Squint and Oculoplasty Clinic

What is squint (strabismus)?
Squint is a misalignment of the two eyes where in two eyes are not looking in the same direction.

This misalignment may be constant, being present throughout the day, or it may appear sometimes and the rest of the time the eyes may be straight called as intermittent squint.

What causes squint?
The exact cause of squint is not known. Six muscles control the movement of each eye (see picture) . Each of these muscle acts along with its counterpart in the other eye to keep both the eyes aligned properly. A loss of coordination between the muscles of the two eyes leads to misalignment. Sometimes a refractive error hypermetropia (far sightedness) or an eye muscle paralysis may lead to deviation of the eye. Poor vision in an eye because of some other eye disease like cataract, etc. may also cause the eye to deviate. Therefore it is important in all the cases of squint, especially in children, to have a thorough eye checkup to rule out any other cause of loss of vision.

What is 3D vision?
When both the eyes have good vision and they are aligned properly, they focus on the same object. Each of the eyes sends picture of the same object, viewed from a slightly different angle. These two images reach the brain, where they are fused to form a single three-dimensional picture with depth perception. This is known as 3D vision. This gets affected in children with squint.

What are the problems faced by a patient with squint?
When the eyes are not aligned properly, each of the eyes is focusing on a different object and sends signal to the brain. These two different images reaching the brain lead to various problems that are different in children and adults. In children it can cause loss of depth perception (3D vision) and lazy Eye Disease (poor development of vision in the squinting eye) An adult can't ignore the image from either eye, and therefore they can have double vision. This can be very annoying and may interfere with work. Certainly loss of 3D vision and cosmetic deformity are also causes of concern.

What are the symptoms of squint?
In a child, the parents may notice the deviation of eyes. It is important to remember that the eyes of a newborn are rarely aligned at birth. Most establish alignment at 3-4 weeks of age. Therefore squint in any child who is more than one month old must be taken seriously and should be evaluated by an ophthalmologist. Adults may notice double vision, or misalignment of the eyes.

How is squint diagnosed?
The squint is diagnosed by the ophthalmologist specializing in that field. He or she would do a few special tests to confirm the presence of squint, and find out the of the squint. In some cases there may be a false appearance of squint due to broad nasal bridge in a child. This is called as pseudo squint.

What is the aim of the treatment for squint?
The aim of treatment of squint in order of importance are:

* Preserve or restore vision
* Straighten the eyes
* Restore 3D vision

When should the squint be treated?
In a child, the treatment of squint and any associated amblyopia should be started as soon as possible. Generally speaking, the younger the age at which amblyopia is treated; the better is the chance of recovery of vision. Remember that the child would never grow out of squint. A delay in treatment may decrease the chances of getting a good alignment and the vision. Earlier the better!

What are the treatment options?
* Glasses
* Patching therapy
* Surgery

Are glasses necessary?
If the child has significant refractive error, glasses are a must. In some cases wearing glasses may correct squint. In other cases, wearing glasses help the eyes to see clearly. This clear vision is very important for the treatment of amblyopia, and also for maintaining the alignment of eyes after they have been aligned by surgery. Remember surgery cannot replace the need for glasses.

What is patching therapy?
In some children, squints cause the squinting eye to become 'lazy' and stop working properly. Patching the 'good' eye will make the lazy eye work harder, which improves vision.
Patching improves vision it does not treat the squint, although the unpatched eye will appear to be straight while the patch is worn. Sometimes when the patch is removed the squint may be temporarily more noticeable but later returns to the pre-patching position. The patch is made from non-irritating material to prevent rashes, and spectacles are worn over the patch. It is thought that the patching therapy works best for children below 7-8 years of age.

How long the patch should be worn?
Patching is recommended for all the waking hours of the child. It is important that the child is involved in some near vision activity during patching, such as coloring, reading or schoolwork. This will achieve maximum effect and help the child comply with patching because it distracts attention from the patch. Perseverance with patching is vital. Their are different protocol to be followed based on various factor such as age of the child, the eye which is weak, etc. The patching needs to be continued at least till the age of 7-8 years.

Squint surgery
Treatment of squint generally requires eye muscle surgery. However, some patients may need glasses, prisms, medications, or may be best left untreated. The best way to determine whether straightening of the eyes is possible and appropriate, is to undergo an examination by a strabismus surgeon who is experienced in treating adults.

Is adult squint surgery only cosmetic?
In the past, most eye doctors thought that adults with misaligned eyes could not be treated successfully, or that treatment was "only cosmetic". Advances in the management of misaligned eyes now provide benefits to most adults as well as children. Treating adults with strabismus can improve depth perception, the way the two eyes work together, and the field of vision. Many patients report improved self-esteem, communication skills, job opportunities, reading and driving.

What are the complications of squint surgery?
Like any other surgery, squint surgery is not without complications. Significant complications of strabismus surgery include endophthalmitis (infection of the eye ball) and retinal detachment, both as a result of accidental perforation of the globe during surgery. These complications are very rare: Perforation of the globe may occur in 0.3% - 2.8% of cases, resulting in endophthalmitis in less than 1:3500 cases, and retinal detachment in even fewer cases.

What are the success rates of a squint surgery?
Nearly 80-90% patients are successfully corrected in the straight-ahead position with one surgery. In some patients the surgery may be only partially successful. In some patients the eye alignment will change over time, resulting in the need for additional surgery after few months or years

How is the squint surgery performed?
The squint surgery is done under local or general anesthesia depending on the age of the patients and the complexity of squint. Squint correction by various techniques including squint surgery is being done on a regular basis at the centre. Several patients including very young children have been treated here with very good cosmetic and visual results. Thought to be untreatable or treatable at a older age, a common myth, the centre advocates early treatment as it gives not only good cosmetic results but also fairly good visual outcome. Facilities for treatment of very young children are available at the centre.

What is Oculoplastic?
Oculoplasty surgery is an upcoming specialty where our specialist deals with problems pertaining to lids, lacrimal system, orbit, aesthetic, lid surgery.

The common problems dealt with are:
* Ocular oncology to deal with cancers of the eye, the orbit, the lids and the face.
* Ptosis / drooping of upper lids.
* Lid retraction / large eyes.
* Watering of eyes.
* Lax lids, dacryocystitis, etc.
* Blepharoplasty of upper lid and lower lid for excess skin, muscle and fat.
* Brow lifts / browpexy.
* Anophthalmic socket with reconstruction for disfigured eyes.
* Artificial / prosthetic eyes.
* Lid tumors and reconstruction.
* Aesthetic lid surgery.

The centre has the expertise as well as equipment to treat the above conditions and has given very good cosmetic results over the years.