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The Squinting Child

Christopher Tinley

Red Cross War Memorial Children’s Hospital

Strabismus saunter...

� Definitions

� Diagnosis

� Classification

� Strabismus at RCWMCH

� Management

� Squint cases

Definitions

� Strabismus = squint, cross-eye, skeeloog,

ulithoba

� Deviation in ocular alignment� Deviation in ocular alignment

� Esotropia = inwards

� Exotropia = outwards

� Hypertropia = upwards

� Hypotropia = downwards

Corneal light reflex

The light reflection from the cornea should be central

Straight

Esotropia

Exotropia

Classification - Comitant

Esotropia

� Accommodative� Partially

� Fully

Exotropia

� Intermittent� True

� Simulated� Fully

� Non-accommodative� Congenital

� Acquired

� Sensory

� CNS defects

� Simulated

� Convergence insufficiency

� Constant� Congenital

� Acquired

� Sensory

� CNS defects

Classification - Incomitant

� Paralytic

� III

� IV

� VI� VI

� Multiple cranial nerve palsies

� Strabismus syndromes

� Duane’s

� Brown’s

Accommodative esotropia

� In order to produce a clear image for near, a hyperopic child exerts accommodative power

� Eyes converge � Eyes converge simultaneously due to accommodative reflex

� Correcting the hyperopiarelaxes this reflex and eyes straighten

� Cycloplegic refraction = NB

Strabismus at RCCH, 1997–2007

� 3429 squint referrals

� 25% pseudostrabismus

Strabismus types n=2566

Non-accommodatives

Prevalence of strabismus

� ? South Africa

� 1% Oman schoolchildren

� 1% Japanese schoolchildren

� 5.3% Welsh schoolchildren

� 0.8% Exo

� 3.6% Eso

� 0.9% other

Esotropias:Exotropias

15

29

1724

37

63

72 7360%

70%

80%

90%

100%

85

71

8376

63

37

28 27

0%

10%

20%

30%

40%

50%

60%

SA Black

n=449

SA Mixed

n=1921

Egypt Arab

n=957

US White

n=968

US Black

n=709

Cameroon

Black

n=137

Singapore

Asian

n=682

Hong Kong

Chinese

n=2704

Exotropia

Esotropia

Ethnic proportions: Eso type

Ethnic proportions: Exo type

*

GP squint referrals

� Age of child?

� Squinting after 3 months is abnormal

� Duration of onset?

Constant or intermittent?� Constant or intermittent?

� Red reflex present?

Management

History Examination

� Age at onset

� Perinatal history

Developmental history

� VA /fixation assessment

� Ocular deviation in prism

dioptres� Developmental history

� Family history

dioptres

� Ocular movements

� Cycloplegic refraction

� Anterior and posterior

segment examination

Cycloplegic refraction = NB

Dilated fundoscopy = NB

Management

� Treat any pathology

� Prescribe glasses as

needed

� Amblyopia therapy� Amblyopia therapy

� Occlude - days per week

� Atropine penalisation

� Surgery @ age 4

� Follow until age 7

Strabismus surgery

Overwhelming

majority �majority �PSYCHOSOCIAL

Surgery – rectus recession

Summary

� A squint after the age of 3 months = abnormal

� should be referred

� Primary healthcare level

Corneal light reflex = NB� Corneal light reflex = NB

� Red reflex = NB

� Secondary/Tertiary level

� Cycloplegic refraction = NB

� Dilated fundoscopy = NB