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Strabismus is a disease involving incorrect positioning of the eyeballs. It is usually associated with different types of monocular or binocular visual impairment. In children with strabismus, one eyeball may turn in or out, but also up or down. The most common symptom of strabismus is the asymmetrical alignment of the eye axis.
Strabismus is a disease involving the incorrect alignment of the eyeballs. They are most often accompanied by symptoms related to visual disturbances. Strabismus allows the child’s eyeballs to move both in and out. It also happens that abnormal eye movement involves upward or downward movement.
The nature of strabismus can be both variable and permanent. If the strabismus is permanent, the symptoms are visible all the time. In turn, the variable nature means that strabismus can come and go. The disease causes many problems that are not only related to the aesthetic aspects. Strabismus can also have serious health consequences.
Check it out: Strabismus – when to see a doctor?
There are many divisions and types of strabismus in the professional literature. Among them, it is worth paying attention to the division of strabismus into:
- one-sided strabismus – we deal with it when the strabismus concerns only one eye;
- alternating strabismus – we deal with it when the strabismus affects one eye alternately.
In addition, a very popular division of strabismus is the division of the disease according to the direction of eye deviation. For this reason, we distinguish:
- convergent strabismus – consisting in tilting the eye towards the nose;
- divergent strabismus – consisting in tilting the eye towards the temples;
- upward squint – tilting the eye towards the forehead;
- downward strabismus – consisting in tilting the eye towards the chin.
Another division worth mentioning is the division of squint into:
- hidden strabismus – it is associated with imbalances in the eye muscles, which may be responsible for the exclusion of binocular vision and problems with fusion, i.e. merging the image from both eyes;
- overt accompanying eye squint – it may be the result of a permanent deviation of the axis of one eye in relation to the axis of the other eye, which is straight ahead. It happens as a consequence of imbalances between individual groups of eye muscles interacting with each other;
- open squint not accompanying – its other name is paralytic. It arises as a result of paralysis of the nerve that supplies a given group of eye muscles. In this way, the possibility of moving the eyeball in a certain direction is blocked.
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There can be many causes of strabismus. Many factors can affect the misalignment of the eyeballs. The most important causes of strabismus include:
- eye arrhythmia, i.e. refractive errors;
- diseases of the eyeball or orbit;
- injuries around the eye, which may reduce the mobility of the globe;
- diseases of the eye muscles and their innervation;
- genetic factors;
- brain injuries;
- diseases of the central nervous system.
The most characteristic symptom of strabismus is the visible misalignment of the eyeballs. However, this symptom is invisible in the case of hidden strabismus. Strabismus can also be detected during the examination, but the disease can also reveal itself when binocular vision decreases. In these people, the misalignment of the eyeballs becomes apparent over time. Then the patient begins to know twice.
Strabismus can also be recognized by the behavior of the child. Children, especially the older ones, complain of headaches or burning eyes. In the case of younger children, it is more difficult, because they cannot speak yet and thus communicate to their parents that something is wrong. Then, apart from the obvious symptoms, i.e. squinting, pay attention to such behaviors as: no movement of the child’s eye in one of the directions; squinting, closing in or rubbing your eyes; moving closer to the TV; bringing objects closer to the eyes; reluctance to draw.
If any of these behaviors occurs in your child, take them to an ophthalmologist as soon as possible. These are symptoms that may indicate certain visual disturbances in a child.
Check when your newborn baby begins to see: Child vision development
Strabismus in infants
Strabismus often occurs in newborns. It can be detected very quickly, because already 3 months after birth, the child’s eyes should be positioned parallel.
However, it is the result of the so-called lazy eye in toddlers. This means that children are visually impaired and only one eye transmits information from the eye to the brain. Vision in the other eye is severely impaired during this time.
At first, the eyes of the newborn wander. Children are able to focus on small objects only around 3-4 months of age. A toddler’s eyes should be able to align parallelly. By the age of 6 months, the baby should be able to focus on people close to him or even on distant objects.
