes to 'balance' them effectively, even if the squint is only in one eye.

As corrective squint surgery usually takes less than an hour to perform, the procedure is often carried out as a day case. The operation is usually performed general anaesthetic (where the patient is asleep).

You may be able to accompany your child to the operating theatre and stay with them until they have been given the anaesthetic. A nurse will be with your child throughout the procedure.

During the operation, your child’s eye will be kept open using an instrument called a lid speculum. The ophthalmologist will detach one part of the muscle that is connected to your child’s eye and will either move it backwards to weaken the pulling effect or shorten it to increase the pulling effect. Once the correction has been made, the muscles will be sewn back into place using dissolvable stitches.

There is very little chance that your child's eyesight will be damaged during the operation because the part of the eye responsible for focusing is not touched. For a short time after the operation, your child will need to use eye drops. The nurse will show you how to use them before you leave the hospital.

Does it hurt?

Surgery to correct a squint does not usually hurt, although your child’s eye may feel slightly uncomfortable afterwards. Your ophthalmologist will use eye drops or ointment to help ease any discomfort. Following surgery, the white of the eye will be red. This is quite normal and should pass after a few days.

Recovery 

After having corrective eye surgery, your child may have a sore eye for a few days. The pain can be treated using simple painkillers, such as paracetamol. Children under the age of 16 should not be given aspirin.

Your child will not have to wear a patch or bandage and can return to daily activities, such as reading, as soon as they feel able to. The aim is to get the eyes working normally as quickly as possible.

Advice following corrective eye surgery

Follow the advice below when your child gets home after an eye operation.

  • Your child may not feel like eating but they should drink water at regular intervals.
  • Your child may complain of double vision. This usually resolves itself over a few weeks.
  • The stitches can take up to six weeks to dissolve and your child may feel like there is a bit of grit in their eye. Encourage them not to rub it.
  • Avoid any soap or shampoo getting into their eye for two weeks.
  • Your child will need to go back to the eye specialist for regular follow-up visits.

If your child wore glasses before the operation, it is likely that they will have to continue to wear them.

Your child should be able to return to school or nursery after about four days.

They should avoid swimming for at least a month after the operation and most other sports for two weeks.








BewiseHealthwise:What minimum should you know about Lazy Eyes?


BewiseHealthwise: Lazy Eyes

Lazy eye, also known as amblyopia, is an early childhood condition where the child’s vision does not develop properly. It usually occurs in one eye, but it can occur in both eyes. Lazy eye affects approximately 2% of children.

A baby is able to see as soon as it is born, and vision continues to develop up until around seven or eight years of age. After this, no further development occurs until sight deteriorates with age, or after eye injury or disease.

How the eye works

Light rays travel through the lens (transparent structure) at the front of the eye, and form images on the retina. The retina is a light sensitive surface at the back of the eye that sends messages to the brain so that it recognises the objects that you are seeing.

During early childhood, it is important that clear images are formed in the eye and are sent to the brain, so that the child’s vision develops normally. If there is a problem with this development, it may result in impaired vision (amblyopia).

Retina


The retina is the nerve tissue lining the back of the eye, which senses light and colour, and sends it to the brain as electrical impulses.

Brain


The brain controls thought, memory and emotion. It sends messages to the body, controlling movement, speech and senses.

Last reviewed: 03/09/2009


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