The Reasons:   

1. Strabismus causes serious problems:

In children vision is lost as a result of Strabismus- Amblyopia

Time: The first years of life are critical. The failure to stimulate the visual brain in this period has a very severe effect on visual development making it ALMOST IMPOSSIBLE TO DEVELOP VISION LATER.

Amblyopia - factors which can be involved:

1        Poor focus - the need for corrective lens.

2        An opacity in the line of vision

3        Poor aim – a turned eye

2. Serious problems cause strabismus

Loss of vision in an eye in infancy and childhood will result in Strabismus. Possible Causes:

Retinoblastoma

Congenital cataract

Optic atrophy- (Cerebral tumours; Hydrocephalus)

Retinal scarring- Toxoplasmosis

When a child presents with Strabismus:

1.      An examination is indicated as soon as possible to exclude an organic cause.

2.      An examination is indicated as soon as possible to exclude significant refractive error.

3.      An examination is indicated as soon as possible to commence amblyopia therapy.

When to refer:

1.      Today -if abnormal red reflex, abnormal pupillary reaction, significant decrease in vision.

2.     Near Future- A squint is found or suspected and the cause is unknown.

Management on Referral:

1.      Visual acuity.

2.      Cover Test and examine eye movements

3.      Cycloplegic refraction

4.      Examination following dilatation of pupils.

Incorrect Assumptions:


1.      Child will grow out of squint
This does not occur for true constant esotropia.  (note poor intermittent alignment in 0-3 months does occur with spontaneous improvement)                 

-Intermittent Exotropia (divergent squint) can recover spontaneously. But beware of exotropia in 0-2 years as this may herald poor vision due to an organic cause- (Tumour or cataract).

2.      Strabismus cannot be treated at an early age.
Early management of strabismus in first months of life improves the chance of obtaining strereopsis and makes for better amblyopia therapy.

Rules:
If strabismus is seen or suspected all serious aetiological factors must be excluded and therapy commenced promptly.

When esotropia is excluded on examination believe examination.

When exotropia is described by parents believe parents not the exam