The child’s parents should consider visiting an ophthalmologist if the infant’s visible strabismus persists over 4 months of age. Remember that strabismus is not only a cosmetic defect. The condition may have specific health consequences.
If parents are concerned, they should see an ophthalmologist. During the visit, the doctor will assess the sharpness and quality of the child’s vision in each eye. It does this by observing the behavior of the eyeballs as they follow a colored toy. A common test is, for example, covering the child’s eyes with each other, so you can easily see which eye is squinting. In addition, the doctor may order a fundus examination, which will exclude, for example, an eye cancer.
The effectiveness of strabismus treatment depends on the appropriately selected therapy. It is very important to start treatment as early as possible. This is important, among others because untreated strabismus can cause many unpleasant ailments, such as headaches or eyeaches. It can also result in the development of amblyopia, which, in turn, can only be fully cured until around the age of 8-10.
In children, strabismus is often treated by covering the healthy eye. Then the sick eye is forced to a greater effort. In addition, perception, convergence and pleoptic exercises are used. In addition, improvement can also be achieved by dripping the eyes with a fluid that dilates the pupil into the healthy eye. This treatment will blur the image in the healthy eye.
It also happens that the doctor decides about surgical treatment. This happens in the case of oblique, vertical or large-angle strabismus. Such a procedure is performed under full anesthesia and consists in interfering with the muscles responsible for moving the eyeball. If muscles need to be weakened, they are moved back, and if they need to be strengthened, they are shortened. However, it should be added that before the surgery (at least two weeks before the surgery), several tests must be carried out, such as: blood count with smear, HBS antigen test, blood clotting test, blood sodium and potassium test, or HCV test.
The decision whether or not to need surgery is very much dependent on the age of the child, the older the child is, the more likely it is. After the procedure, the child should still be under the care of a doctor.
Surgical treatment of strabismus in children and complications
When it comes to postoperative complications, they are relatively rare in the treatment of strabismus in children. The most common complications include insufficient correction of strabismus. Occasionally a mild astigmatism may develop, but this usually disappears with time.
Other possible complications of strabismus surgery in children are:
- sclera perforation,
- loss or slip of a muscle,
- postoperative infection,
- granuloma at the site of the sutures.
However, it should be emphasized that they are very rare. It is worth adding that in most medical facilities, dissolving sutures are used for this type of treatment. This procedure is fully reimbursed by the National Health Fund.
The length of strabismus treatment in a child depends on the severity of the disease (the size of the strabismus angle, the depth of amblyopia), as well as the child’s age. The fact is that the sooner treatment is started, the sooner the child will be cured, however, it should be borne in mind that the treatment of strabismus usually takes several years.
A squint and a lazy eye
Sometimes placing the eye in strabismus leads to the development of amblyopia in this eye in a young child. Amblyopia, i.e. lazy eye is a decrease in visual acuity for no organic cause. This is when one eye has poor vision due to the lack of interaction between the eye and the brain.
Most often, the “lazy eye” is only in one eye. When it comes to strabismus, one of the eyes is focused outside the object the patient is looking at. Then the brain shows its natural tendency to ignore blurred images, which causes the eye in which such an image is created to become weaker and weaker over time.
Ultimately, such an eye can stay in this position forever, becoming a visually impaired eye. That is why it is so important to recognize amblyopia as soon as possible.
Strabismus diagnosis
In the case of diagnosing strabismus in children, it is rather problematic and results from the fact that children often do not want to cooperate and make examination difficult by covering their eyes or crying, and their problem with maintaining concentration for longer does not help.
There are, however, a number of different studies designed specifically for children, and one is alternating eye coverage test (cover test), during which one eye is covered with a hand, dark glass or a veil, and the other at the same time looks straight at the indicated point. If this squint eye is obscured, its exposure does not change the form of eye movement, because the unobstructed healthy eye “guides” and maintains its line of sight straight ahead. However, if it is the healthy eye that is covered and the squinting eye is looking straight ahead, the eye that “leads” after the removal of the veil begins to look straight ahead, which causes the squinting eye to stand in the strabismus.
