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Reason for Squint Eyes (Strabismus) in Indian Children: Main Causes, Diagnosis & Treatment

With inputs from Dr. Uma M - Consultant Family Physician, and Diabetologist

Updated on: November 2023

With inputs from Dr. Uma M - Consultant Family Physician, and Diabetologist

Updated on: November 2023

Reviewed by Dr Raja Indana

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Worried your child or your newborn baby may be squint-eyed? Identifying a squint in your child is often not too difficult. Squint eyes is a condition where each of the eyes points in a different direction. This misalignment is common in younger children and can be found at birth or can develop later. Needless to say, squint eyes affect adults as well. The reason for squint eyes in Indian children is many. Sometimes babies are born squint-eyed if one or both of their parents suffer from a similar misalignment of the eyes. However, you can be assured that squint eyes are relatively easy to diagnose and treat. But first, let us look at what exactly a squint eye is and how it is caused.

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Chapter 1: What is Squint Eye or Strabismus?

Squint or strabismus eye is a problem associated with the eyes in which both eyes look in different directions at the same time

Squint Eyes in children MFine - reason for squint eyes

This is a squint-eye picture. Normally, when you look at an object, your eyes capture the image of that object just like a camera does. The images of the object captured by both eyes are slightly different from each other. Your brain fuses the two images to form a 3-D picture of that object and this is called binocular vision.

This binocular vision helps the in-depth perception of that object. The eye movement is controlled by six muscles that are present in your eye.
Your brain sends signals to these muscles to direct their movement and help you see in different directions.

For normal binocular vision, both your eyes need to be aligned in the same direction. But that’s not the case in a squint. Here, one eye focuses on the object (referred to as the fixating eye) whereas the other one looks at something else (referred to as deviating eye).

Squint eyes most commonly occur in
children less than 6 years of age but can occur in
people of all age groups.

Squints may be constant (if occur all the time) or maybe intermittent (if it happens sometimes). In some cases, the same eye deviates every time (unilateral) whereas in other cases, the eyes may show an alternate pattern of turning.

Squinting results in a lack of 3D vision or depth perception (stereopsis), and even loss of vision in the affected eye (amblyopia) if not corrected.

Depending on the direction of the movement of the deviated eye, strabismus types are classified into the following: Look at the following squint eye images.

1. Hypertropia

marked by upward turning

2. Hypotropia

marked by downward turning

3. Esotropia

(also called crossed eye)
marked by inward-turning

4. Exotropia

(also called walleye)
marked by outward turning

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Chapter 2: Reason for Squint Eye

Squint can occur in both children and adults, but the reason for squint eyes is different in both. Some of the common reasons are:

Hereditary: You may have a family history of squint eye.
Congenital: Some babies are born with a squint as their eyes have a tendency to cross by birth.

It is estimated that about 2/3 of all babies have exotropia eye or outward turning of one or both eyes at birth.

Weakness in eye muscles: You may develop squint eyes later in your life as a result of weak eye muscles. Eye muscle weakness is a common reason for squint eyes in adults. Some of the problems that may result in weakness of eye muscles are Grave’s disease (thyroid gland problem), Myasthenia gravis, diabetes, stroke, and brain tumours.
Eye disorders: Some eye diseases such as cataract, glaucoma, corneal scars, and optic nerve disease can cause squint eyes.
Injuries: Any kind of head or eye injury as a result of an accident or an eye surgery can make your eye muscles weak, resulting in a squint.

Strabismus Syndromes:

Sometimes the reason for squinting eyes is related to a structural abnormality in the eye or surrounding tissues. Diseases like Duane syndrome, Möbius syndrome, Brown Syndrome, and Parinaud Syndrome are some conditions that cause squint eyes.

Refractive errors and strabismus:

You may also develop strabismus as a result of eye problems such as:

Squint Eyes in children MFine - Strabismus

Myopia or nearsightedness: an eye condition where you find difficulty seeing distant objects.

Hypermetropia or farsightedness: an eye condition where you find difficulty in seeing things closer to you.

Astigmatism: an eye condition that causes blurry vision of an object that is either placed near to or far away from you. Astigmatism is caused when the shape of your eye is different from that of a normal eye.

