Squint - glasses / surgery

[Natfontana]

Hello everyone

My dd has developed a sudden squint about a month ago, mostly in the left eye but very occasionally in the right one. She had a very rushed hospital consultation a week ago and was prescribed glasses in the first instance as she is a bit long-sighted (+2.5 in both eyes). She has been wearing her new glasses full-time since Friday (so this is day 4) but there doesn't seem to be any straightening as yet. If anyone has any experience / knowledge of this subject matter, I would really appreciate it if you could answer the following:

1. If a child has a fully accommodative squint, how long does it take to straighten with glasses? I've not found very much information online as to the usual timeframe (just one scientific journal which suggested that an assessment could be carried out after a month or so as to whether the glasses were working).

2. If a squint does not straighten with glasses, is surgery usually indicated? And will the docs do this immediately (or does the squint need to be monitored for months / years)? I've read many people posting that they had their kids' squints straightened through surgery but they often don't mention (i) if glasses are still required post-surgery or (ii) if the child has full binocular vision or whether the squint is just cosmetically fixed.

We are due a follow up in over a month but I'd love to hear of your experiences as I didn't have the opportunity to ask these questions in the hospital! Felt slightly fobbed off by the doctor who told me to take it one step at a time....

Thank you, Nat

DD is 3 years (and 3 months) by the way...

It can take about four months for the glasses to start working- not in all cases, but generally speaking. If there’s no change after that point they may decide to increase the strength of the glasses. If this doesn’t work then surgery can be considered. But it absolutely depends on the size/angle of the squint, whether it alternates right to left, and whether there is any binocular function. These things take time to work out in small children. You do have to be quite patient I’m afraid, and the advice to take one step at a time is quite correct.

Dd got glasses at 18 months due to a squint and being long sighted in both eyes. She didnt have squint surgery until age 4ish not long before she started school. She had patching treatment as she had poorer sight in 1 eye. She still has glasses now and is age 16.

P.s. dd does not have binocular vision

DD had glasses from 3, squint in one eye.

Caught before needed patching and after 6 months with glasses hospital confirmed she has full vision with glasses on.

Will have to see long term. The squint is stable. Not noticeable when in her glasses.

Dc had patching for couple of yrs (up to age 7 patching can help), squint mostly resolved I think, still wears glasses for seeing! (Strong prescription)

Barleysugar, many thanks for your prompt reply. Do you work in opthalmology etc? Or have a a child affected by a squint?

Wow, I'm really surprised it can take as long as four months for glasses to work - I had initially thought the glasses would either work or not pretty much instantly! So I guess it is a waiting game for a few months.

Do you have any idea long it takes roughly from the initial assessment before they can diagnose the type of squint? There seem to be so many types, each with different treatment /outlook. Feel so overwhelmed as I have no idea what we are dealing with at the moment....and as my daughter's squint varies massively depending on the time / day, I feel it's going to take a long time to get a proper diagnosis. Her squint was minimal on the day she was at the hospital but other times her iris is so far into the corner of her eye you can barely see it!

GuyFawkesDay, do you happen to remember how long it took your DD's squint to straighten once in her glasses?

Dementedpxie and ilovethewild, many thanks for sharing your experiences.

My dds squint was still noticeable with glasses on which is why she got the op. It was more for cosmetic reasons and to stop any nasty comments that may occur

Barleysugar, many thanks for your prompt reply. Do you work in opthalmology etc? Or have a a child affected by a squint?

Both are true! My daughter had the opposite problem tho ,her eye turned out! Had surgery age 4. She’s 13 now and no issues at all.

Is her vision very poor in one of her eyes? Unless it is, the reduction in the angle of the squint In fully or partially accommodative esotropia is usually pretty quick.
Are the glasses fitting properly - she’s not looking over the top of them is she.

It can take much longer to improve amblyopia (which is when the eye(s) see much less than expected even when wearing glasses).

At the next appointment, ensure that the drops have had sufficient time to work, some children take much longer to reach full cycloplegia. 30 minutes minimum, preferably 40.
+2.50 is a very low prescription for someone with an accommodative squint, especially an alternating one.

Hi underneaththeash, thanks so much for taking the time to respond. She was still squinting in glasses today - when you say the esotropia usually resolves "pretty quick" do you mean in a matter of days? If so, perhaps we are looking at non-accommodative esotropia.

