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. Any constant squint at any age, or an intermittent squint persisting beyond 3 months, is abnormal and warrants referral – a true squint does not grow out. 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, and 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 the key primary-care skills are to detect the squint, check the red reflex, and 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; or significant refractive error, especially long-sightedness.
Source: NICE NG127 · NHS childhood vision screening (UK NSC)
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