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Chapter 3: Symptoms of Squint Eye

An obvious sign of a squint eye is, that your eyes are not pointing in one direction. Since you are not looking at one place, you may face the following vision-related issues:

Visual confusion:

You may see two objects at the same place, and the brain fuses the image from both eyes into one, causing visual confusion.

Double vision:

You may see two images of the same object, where one image is blurred and the other one is clear. The deviating eye shows blurred images, and your fixed eye will show clear images.

Lazy eye or amblyopia:

This is a condition characterised by permanent loss of vision in the deviating eye. If the squint is left untreated, over a period of time your brain starts ignoring the blurred image produced by the deviating eye, and you get to see only one image that is produced from the fixing eye. Gradually the vision in your deviating eye reduces until it is completely lost forever.

Silent symptoms of squint eye:

Another classic symptom of squint eyes is closing eyes in bright sunlight.
If you constantly turn your head to one side or move it up or down to see things around you, then you may be suffering from squinting eyes. This is common in babies as well. In some cases, short-term squint in children is commonly seen when they’re daydreaming or when they are excessively tired.

Sometimes baby squinting eyes may worry you about the strabismus eye but in most scenarios, he/she might not actually have it. This condition is commonly known as pseudostrabismus. Usually, infants with a fold of skin at the inside of their eyelids or those with wide, and flat noses may have crossed eyes when they look to the sides. This is actually because of their facial structure and is completely normal. If you have concerns about a squint eye, consult an ophthalmologist to ensure good eye health.

”

Important:

“A lot of new parents come to me with worries that their baby has squint eyes. However, it’s completely normal for young babies to have squint eyes since they’re still learning how to focus. In most cases, squinting resolves by itself. In case the condition persists as they grow, there are exercises and procedures that can be used to treat it.”
– Dr Uma M, Consultant Family Physician and Diabetologist

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Chapter 4: Diagnosis of Squint Eye

Early diagnosis and treatment of squint eye are important to prevent vision loss. Sometimes squint can be an indication of an underlying disease such as retinoblastoma (cancer of an eye). So early detection can not only help in ruling out any possible disease but also ascertain treatment success.

Squint eye in babies below 3 months of age is
quite normal, but if the squint persists beyond
this age, then it must not be ignored
as it may lead to vision loss.

If you suspect having squint, then make an appointment with an ophthalmologist who will perform a couple of tests to check your eye health. Following diagnostic tests are commonly done for squint eye:

Routine eye checks:

During a routine eye check-up, your ophthalmologist may ask you a couple of questions to learn about any family history of squint eye or strabismus surgery during childhood. Family history will also help him screen for possibilities for any serious underlying health problems.
The ophthalmologist may perform some tests to check your vision by asking you to read from a distance
He may perform a cover test by covering and uncovering each eye, in turn, to see your eye movement and turning.
A retinal examination will help the ophthalmologist examine the backs of your eyes

Hirschberg test or Hirschberg corneal reflex test:

Squint Eyes in children MFine - Hirschberg Test

This is a common diagnostic test for strabismus. This is an easily performed test in children, particularly those who are non-cooperative. To perform this test, your ophthalmologist will project a light source such as a penlight into your both eyes simultaneously. As you look directly at the light, he will compare the placement of the corneal light reflex in each eye. Your fixating eye will have the light reflex in the centre of your pupil, but your affected eye will have the reflection away from the centre of the pupil.

If your doctor notices some other physical symptoms, he may perform additional tests to examine your brain for conditions like cerebral palsy or Guillain-Barré syndrome.

Sometimes, children suspected of pseudostrabismus in earlier diagnosis are likely to be diagnosed with true squint eyes later.

Hence it is very important to undergo a detailed diagnosis to rule out any possibility of strabismus in such children to avoid the serious consequences of squint eye.

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Chapter 5: Treatment for Squint Eye

A cure for squint eye can be achieved if it is diagnosed early. The cure for squint eye depends very much on the cause of squint eye. Squint eye treatment in adults includes exercises and the use of glasses that are helpful in achieving normal binocular vision. Some examples of these squint eye treatments without surgery are as follows:

Glasses and eye patches:

Wearing glasses can be helpful if the reason for squint eyes is vision problems such
as myopia or hypermetropia.

