HNY Policy and Pathway Repository - York

Strabismus (squint) is a misalignment of the eyes¹. When looking at an object the non-fixating eye can be turned in (esotropia), out (exotropia), up (hypertropia) or down (hypotropia). Squints can be intermittent so it is important to take any report of a squint seriously as if untreated children can develop amblyopia, which can lead to permanent poor vision in the affected eye.

Most squints are idiopathic and a routine referral is indicated in these cases to assess and start treatment. There are however some serious but rare causes, which would warrant more urgent referral.

Exclude red flags²

• Headaches
• Abnormal red reflex
• Any neurological abnormalities (including diplopia, nystagmus and limited abduction)
• Constant exotropia in a young child
• Proptosis

Assessment

• Assess for visible ocular abnormalities, pupil asymmetry and ptosis
• Eye movements (including nystagmus)
• Corneal light reflex – get the child to fixate on a light 50cm in front of their eyes and observe for light reflecting back from the same place on both corneas. Asymmetry of where the light reflects from indicates a squint
• Red reflex
• Fundoscopy (where possible) noting features of the optic discs
• Visual acuity (in older children)
• General assessment for abnormal head posture, features suggestive of cerebral palsy, dysmorphic features

 

Management

• The main role of primary care in management of childhood squint, besides referral is supportive and informative.
  • Compliance with occlusion therapy is the main barrier to improvement of visual acuity².
  • Signpost parents and carers to further support and information (see patient information section)
• In secondary care
  • Determine and treat underlying causes of squint (if present)
  • Corrective glasses
  • Occlusion therapy
  • Penalisation therapy (atropine drops to blur the vision in the normal eye, urging the child to use the other eye)
  • Eye exercises
  • Surgery
  • Botulinum toxin

Referral Information

• Indications for referral
  • Refer all children with squint to ophthalmology
  • More urgent referral may be considered if:
• There is a delay in presentation (to facilitate earlier treatment)
• There are red flags suggestive of a serious underlying cause
  • Referral to paediatrics should be considered where there are features of other conditions that require paediatric opinion (e.g. developmental delay, cerebral palsy)
• Information to include in referral letter
  • History of when the squint was first noticed and whether it is intermittent or constant
  • Any other neurodevelopmental problems
  • Red flags
  • Features on assessment (see above)

Patient information leaflets/ PDAs

NHS.uk/conditions/squint/

Moorfields.nhs.uk/condition/squint-strabismus

video by paediatric consultant at Moorfields Eye Hospital explaining squint and treatments

 

References

¹Bestpractice.bmj.com/topics

²NICE/topics/squint-in-children/background-information/causes/