In response to your questions / comments:

• she is mostly looking through the glasses although I have caught her peeping over the top a few times
• when I asked at the hospital they said that there was no evidence so far the vision in one eye was worse than the other (she is squinting 95% with the left eye however)
• drops were in for at least 30 mins - bizarrely she had a drops test at the optician a week before showing prescription of +1.75 (right) and +2.25 (left); I don't understand how there can be two different results but at least the "worst" result from the hospital was still not too bad

So glad to have found this thread. My dd is 11 and has just been found to possibly need surgery for double vision. Came as a real shock.
Hope your dd’s glasses help soon OP

If the glasses are going to reduce the squint they will usually show an effect within a few days. When a child develops a squint the first stage of treatment is to prescribe glasses for any longsightedness. For some children the eyes will be straight with the glasses on and this is called a fully accommodative esotropia. A partially accommodative squint is when the eyes are straighter with the glasses on but there is still some squint. For some children the glasses make no difference. Once thechild has worn the glasses to see how much difference they make further treatment depends on a number of different things. Squint surgery can be functional when the eye is straightened and the child is then able to use their eyes together with binocular vision , or cosmetic ( although this term is not favoured as much now ) when even when the eyes are straight the brain is not able to use the eyes together and only one eye is being used at a time. Children with accommodative squints can have a low to high amount of longsightedness there are no hard and fast rules. If your daughter’s squint is not straightening with the glasses . If she has only started squinting fairly recently she will hopefully have the potential for binocular vision and therefore correcting her squint sooner rather than later gives her the best chance of this. Squintclinic.com is a good website with reliable information.

My son developed a squint just before his 3rd birthday. Hospital referral and he was given a patch and had surgery approximately 10 months later. More patching followed by surgery on the other eye 12 months later. He then had glasses and more patching. After another year they talked about more surgery. I wasn't happy and told the orthoptist I was going to ask for a referral for a second opinion and was told Consultant was retiring and we would be seeing new Consultant. Son is now 7. New Consultant says he probably won't do surgery and wants to see him in a few months to assess what is going on. Son gets bifocals and for the first time things start to improve. He wore bi focal glasses for another 4 years. At 11 he was discharged with no squint, no glasses and 30 years later got reading glasses.

Don't know how things have changed but I recently asked him how he felt about it all, the surgeries, the endless hospital appointments, patches, glasses, bifocal glasses and he said he was glad we did it.

Hope it goes well with your little one.

OP I can imagine how upset you are, I remember crying and just wanting my son to be OK. I worried about his vision, I worried about the patches and glasses, I worried about him getting bullied and of course I worried about the surgery. I can honestly say he was pretty good through it all, he didn't like the surgery but I think that is fair enough. He was a trend setter and most of the boys in his class wanted Clark Kent glasses like his (horrible big black frames that he loved for a time) then they all wanted surgery to get a bionic eye like him (the 6 Million dollar man was big at the time.)

The song says "Sometimes it's hard to be a woman" I think it should be "Sometimes it's hard to be a mother."

Rodders92, thanks so much for taking the time to reply. It's been over a week now and I am still seeing no improvement (there could be some minimal straightening but it is hard to compare because of the effect of the magnification of the glasses). I'm really worried because if it's not the accommodative kind she has, the odds of her regaining binocular vision seem to be slim (the strabismus management guidelines from the Royal College of Ophthalmologists seems to suggest the most likely outcome would be suppression in the weaker eye).

I've also read a study that say that if binocular vision is lost for more than six months then it is effectively irreversible...can anyone shed any light on this? If it turns out she has a form of non-accomodative esotropia I'm wondering if we should try to find the money to have the surgery done privately so that she has the best shot of falling in this six month period...can anyone shed any light on this? Is time of the essence? It just seems that if she needs a four month trial of the glasses (to see if they work), she would never get a surgery date in time. If surgical correction is genuinely time critical for the purposes of restoring binocular vision (not just cosmetic alignment), does anyone know what the NHS waiting times look like for surgery? I'd never forgive myself if she lost her binocular vision because she was on a waiting list....

Also does anyone know how long it takes between your first appointment and being able to get a formal diagnosis of the type of squint?

1forsorrow, thank you so much for taking the time to share your story. Do you know exactly what the of squint your son had? And does he now have binocular vision? If not, how does he cope without it? I know there are much worse things children can get but I am genuinely devastated for my daughter and so worried not only for her sight, but the psycho-social implications long-term. It's also the uncertainty right now that is really difficult to deal with...I'm finding it difficult to sleep and relax because I am so anxious.

Flossie44, sorry to hear about your daughter. It's so worrying, isn't it? I genuinely hope she is ok, keeping fingers crossed for you.