Squint Eyes in children MFine - Wearing Glasses

This will help you in both correcting your hypermetropia and keeping your eyes aligned. If you have developed a lazy eye, then your eye doctor will suggest you wear eye patches over the fixating eye or will put a few drops of atropine eye drop into your fixating eye to blur its vision to force you to use your affected eye. This will gradually strengthen your weakened eye.

Botulinum toxin injections or botox:

Botulinum toxin is injected into the affected eye under topical anaesthesia to cause temporary paralysis of an eye muscle. This results in the long-term improvement in the alignment of the eyes. It takes 1 to 2 weeks post-injection to develop the effect, and it lasts up to 3 months.

Squint Eye Exercise:

Your ophthalmologist can teach you a couple of eye exercises to help resolve your squint. Squint eye exercise can act as complementary to the medical treatment for misalignment but cannot be its substitute. Check out the following simple home remedy for squint eye exercises that you can perform at the comfort of your home:

Squint Eyes in children MFine - Pencil pushup

1. Pencil pushup or Home Based Pencil Push-Ups (HBPP):

Take a pencil and hold it in your front. Choose a point that you want to focus on (the pencil tip, or the eraser on the other end, or any mark on the pencil). Keep both eyes focused on this point and slowly move the pencil closer to you till it touches your nose. Keep your eyes fixed on the focal point for as long as you feel comfortable. Stop the exercise when your vision turns blurry. This exercise is a great squint eye treatment in adults and is helpful in “convergence insufficiency.” is a condition when your eyes find it difficult to align. One of the main convergent squint causes is due to close tasks like reading or computer work.

Squint Eyes in children MFine - Brock string exercise

2. Brock string exercise:

This exercise is a good home remedy for squint eye and was developed by a Swiss optometrist named Frederick Brock to help improve eye coordination. Take a string of length about 5 and 12 inches; thread the string with three beads of different colour keeping an equal distance between each of them. Stick one end of the string to a handrail or pin it to the wall while holding the other end to your nose. Look at each bead turns. Make sure that you are seeing the same pattern every time. The bead you are looking at is lying at the intersection of two similar strings making an “X”. If you see the “X” before or after that bead, then this is the indication that one of the eyes is not pointing at the bead. Repeat this exercise until you do it right with all the beads.

Surgical treatment:

A surgical procedure is only recommended when all other squint eye treatment without surgery options have failed to correct the eye misalignment.

What is squit surgery?
Squint surgery in adults and babies are performed in the hospital or at a doctor’s clinic where you may have to stay for full or half a day. There is no squint eye surgery age limit as this surgery is safe to perform for all ages.

Before performing the surgery, your ophthalmologist will give you general anaesthesia to sedate you. To correct the misalignment, an ophthalmologist will either tighten or loosen or move some of your eye muscles. During the procedure, you will not feel pain as you will be under the effect of anaesthesia, but after the surgery, you may have some discomfort. You will however be given some antibiotics, steroid eye drops or ointments to heal faster.

You may return to your normal routine in a few days after squint surgery with some precautionary measures. Your doctor may advise you to avoid submerging your head in the water for about 2 weeks after squint surgery and take your medicines properly. You will also be advised to avoid straining your eye too much for some time. In some cases, there arises a requirement for another surgery soon after the first one or maybe a year later due to the reoccurrence of the squint.

Squint surgery in adults and older children is a necessary step. Small children as young as 1 year of age can comfortably be operated. It is advisable to get the surgery done as early as possible, as misalignment can be corrected and binocular vision can be sustained if corrected an early age.

The treatment options for squint eye include:
– Glasses
– Eye patch for non-squinting eye
– Botulinum toxin or BOTOX injection
– Eye exercises: Home Based on Pencil Push-Ups and Brock string exercises,
– Surgery to loosen or tighten the eye muscles to correct the misalignment.

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Chapter 6: Frequently Asked Questions On Squint Eyes

Q. What is squint meaning?

Ans: Squint is a condition associated with misalignment of the eyes. If you have a squint, one eye (fixating eye) will focus on the object that you are seeing while the other one (deviating eye) will turn inward, outward, upward, or downward depending upon the type of squint you are suffering from.

