Squint

Q. I have no child with squint - why should I even bother to read this article which appears totally irrelevant to my life?

A. This article gives you basic information on a subject which has many myths and misconceptions. It is entirely possible that a nephew or niece may develop a squint or be born with one or a friend of yours who trusts you for 20 years has a child with a squint and wonders whether medical treatment can help. Read the article and answer all questions, from relatives, friends and work colleagues with confidence!

Q. What is 'squint'? Is it hereditary?

A. Squint is an imbalance in the movements of the two eyes. Normally both eyes move in perfect symbiosis,e.g. when one wishes to look left, both eyes move effortlesslessly to the left side - the left eye moves outwards and the right eye moves inwards i.e. towards the nose. Or when one wishes to look straight, both eyes will stay in the centre. If this does not occur, one eye may either not move at all in one direction (paralytic squint) or when one eye looks straight, the other may either diverge(move outward) or converge( move inward).

Occasionally there may be a family history of squint - however most squints are due to spontaneous genetic factors and are not hereditary.

Q. What are the types of squint?

A. Squints may be either paralytic (due to muscle or nerve palsies) or non-paralytic. If you wish to get confused, the technical words for these are non-committant and concommittant squints respectively. If the squinting eye diverges or moves outwards, it is a divergent squint. If it converges or moves inwards, it is a convergent squint.

Q. What is an "apparent" squint?

A. Some kids have a depressed bridge of nose or greater or lesser distance than normal between the 2 eyes. This gives the appearance of squint, though there is no imbalance between the movements of the 2 eyes. Most kids grow out of this, though some may need plastic surgery to the face. However, it is best to let the eye surgeon decide which squint is real and which apparent.

Q. Are all squints present at birth?

A. No. Squints may be latent at birth and manifest after a few months or years. This event may occur following lowering of body resistance e.g. following an illness. Certain squints may occur in adulthood, due to trauma or certain endocrine disorders such as diabetes or thyroid disease or due to certain neurological conditions. A rare cause is iatrogenic,i.e. caused by eye surgeons during eye surgery by mishandling of the ocular muscles!

Q. If detected at birth, should I wait for the child to 'grow out' of squint?

A. If the squint is divergent, it should be referred to the eye surgeon immediately on detection, as the only treatment for this is surgery - these squints never resolve spontaneously. If the squint is convergent, it should be referred preferably before the child is 3 years of age. Some of these are due to high hypermetropic refractive errors (accommodative squints) and can be corrected by appropriate plus powered spectacles and in some cases eye exercises.

Q. Should every child be referred to the eye surgeon by the age of 3 years?

A. Yes. The ophthalmologist will look for refractive error after dilating the pupil. The child's co-operation is not required. Corrective glasses, if found necessary, can be prescribed even to kids 2 years old. This can reduce or even eliminate an accommodative squint (see previous answer).

More importantly, the ophthalmologist may detect a marked difference in spectacle number between the 2 eyes, or presence of a number in only one eye. There is every likelihood of this eye becoming a lazy(amblyopic) eye. The earlier this condition is detected, the better is the prognosis for improving vision in the lazy eye. This is done by prescribing the correct number; patching the good eye and giving stimulatory exercises to the lazy eye. This is best done before the age of 5 years. After the age of 8 years, chances of significant visual improvement are remote.

Q. What are intermittent squints? How are they managed?

A. As the name suggests, these squints are not constant. They may be seen or manifest, only when the child is daydreaming or unwell or exhausted or emotionally upset. These squints are usually kept under observation. They may either resolve spontaneously, thus requiring no treatment or become constant requiring treatment.

Q. Is there any role for medical management of squint? Any eye drops or Vitamin pills?

A. There is absolutely no role for medical management of any manifest squint, except those due to endocrine or neurological disorders. Some intermittent squints and some traumatic squints may resolve spontaneously over time.

Q. At what age should squint surgery be advised?

A. In divergent squints, it should be done when detected as waiting does not help. In convergent squints of the non-accommodative type (no significant refractive error), again, the earlier operated the better.

In convergent squint due to accommodation, corrective glasses are first prescribed. If amblyopia exists it is treated as mentioned earlier. If the squint shows signs of improvement by these methods, surgery is delayed till no further improvement occurs. The remaining or residual squint is then surgically corrected.

Q. Do squints cause psychological problems?

A. Yes. Children with obvious squints are often teased by their peers in nursery and school. They then become shy, withdrawn, introverted. Even if bright, they refuse to volunteer to answer questions in class and consequently often do badly at studies. They end up with an inferiority complex and may even become social misfits.

Q. Is squint surgery 'safe'?

A. Yes. Modern anaesthesia ensures that squint surgery can be safely done even in newborns. There is no danger to vision, as the surgery is an extra-ocular one and the eyeball is not opened. Hence there is virtually no risk of blindness following squint surgery It is usually performed as a day care surgery, even if under general anaesthesia. The bandage on the operated eye is usually removed after 24 hours. No special post-operative precautions or care is required. Stitches are required, which dissolve on their own leaving no scar. The child can resume school in a week, though he may have to continue drops for one month.

Q. Can squint be operated at a later age?

A. Yes. Squints can be operated at any age for cosmetic reasons and the eyes can usually be made perfectly straight. In fact, many ignorant parents bring their unmarried daughters with squint for correction before she enters the " marriage market" as the dowry she has to pay goes up manifold if she has a squint! However, if the surgery is done after the child is 5 or 6 years old, the squinting eye is already lazy. Hence, though the eyes are made straight by surgery, vision in the lazy eye cannot be restored. Therefore, ideally, squints should be referred to an eye surgeon as soon as they are detected.

Q. Can squint be a marker for a serious eye disease?

A. Yes. An eye blind from birth or blinded later in early childhood, due to unilateral cataract or eye tumour such as retinoblastoma or severe trauma can also develop squint. An eye surgeon will always rule out these diseases before he proceeds further with squint management.

Q. Can paralytic squints be corrected surgically?

A. Yes. Paralytic squints either resulting from birth trauma, such as forceps delivery causing 6th nerve or lateral rectus muscle paralysis or due to vehicular or other trauma in adulthood can be successfully surgically corrected using muscle transpositioning techniques.

Q. Your chapter was too long. Is there a single "take home" message you have for people like me who refuse to read the whole article?

A. Yes. Please note that almost all squints can be corrected surgically for cosmetic purpose at any age. Best visual results come from those patients corrected in early childhood before the age of 5 years. Do advise those near and dear to you who have a patient with squint in the family to take them to an eye surgeon as early as possible for opinion- in case the squint is due to retinoblastoma, you may even save a life!