Calling all orthoptists squint advice...

[Missmiller]

Hi I would appreciate any help re this if you have knowledge in the area...

My 7year old child has glasses to correct her +4.00 prescription in each eye. Without her glasses, her left eye has a convergent squint, very evident. The glasses control it well.

She has been discharged by the hospital eye clinic and is now reviewed by a high street optician every 6 months.

We were told today that my daughter may need to have surgery as a 10/11 yr old as her squint will never go and contacts may not correct it.

This is contrary to previous advise saying she would not need surgery and it may improve.

I feel quite anxious about what the likely prognosis is:

Can anyone help with their expertise or experiences please?

Xxx

I’m an orthoptist. If her squint is controlled by her glasses , contact lenses should give the same control. If her squint is completely controlled with the glasses on it is fully accommodative and the only treatment usually needed is correction of the longsight by glasses or contacts, occasionally a child with a fully accommodative squint can start to squint even with their glasses this is called decompensation and may then need surgery but most children with this type of squint continue to control when the glasses are on

Thank you for your reply. The optician today was saying that contacts do not always correct it like glasses do.

She was talking about how, as a teenager, she may not wear her glasses etc and therefore, may wish to opt for surgery to straighten the eye.

I hoped the squint may also improve as she ages, but we were told it will never go.

Sorry for the long explanationIf the contact lenses do not under correct the longsight they should give good control of the squint. With a +4.00 prescription if she doesn’t have her glasses on she will have to do an extra 4 dioptres of focussing (called accommodation) compared to someone who isn’t long sighted. The closer things come the more accommodation is needed so if she is looking at something 30cm away she would need to focus 3 dioptres if she has her glasses on but 7 dioptres if she doesn’t wear them. Children can over accommodate very well so without her glasses she can see quite well but the excess accommodation for her is causing the eye to turn in. The ability to accommodate declines rapidly with age so she will be able to see less well without her glasses as she gets older even as a teenager into early adulthood . Squint surgery is not carried out for a squint that is controlled when glasses or contacts are worn so she would not be able to decide she doesn’t want to wear glasses and have surgery instead as we know that glasses will be needed later on . The only way she can straighten her eye without glasses is to relax her accommodation and let her vision blur. The type of squint she has is not likely to change significantly with age.

I'm a Optometrist with an extra qualification in children's vision. Sometimes contact lenses do give a little less control over the squint than glasses due to the "base out" effect in glasses being lost with contact lenses.

However, that wouldn't be that significant with your daughter's prescription as it's not that high.

It's also likely that she'll get a little bit less longsighted in her teens anyway. (Although she'll then get a little worse in her 40's)

It's very unusual to operate on a fully accommodative squint.

If she does choose to wear contact lenses and they don't provide full control over the squint, there are exercises you can do to increase the strength of the eye muscles (increasing fusional reserves).

Thank you. I think I understand it all but it’s really hard to get my head around.

I wonder why the optician mentioned the possibility of surgery and referring her back to the hospital when she’s about 10/11. It really alarmed me and my daughter(she is very bright so understood all that was being discussed).

My daughter’s squint became obvious when she was 3 years and 2 months old. 5 months previous to this she had a very very severe case of chicken pox and unfortunately she carries a LOT of facial scars still now. I have read about the possible link between chicken pox and squints and feel sick to the stomach that this may have weakened her eye muscle.

Anyway, not a lot we can do now. Glasses suit her loads but I worry about her as she’s already talked about how she wishes she didn’t have to wear them :(

Thanks a lot for your help.

Also... I find articles online which give false hope such as this

”Some children do indeed outgrow accommodative esotropia. However, it takes several years and usually not before 9-12 years of age or older. Children do not outgrow accommodative esotropia in only a few months.It is difficult to predict which children will outgrow their need for glasses“

@Missmiller - it is possible to "outgrow it", as children become less longsighted as they get into their teens.

It's difficult to explain, but an esotropia occurs because of the link between accommodation and convergence. So as a prescription (usually) weakens during tweens/teens you no longer need to accommodate as much to see properly and therefore less convergence occurs. It depends on an individuals AC/A ratio (so the amount of convergence to accommodation).

For example, my daughter is currently +4.50/+5.00 and doesn't squint as she has a low AC/A ratio. If she had a prescription of +6.00 she may squint. Your daughter may end up being +3.00 for example and her A/C ratio may then be low enough that she doesn't squint (although it may still happen when she's tired).

However, we just don't know and I wouldn't dwell on it, she's fairly happy in her glasses, she has the type of squint that doesn't require surgery and her prescription isn't too high (and should reduced a little) and when the time comes she can try some contact lenses.

Most children start off longsighted and often that can reduce with age as emmetropisation happens. If your daughter is +4.00 at 7 her prescription may come down with age but she will remain longsighted. You don’t grow out of accommodative esotropia however some children gain some control without glasses by using fusional reserves. Accommodation of the eyes is part of the near reflex which also includes convergence of the eyes and the pupils to get smaller. So if you are having to do extra accommodation because you are longsighted this stimulates more convergence of the eyes, for some children their fusion is strong enough to prevent a squint developing and others will develop a squint. With a +4.00 or less prescription the control of her squint is likely to be little different with glasses or contact lenses and surgery is not indicated unless she starts squinting when the glasses are worn , some children start off as fully accommodative squints and then can start to squint even with glasses but for most it tends to remain fairly stable

Thank you for all the helpful information. It really is a lot to take in but I keep re reading this to try understand it. I really appreciate your help as it causes quite a lot of anxiety not knowing what to expect xx