Q. Does squint affect your day to day life?

Ans: Squint affects the way you see things around you. People with squint often find it difficult to make out the 3-dimensional measurement of objects around them. If left untreated, it may lead to vision loss in the affected eye. So yes, it does affect your daily life activity. But squint eye can be successfully treated.

Q. Does squint eye increase with age?

Ans: A squint is a condition where the eyes focus in different directions. Squint in babies and toddlers is common but can occur at any age. If not treated in early age, the condition may progress and cause vision loss in the affected eye later.

Q. What causes squint eye blindness?

Ans: If left untreated, squint eye may result in permanent vision loss in the affected eye. This condition is known as amblyopia or lazy eye.

Q. Why is my baby squinting eyes?

Ans: Squint eyes are mostly present in children; however, it may occur in adulthood too. Squint in babies less than 3 months of age is normal, but if squinting persists beyond this age, then it is better to consult an eye doctor.

Q. Is squint eye and lazy eye the same?

Ans: Squint is an eye problem that happens due to the misalignment of the eyes. Amblyopia or lazy eye develops as a consequence if squint eye is not treated. Lazy eye is a condition of permanent loss of vision in the affected eye.

Q. Can squint come back?

Ans: Yes, it is possible that you may get squint or double vision after squint surgey or after complete treatment.

Q. Who does commonly get squint eyes?

Ans: Squint eye is particularly common in younger children but may affect adolescents and adults also. Squint eye is a condition of misalignment of the eye where both eyes look in different directions.

Q. What is the reason for squint eyes?

Ans: Some reasons why squint eyes occur are:

Family history of squint eye (hereditary)
It may be present by birth (congenital)
Weakness of eye muscle and eye diseases
Head injury or trauma during an eye surgery
People having vision-related problems such as myopia, hypermetropia, and astigmatism may also develop squint eye
Children born with diseases such as Duane syndrome and Möbius syndrome are at risk of developing a squint.

Q. Can eye-straining cause squint eyes?

Ans: It has been found that people often squint when reading a book or working on a computer. Also, children may squint a bit during daydreaming or when excessively tired.

Q. Is squint eye hereditary?

Ans: Yes, you may get squint eyes if anyone in your family has had this problem.

Q. Can eye surgery cause squint eyes?

Ans: Yes, you may develop squint eyes after eye surgery.

Q. Are vision problems linked to squint eyes?

Ans: People having vision-related problems such as myopia, hypermetropia, and astigmatism may develop a squint eye.

Q. What is the cause of squint eyes in adults?

Ans: Squint eyes may have hereditary connections. In adults’ eyes, muscle weakness is a common cause for squint eyes.

Some of the problems that may cause weakness in eye muscles are Grave’s disease (thyroid gland problem), Myasthenia gravis, diabetes, stroke or brain tumours. Adults may also get squint eyes as a result of eye surgery or after an accident.

Q. How do I know if I have a squint?

Ans: The most obvious sign of squinting is, your eyes do not point in the same direction. One eye will point at the object that you wish to see whereas the one with squint problem will turn inward, towards your nose, outward, upward or downward.

Q. Is it possible that my child is exhibiting squint eye symptoms, but actually does not have it?

Ans: Yes. This condition is called pseudostrabismus. Some babies have broader skin folds at the inner corner of the eyelids. This is often associated with a broad flat nose, especially between the eyes. These features contribute to a crossed eye appearance as the sclera or white surface
of the eye towards the nose is less visible. This is especially noticeable when the child looks to the side. This may create an illusion of having a cross-eye where it is not so.

Q. Is squint in children different from that in adults?

Ans: The symptoms of squint eye are the same in both children and adults, but the reason for squint eyes may be different in both.

Q. Are double vision and lazy eye the same?

Ans: It is very common that a person with squint eyes may see two images of the same object known as double vision. Whereas, the permanent loss of vision in the deviating eye is known as lazy eye or amblyopia.

Q. Are strabismus eye and pseudostrabismus the same?

Ans: Strabismus or squint eye is an eye problem where your eyes do not point in the same direction. In contrast, pseudostrabismus is a condition of false strabismus due to specific facial features.

Q. Does squint causes difficulty in seeing sunlight?

Ans: A person suffering from squint eyes often closes his/her eyes in bright sunlight.

