Consultancy Corner: Looking at the myth on squint squarely in the eye

Kavya’s cute, chubby baby’s eyes were turned inside, giving her a cross-eyed look. Her parents were extremely anxious. This little child had a flat nasal bridge along with small folds of skin near the inside of her eyes, resulting in this peculiar look.
Consultancy Corner: Looking at the myth on squint squarely in the eye
Dr. Manjula Jayakumar, Consultant: Paediatric Ophthalmology, Dr.Agarwal’s Eye Hospitals Chennai

Chennai

As her nasal bridge straightened and the folds retracted, her eyes would start looking better and the cross-eyed look would eventually disappear as she grows older. Conditions such as Kavya’s fall under a case of false squint. 
What is a squint? Generally, the eyes of a person look straight and fix on the target perceived. Squint is a condition where there is ocular misalignment, in which while one eye looks straight, the other looks either inward, outward or upward. Not all newborns are endowed with straight eyes. A large population study has shown that only 30 per cent have straight eyes, 69 per cent have variable amount of outside deviation and only one per cent has inside deviation. In most cases, these deviations disappear within two months of birth, as the child would develop straight- looking eyes. However, if the condition persists, it is diagnosed as a congenital or birth squint and this deserves an eye evaluation. It is much more common to see a congenital esotropia (inside deviation/ cross eyed) than a congenital exotropia (outside deviation/wall eyed). The cause of congenital squint could be due to a combination of factors like imbalance in muscle forces, with absence of cortical fusion. 
Even if a child is born with straight eyes or the eyes remain straight during the initial few years of life, they can subsequently become crossed. This can be due to an uncorrected refractive error, imbalance in muscle forces or nerve palsy. There are also special types of squint which are associated with head tilt or face turn. 
Squint is primarily a muscle problem but it could also be due to a disease inside the eye. The diseases could be due to a myriad of causes like an opacity in the cornea, cataractous changes in the lens, retinal problems like coats disease or intraocular tumours like retinoblastoma. Therefore squint could just be a simple manifestation of a more dangerous disease inside the eye and hence every squinting child needs a complete eye examination.
Consequences
* The eye that squints often, usually has a decrease in vision or develops into a lazy eye but a squint that alternates freely between the two eyes is a sign of equal vision in both eyes.
* A child may have double vision as in a case of an intermittent squint or during the acute phase of a  paralytic squint. 
* A squinting child is a picture of poor cosmesis and this may lead to ridicule during the upbringing years which may create permanent psychological scars. 
One of the biggest disadvantages in a squinting child is the absence of binocular vision. Binocular vision is a gift in all predators which gives the animal the ability to use both eyes together and this results in depth perception or stereopsis and the binocular summation helps to improve the overall clarity of vision. This will help the predator to zero in on the prey. Man is also endowed with binocular vision and this is completely absent in squinting patients except in intermittent squint where there are periods of non-squinting time when binocular vision is possible. A few decades ago squint was considered to be a lucky charm for the child. He would be allowed to grow, live and die with it. It was offered the least attention by most parents. Today there is awareness but this has to increase a lot more. Things to be remembered are a squinting child needs a complete ophthalmic examination, some squints can be corrected with spectacles and most by surgery which is safe, simple and effective. Surgery when done at the right time can restore binocular vision especially in intermittent squints but most importantly it helps children to grow into self-confident individuals.

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