Can a squint be corrected in adults?

If you have a squint, you may be wondering if it can be addressed. Here to discuss the different ways it certainly can be, alongside its causes, impact on quality of life - and other important questions patients may have - is leading consultant adult squint surgeon Mr Nadeem Ali. 

What’s the most common cause of squint in adults?

The most common cause of squint in adults is actually a squint leftover from childhood.  About five per cent of children end up with having a squint, and a lot of them undergo treatment in childhood, but they're still there after growing up. In fact, they often recur, and are often worse than they were as a child. Patients often have patching, glasses, and/or squint surgery as a child, and then the squint returns in middle age - or any age really; from 20 until 80.

Other causes of squint in adults are things which place the eyes out of alignment, such as trauma:

• head trauma;
• facial trauma;
• eye socket fractures;
• neurological conditions such as MS;
• some brain tumours.

There are also conditions like thyroid eye disease or inflammation around the eye. All of these things can affect the muscles of the eyes and result in a squint.

How does squint affect quality of life?

Squint impacts quality of life in two ways. One is in terms of visual function, or in other words your ability to see with both eyes a single image. There are patients who have a squint who suffer from double vision, seeing two of the same objects.

Some people don't have double vision, but they have visual confusion. An object which is off to the side can appear in the centre and get in the way of things. That can cause immense problems with people's lives. They can have problems driving, reading, or working on a computer. Even walking around, especially things like going downstairs can be quite difficult. That's the functional side of things.

The other side of squint in adults is how it affects someone's appearance. It affects their life due to the effect it has on interaction, social interaction, self-confidence, and their self-esteem. Many people are almost paralysed by lack of confidence in meeting people for the first time, whether that be in a social environment or a work environment. Even Zoom meetings can be a source of self-consciousness. The other thing about people whose appearance is affected, is they very often have some visual problems as well, which they've just gotten used to and accepted as normal.

How is squint treated?

There are some non-surgical options. Of course, with any surgery, one option is just living with it, and that’s unfortunately an option required for some patients because surgery isn’t possible for them. That’s either because they've had too many operations in the past, or because the risks of surgery might be too much for them to go through with it.

There are some squints which can be helped with prism glasses. That's normally to correct double vision; they do have a very good functionality, and they help many patients. However, they have some issues:

• Don't correct large angles of double vision.
• Don't help double vision in all directions.
• Can be cumbersome and expensive.

Botox™, or botulinum toxin, injections are also available. It's the same drug that's used to treat wrinkles, and can temporarily paralyse a muscle, allowing the eyes to go straight for a period of a few months. It wears off. Surgery becomes the final option for many people.

Who is a suitable patient for squint surgery?

Squint surgery is recommended when a squint or double vision is impacting somebody's life enough that they're willing to take the small risks associated with it. That’s the basic equation that’s going to prompt the decision whether now is the right time. If somebody is troubled by their squint or double vision, and it's affecting them on a day-to-day basis, that's when they should consider it and then they'll be assessed. Based on that assessment, a plan for surgery will be made and an assessment of the chance of success and also the risks associated with it. That discussion is had between the doctor and the patient, and they can come to a common ground whether surgery is indicated.

What’s involved in the procedure?

Squint surgery involves moving the muscles around the eyes into different positions, or increasing or reducing the strength with which they pull on the eye. We often say the eye muscles are like the reins on a horse. They come from behind and they pull on the front. Depending on which side is pulling more, the eye will turn in that particular direction. The basic principles are, you can either weaken a muscle or strengthen a muscle. Depending on various combinations of weakening and strengthening, you can predictably move the eye into different directions and therefore correct a squint.
 

Most surgery for a squint or double vision is done under a general anaesthetic so you don't feel anything during the procedure. You're given plenty of analgesia at the end of the anaesthetic so when you wake up, you're not in pain. There’s a requirement for simple pain relief, such as paracetamol or ibuprofen, for two to three days for most people. However, most patients don't describe it as a severe pain, and it’s more like a dull ache in the eye. After two or three days the eye is not painful at all, but it can be a bit itchy.

What are the risks and benefits of squint surgery?

We'll start with the benefits. Squint surgery is often described by our patients as absolutely life-changing, whether that’s for their appearance and regaining self-confidence, or whether that’s to correct disabling double vision. It's often something they wish they had done many years ago. It completely changes their lives.

With regard to risks, it's a very safe procedure, actually. It's much safer than most other eye operations. The reason for that, is we don't go in the eye itself. We're operating on muscles outside the eye.

There are some risks, however. There's always a chance that you could overcorrect or under correct a squint. You end up with the eye not being exactly as you hoped for, but being too far one way or the other. That might then require another operation to correct it. You can sometimes induce or cause double vision, which wasn't there before, although that’s actually very rare, probably just a few percent. There are some issues occasionally with scarring on the surface of the eye. You can get some redness, which doesn't fully disappear. But for most patients, especially if it's their first or second operation, that's not normally a problem.

The risk of something like losing vision in the eye is less than one in 4,000. So, it's really a very safe procedure. The recovery, however, does take a good few weeks in order for the surface to settle down.

What’s recovery from squint surgery like?

This is where squint surgery is a bit different to other eye operations. The recovery process is often quite long. I normally tell patients it's six to eight weeks for the eye to return to a normal state. During that period, the eye will be uncomfortable, gritty, scratchy, often watery, due to the stitches we put in. These take about six to seven weeks to dissolve.

People often wonder about pain, and most squint surgery is really not painful at all. A few days of basic pain relief like paracetamol and ibuprofen is normally enough. People can get back to work after about seven to 10 days, back to driving after about two weeks, back to physical activity and sport after a couple of days. It's a slow, irritating recovery, but it's not painful or too burdensome. At around eight weeks, the eye is a lot whiter. You can go back to wearing contact lenses, and most people wouldn't know you've had the surgery done.

Am I eligible for squint surgery for adults if I have double vision?

If you have double vision, again, you need to see a specialist in adult double vision surgery who will assess you, measure the amount of double vision you have, see whether it's possible to correct that with prisms or not. If it isn’t - or somebody wants freedom from prism glasses - they would then be able to discuss the option of surgery with a specialist. Again, it's always going to be a balance of the risks versus benefits, but I’d say over 90 per cent of people who want double vision surgery are eligible for it.

Is squint surgery for adults really worth it?

Well, the first question is, do you have a squint that you perceive is affecting your life? The fact that somebody is asking that question normally means that it is affecting their life. You need to see a specialist, ideally one in adult squint or adult double vision surgery for assessment. This is because having a squint or double vision doesn't always mean that surgery is the right thing for you, or is something you’ll want to go for once you hear the chances of success. You have to do a bit of research and find the right person to talk to discuss the procedure with you in-depth, and help you make that decision.

If you’re considering getting treatment for squint in adults, arrange a consultation with Mr Ali via his Top Doctors profile.