Q. Does a person with squint eyes see many things in one time?

Ans: A person having squint eyes may see two objects at the same place. In such a case, the brain fuses the image from both eyes into one. This results in visual confusion.

Q. How is the squint eye detected?

Ans: To see if you have squint eye, your doctor may do a couple of tests:

Tests to check your vision by asking you to read from a distance
Cover test to see your eye movement and turning
A retina examination to see the backs of your eyes
Hirschberg corneal reflex test

Q. Is squinting in children normal?

Ans: Squinting is normal in infants of age less than 3 months, but after this age, they need to be examined for true squint eyes.

Q. Does cancer cause strabismus?

Ans: Sometimes, the reason for squint eyes may be the presence of an underlying disease like eye cancer.

Q. What diseases are often mistaken with strabismus?

Ans: Some of the diseases which may mimic the symptoms of squint are:

Brain tumour
Retinoblastoma (cancer of the eye)
Headaches
Abnormal red reflex
Double vision
Nystagmus (involuntary, repetitive, side-to-side eye movement)
Face turned to the side
Cerebral palsy (disease of the nervous system)

Q. Can strabismus be the sign of any underlying condition?

Ans: Yes, it may be an indication of retinoblastoma, a type of eye cancer.

Q. What is the confirmatory test for strabismus?

Ans: Hirschberg corneal reflex test is the confirmatory test most often used for diagnosis of strabismus.

Q. How early can strabismus be detected?

Ans: Most children with squint eyes are diagnosed when they are 1 – 4 years old. It is rare that a child develops squint after age 6. If this happens, it is important to see a doctor right away to rule out other conditions.

Q. Can squint get corrected on its own?

Ans: Squint does not go away on its own, but it is possible to treat all types of squint. Early treatment not only prevents vision loss but also ensures sustained binocular vision.

Q. Is squint surgery a safe option?

Ans: Like any other treatment, surgery has its adverse effect. Your doctor will suggest if squint surgery is the best option for you or not. Overall it is absolutely safe.

Q. What is the best treatment of squint eye?

Ans: Treatment depends on the cause of the squint eye. Your doctor will be the best person to judge which treatment is suitable for you. The treatment options available are:

Glasses
Eye patches/eye drop
Botulinum toxin injection
Eye exercises
Surgery

Q. What care should I take after strabismus surgery?

Ans: Your doctor will tell you what all precautions you need to take for some time. Some of them are:

Take your medicines properly
Do not strain your eyes too much
Do not submerge your face into the water for about 2 weeks after the surgery

Q. Is squint eye correction possible without surgery?

Ans: Certainly, there are non-surgical options available for correcting misalignment. Your eye doctor will suggest the option that will work best for you.

Q. Is squint eye correction possible in adults?

Ans: Yes, all forms of squint eye are treatable. But it is advisable to get it treated as early as possible to get the best results.

Q. Is there any squint eye treatment for babies?

Ans: There is no limit on squint eye surgery age. Babies as young as 1-2 years of age can be comfortably operated.

References

Squinting means both eyes are looking in different directions. Squint eyes most commonly occur in children less than 6 years of age but can occur in people of all age groups. Depending on the direction of the movement of the deviated eye, strabismus types are as follows:
hypertropia (up), hypotropia (down), esotropia eye or crossed eye (in), and exotropia eye or wall eye (outwards).

Some of the common reasons for squint eyes are:
– Hereditary
– Present by birth (congenital)
– Eye muscle weakness and eye diseases
– Head injury or trauma during an eye surgery
– Some of the vision-related problems such as myopia, hypermetropia, and astigmatism can also cause squint eyes. Children born with diseases such as Duane syndrome and Möbius syndrome are at risk of developing a squint.

A person with a squint exhibits the following symptoms: visual confusion, double vision, amblyopia or lazy eye, closing eyes in bright sunlight, and turning one’s head to one side or up or down to see things. Babies often squint when tired and while daydreaming.

Early diagnosis and treatment of squint eye can prevent vision loss. Squint can be an indication of serious health problems like cancer of the eye. Common diagnostic tests for squint eye are the Cover test and the Hirschberg corneal reflex test. In case of other physical symptoms during the check, the doctor may perform additional tests to see if any brain condition.

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