Hi Natfontana, If her squint is not improved by the glasses then surgery fairly soon should be considered. The longer the squint is there before correction the less the chance that binocular vision will be regained. Some children will have binocular vision again if the squint has been there longer than 6 months but this chance lessens with an increased delay. How long the NHS waiting list is will depend upon where you are being seen, in our trust it is about 4 months. Before they operate they will usually want a couple of measurements of her squint that are fairly stable to plan how much surgery they need to do. I’m an orthoptist so can answer any squint related questions you have

The 4 month trial would be if there was amblyopia (which is when the eye sees less well than it should). They won't leave your daughter in glasses that are a low prescription that aren't correcting the squint for 4 months.

It does sound as if it is not accommodative (or only partially). What happens next will depend on your area and consultant. It my region, she'd probably be put on the list for surgery (as long as you consented) and the surgery would happen within a couple of months.

You're now a couple of weeks in, I think. So, yes, I'd have a plan B in place if waiting lists are long - you could even make an appointment for just after the NHS one which you could cancel if the wait is short. I suspect having a plan will make you less anxious too?

With regards to binocularity it's very hard to say. The majority of people retain some peripheral binocularity and it may be that your daughter's squint is significantly less/absent in the distance too. It's all very hard to say without actually having seen her.

Natfontana - it is a worry, yes. Does it bother your dd? Is she conscious of it?

My dd has double vision on and off for a couple of years. No obvious evidence of a squint however. She was finally seen by an ophthalmologist, who diagnosed ‘bilateral superior rectus palsy’. Probably congenital apparently and decompensating rapidly. She was give normal lense glasses (she has 20:20 vision) but one of the lense is blurred out. I’m guessing the modern patch scenario.

Can any of the optometrists here explain anymore about this palsy she has in both eyes?? She’s had her glasses 3 weeks and is now completely unable to see without them, in that she has permanent vertical double vision. And is unable to function visually.

Is this normal to decline so quickly?

Rodders92 and underneaththeash, thank you so much for your responses - your comments were really helpful (and reassuring!) and I really appreciate you taking the time to respond - it is very kind of you both. If I could trouble you with a few more questions, I'd be ever so grateful:

1. Her squint seems to vary in size depending on the day / time of day and possibly (but not definitely) where or how far she is looking. Is this normal? Or because it is early days and not fully established (the squint started mid-Jan)? Or could we be looking at an incomitant squint? If so, are these hard to diagnose? And is treatment also likely to be surgery for this type of squint?

2. Given that the squint varies in size, I'm concerned this may affect or delay diagnosis? Can it take multiple visits to understand what type of squint it is or is it generally ascertainable from the second assessment (post-glasses trial)? I'm also worried as to how the orthoptists can possibly accurately measure the angle for surgery if they only ever measure on a "good" day!

3. We are being seen at Moorfields. I'm sure you probably won't know what the NHS waiting lists look like for this particular hospital (anyone??) but is there any particular surgeon you know of / would recommend if we chose to go the private route. Would prefer to go to the absolute best if we are having to pay. Also, does anyone have a ballpark figure for private surgery (including anaesthetist, hospital etc)....need to work out if we will need to remortgage our house!!!

Thank you so much once again for your time - you are really helping me out at this difficult time.

Nat

Sending you a huge hug nat. I can feel your pain in your words. I really hope you get some answers soon. Xx

Hi Nat
Some squints in children will measure the same at different viewing distances and some will have what is called a near/ distance disparity. For convergent squints if there is a disparity the squint is more often bigger for close up viewing. Squints will often also be worse when a child is tired or unwell but the amount of variation is relatively small. Most squints in children are concomitant and not incomitant and part of the examination will be looking at her eye movements to exclude an incomitant squint, the small percentage of incomitant squints in children are due to a a problem with extra-ocular muscles or their nerve supply. Squint measurements are used to plan surgery as the ophthalmologist will adjust the eye muscles by a certain number of millimetres depending on the angle of squint. For a convergent squint the most common operation carried out is recession of the medial rectus and sometimes resection of the lateral rectus as well and depending on the exact pattern of the squint surgery can be on one or both eyes. It is worthwhile asking for an appointment later in the day if you are noticing her squint more with tiredness. Ophthalmologists specialise in certain areas and for squints you will need a specialist strabismus/paediatric surgeon. Moorfields is a very large centre so you are likely to have a choice of surgeons. I don’t work in London so don’t know how much you are likely to pay for private surgery there but you should be able to find this out from Moorfields