Squint

SQUINT

Squint refer to appearance in which both eyes are not facing the same direction.  It can be exo (eye deviated out) , eso (eye turning in), hypo (eye turning down), or hyper (turning up) or in combination. It can be congenital (develop since birth) or acquired (develop later in life). 

For congenital cause of squint, it can be due to the brain unable to coordinate the eye muscle movement, abnormal eye refractive power (too short sighted or long sighted) or disease which reduced vision in one eye (eg. cataract or other eye abnormalities).

The cause of developing squint later in life can be neurological cause (nerve that supply muscle is not working) or mechanical (muscle entrapped in a fracture).  Sometimes it can be both , eg. in a car accident in which there is a fracture in the floor of orbit with entrapment of muscle together with multiple cranial nerve injury.  Recently , high myopia (severe short-sightedness) is also recognised to be associated with double vision.

In a child, the eye which is deviated out may develop less image information and hence become lazy and hence not able to see well if left untreated (ambloypia).  Therefore it is important to treat squint otherwise child will have reduced vision in the 'squinting eye' and will not develop stereoscopic (3D ) vision which may adversely their career choices.  Sometimes, the child may also develop abnormal head movement (eg head tilt) in order to achieve single vision. It is important to note that children seldom complained of double vision as they suppress the abnormal easily and hence parents need to pay attention.

However, it is important to note that many Chinese child may with wide distance between eye (wide inter-canthal distance) with epicanthic fold may appear to have squint with both eyes turning in.  However, a visit to the doctor usually will reveal otherwise.  No treatment is required for this group of children.

In adult, squint can cause double vision which many people find disabling. The double vision can be horizontal or vertical depending on which muscle it affected.  It is important to seek ophthalmologist attention to identify the issue.

TREATMENT

As some cases of squint may be related with brain disorder, it is important to seek doctor to confirm the diagnosis and cause of squint first.

Treatment varies with cause.  In some cases, medical treatment such as glasses or fusion glasses) may be adequate.  However,  in other scenarios, squint surgery or stabismus surgery may be required to restore binocular single vision and stereopsis.  This is an operation require general anesthesia but can be discharged same day post recovery.  Sometimes, in order to restore single vision, adjustable sutures may be required.

Pre op: This girl has left divergent squint (left eye deviated out) since young. She is keen to look more normal in order to get a job/training opportunity.

Pre op: This girl has left divergent squint (left eye deviated out) since young. She is keen to look more normal in order to get a job/training opportunity.

Post op: Eyes looks straight and normal now. The patient regained confidence.

Post op: Eyes looks straight and normal now. The patient regained confidence.

Pre op: this patient has a slightly more complicated squint with right eye deviated in and left eye deviated up.

Pre op: this patient has a slightly more complicated squint with right eye deviated in and left eye deviated up.

Post op: The child looks better with a straighter eyes. Now he can concentrate on building his life and getting a job.

Post op: The child looks better with a straighter eyes. Now he can concentrate on building his life and getting a job.

Pre op: this girl lack confidence due to squint appearance.  Also her field of vision is limited.

Pre op: This girl has low confidence due to right squint eye.  Also her field of vision is limited with minimal stereopsis

Post op: After surgery, she looks better, more engaged.

Post op: Can you believe this is the same person?  Her eyes look bigger, she looks engaged.  Her field of vision is also bigger.

Pre op: convergent squint in a Down syndrome patient

Pre op: convergent squint in a Down syndrome patient

Post Squint surgery: Both eyes look straighter now.

Post Squint surgery: Both eyes look straighter now.

Pre op:

Pre op : Left CN VI palsy cause eye to turn inwards. Patient always see double that he is not able to drive safely and enjoy his golf.

Post Squint surgery: Both eyes look straighter now.

Post Squint surgery: Left eye look much straighter.  Patient is able to drive and play golf again.

Pre op:

Pre op : Left CN VI palsy.  On left gaze, the left eye is not able to turn outwards.

Post Squint surgery: Both eyes look straighter now.

Post Squint surgery: left eye is able to turn outwards.

Pre op: convergent squint in a Down syndrome patient

Pre op : Left CN VI palsy secondary to trauma.  Patient has to wear the unsightly Fresnel prism in order for the image to look single.

Post Squint surgery: Both eyes look straighter now.

Post op : After adjustable squint surgery, patient is able to see one again after one surgery.  No more ugly fresnel prism!!!

Pre op :

Pre op : Child with right exotropia (outward turning right eye)

Post Squint surgery: Both eyes look straighter now.

Post op : The child eyes look straight on primary gaze.  No more teasing by other children at school!!

Post op : Post Left CN VI palsy surgery with modified Uchida procedure and adjustable suture, patient is able to see one with good range of eye movement.

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