In addition, the following tests are also used:
- Hirschberga,
- Krimski,
- flies,
- next to
- Butterfly,
- TNO.
In diagnostics, not only eye movements and the strabismus angle are examined, but also binocular vision, which is checked during tests and with the use of a special device called a synoptophore. Thanks to this, it is possible to determine the correct functioning of the eye muscles and the correct reception of visual stimuli, which in turn makes it possible to find out the cause and type of strabismus. All this is necessary to implement the appropriate treatment.
Sciascopy is also used in the diagnosis of strabismus, i.e. a test involving the illumination of the patient’s pupil from a distance of 1 m and observation of the shadow movement within it. Thanks to the use of spectacle lenses of different power, it is possible to accurately measure the refractive error. Sciascopy is performed in children after pharmacological paralysis of accommodation with the help of special drops. Such eye instillation takes about 30 minutes.
Refaction can also be examined by computerized examination, which is based on the principle of automatic infrared scopes. However, this version of the study is difficult to perform due to the child’s unwillingness to cooperate. After the skiascopy and computerized examination, visual acuity is re-examined after attaching the test lenses.
It should be added that in the diagnosis of strabismus, the fundus examination is also performed, thanks to which it is possible to identify some dangerous causes of strabismus, e.g. eye cancer. Before this test, the child’s eyes should also be instilled (the dilated pupils thus facilitate a more precise observation of the fundus).
It is worth mentioning here that the series of tests may take a long time, therefore you should reserve at least 2 hours for an appointment with a specialist.
Strabismus in children and the consequences of untreated
If left untreated, strabismus can lead to decreased visual acuity and monocular amblyopia. This is due to the image formed in the wrong place in the retina, which is suppressed in order to avoid duplication. These types of disorders, in turn, lead to the inability to develop spatial vision. For this reason, children whose strabismus has not been treated will have huge problems in adulthood (they will not be able to obtain, for example, driving license) and will not be able to work in many professions. It is also an aesthetic problem.
Untreated strabismus can also have tragic consequences for other reasons. It can lead to a delay in development. This is due to the fact that a child who has strabismus cannot see properly, and this in turn causes problems with, for example: distinguishing and recognizing shapes; moving, walking and sitting down; learning at a later age. Fortunately, the sooner the strabismus is noticed, the sooner treatment can be started and therefore the child’s chances of avoiding these types of problems increase.
Most patients notice improvement after one episode of surgery. It is not always possible to accurately predict the amount of eye muscle correction needed to achieve perfect eye alignment in every direction, and strabismus may come back over time. It is quite common for children (and adults) to require further surgical treatment over time.
Strabismus and the frequency of occurrence
In the case of hidden strabismus, this occurs in over 50% of people. In the case of children, this value is only 4 to 5 percent and is due to the fact that effective treatment of strabismus is only possible in them. When it comes to accompanying strabismus, it is found less and less in adults. In adults, accompanying strabismus is the result of neglect of treatment at an earlier age. In turn, paralytic strabismus is more common in adults than in children.
It is worth adding that quite often you can see children squinting themselves for a short time when they are tired or daydreaming. Babies sometimes cross their eyes – this is quite normal, it happens especially when they are tired. However, it is estimated that about 1 in 500 babies have strabismus, which is more than just occasional fatigue.
Strabismus in children – prevention
In some forms of strabismus, it can be detected early thanks to preventive examinations in young children. It is best to conduct such tests in infancy or between 2 and 4, or 6 and 7 years of age (and also when we notice disturbing symptoms in a child). It should be added that this type of research must be performed in the case of the so-called premature babies, because they have strabismus, as well as refractive errors, more often than in full-term babies, and in children from families with: refractive errors, strabismus, amblyopia or congenital eye diseases.
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