GPAtlas🧭 When to suspect
Suspect a squint (strabismus) whenever a child's eyes are misaligned – one eye turning in (esotropia), out (exotropia), up (hypertropia) or down (hypotropia) while the other fixes on a target. The misalignment may be constant or intermittent.
Intermittent horizontal misalignment can be normal in the first weeks of life, but by about 3 months the eyes should be aligned. A true squint does not grow out, and either of these is abnormal and warrants referral:
• Any constant squint at any age
• An intermittent squint persisting beyond 3 months
The commonest type, accommodative esotropia, typically appears between 18 months and 3 years.
The prize is preventing amblyopia ("lazy eye").
• The developing brain suppresses the image from the misaligned or out-of-focus eye.
• If this is not corrected within the sensitive period of visual development, the loss becomes permanent (treatment is far less effective beyond about 7–8 years).
A squint can also be the first sign of sight- or life-threatening pathology – retinoblastoma or raised intracranial pressure – so in primary care:
• Detect the squint
• Check the red reflex
• Refer down the right pathway
| Classifying the squint | What it means in primary care |
|---|---|
| By direction | Esotropia (inward) · exotropia (outward) · hypertropia (upward) · hypotropia (downward). |
| By timing | • Constant – abnormal at any age • Intermittent – may be physiological in the first 3 months • Refer if persisting beyond 3 months |
| By eye movements | • Concomitant/non-paralytic – full eye movements, angle constant in all directions • The usual childhood squint → ophthalmology • Incomitant/paralytic – restricted movements, angle varies with gaze, often diplopia • Suggests cranial nerve palsy or intracranial pathology → urgent neurology |
| Pseudosquint | • An apparent squint from epicanthic folds, a broad/flat nasal bridge or wide-set eyes • Corneal light reflexes are symmetrical and the cover test is normal – common, and not a true squint |
Suspect a squint particularly where there is:
• A family history of squint, amblyopia, childhood glasses or retinoblastoma
• Prematurity, low birth weight or retinopathy of prematurity
• A neurodevelopmental condition (cerebral palsy, Down syndrome)
• A craniofacial anomaly
• Significant refractive error, especially long-sightedness
Source: NICE NG127 · NHS childhood vision screening (UK NSC)
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