Squint in Children

A squint (also called strabismus) is when the two eyes do not look in the same direction. One eye looks straight ahead while the other turns inwards, outwards, up or down [1].

• Esotropia: the eye turns inwards, towards the nose.
• Exotropia: the eye turns outwards, away from the nose.
• A squint can be constant (there all the time) or intermittent (comes and goes, for example when the child is tired, unwell or daydreaming).

It is normal for a newborn baby's eyes to wander or cross now and then in the first few months. A squint that is still there after about 3 to 4 months of age, or one that is there all the time, should be checked by an eye doctor [1].

Image to add

Simple drawing of a child's face in three versions: eyes straight, right eye turned in towards the nose (esotropia), and right eye turned out (exotropia). Alt text: "Drawing of a child with straight eyes, an eye turning inwards, and an eye turning outwards."

What causes it?

Often there is no single clear cause. Common causes include:

• Focusing problems, especially long-sightedness. The child works hard to focus, and the eyes can turn in. Glasses alone may straighten the eyes [1][4].
• Family history.
• Problems with the muscles or nerves that move the eyes.

Rarely, a squint is a sign of a serious eye problem that blocks vision in one eye, such as a cataract (cloudy lens) or retinoblastoma (a rare eye cancer in young children). A white or unusual glow in the pupil in photos taken with a flash is a warning sign [5].

Any child can develop a squint. It is more common in children who:

• are long-sighted (need glasses to see clearly up close and far), which can make the eyes turn in [1]
• have other focusing problems, such as short sight or astigmatism [1]
• have a parent, brother or sister with a squint or lazy eye
• were born premature (early) or with a low birth weight
• have conditions affecting the brain or development, such as cerebral palsy or Down syndrome [1]

You may notice that:

• one eye turns in, out, up or down, all the time or now and then
• your child closes or covers one eye, especially in bright sunlight
• your child tilts or turns their head to look at things
• your child has trouble judging distances or bumps into things

Some lazy eyes have no visible squint at all. This is why eye checks in young children are important.

At the eye clinic, the eye doctor or orthoptist (a specialist in eye movements) will:

• check vision in each eye, using pictures or letters suited to the child's age
• do a cover test to see if an eye moves to look straight
• use eye drops to relax focusing, then check if glasses are needed
• look inside the eyes to make sure they are healthy

What can happen?

Lazy eye (amblyopia). When the eyes point in different directions, the brain gets two different pictures. To avoid double vision, a child's brain learns to ignore the picture from the turned eye. Over time, that eye does not develop good vision. This is called amblyopia or lazy eye [2][3].

Lazy eye can be treated very well in young children, while the vision system is still developing. Treatment should ideally start before age 7, and works much less well as the child gets older. If it is not treated in time, the poor vision can be permanent [2][3].

A squint can also:

• reduce 3D vision (depth perception)
• affect a child's confidence, especially as they get older [1]

Arrange an urgent eye check (within days) if you see a white or unusual reflection in the pupil, either in real life or in flash photos [5].

The aims are to give each eye the best vision and to straighten the eyes.

1. Glasses: often the first treatment. They correct focusing problems and can straighten the eyes on their own, especially in long-sighted children [1][4].
2. Patching: a patch is worn over the good eye for a few hours a day, so the brain is made to use the lazy eye. A large study found that 6 hours a day worked as well as full-time patching, even for severe lazy eye [7]. Your eye team will advise how many hours your child needs [3].
3. Atropine eye drops: a drop in the good eye blurs its vision for a while, so the lazy eye has to work. A large study found these drops worked about as well as patching for moderate lazy eye, and parents often found them easier [6].
4. Eye exercises: these help only in certain types of squint, such as some outward-turning squints when looking up close. They do not fix most squints [1][4].
5. Surgery: if the eyes are still not straight, an operation can tighten or loosen the eye muscles. It is done under general anaesthetic (asleep), usually as a day case. Surgery straightens the eyes, but glasses and patching may still be needed for the vision [1][4].

Common myths

• "My child will grow out of it." No. Apart from occasional wandering in young babies, children do not grow out of a true squint. Waiting can lead to permanent lazy eye.
• "Crossing your eyes for fun will make them stay that way." No. Crossing the eyes on purpose does not cause a squint.

Most squints cannot be prevented, but you can prevent lazy eye by acting early:

• Get your child's eyes checked early if you notice a turn, or if there is a family history of squint or lazy eye.
• If glasses are prescribed, make sure they are worn all the time as advised.
• Stick with patching or drops and keep follow-up appointments. Treatment can take months.
• Take a flash photo now and then: both pupils should glow the same colour.

Where to get help in Brunei

You can walk in with your child to any Community Eye Clinic at your health centre. No referral is needed. The team can check your child's eyes and refer to the children's eye (paediatric) and squint specialists if needed.

For a sudden squint or double vision, especially with headache, vomiting or drowsiness, go to the hospital Emergency Department straight away.