What are the key clinical features to assess when diagnosing strabismus in children?

When diagnosing strabismus (squint) in children, key clinical features to assess include the type and severity of the squint itself, and the child's visual acuity ¹. It is also important to assess for any underlying cause and to determine if a refractive error is present, as this often coexists with squint ¹,³. Assessment should also include looking for any significant abnormal (compensatory) head posture ¹. The aim of management, which guides assessment, also includes maintaining or restoring normal binocular vision ¹. It is crucial to identify if the squint is paralytic or non-paralytic ². In children with cerebral palsy, assessment for strabismus is part of the initial ophthalmological and orthoptic assessment, and may involve looking for problems with controlling eye movements ³. Specific red flag features that necessitate urgent assessment and referral include:

• Limited abduction of the eye ¹.
• Double vision ¹.
• Headaches ¹,².
• Nystagmus, which is involuntary, repetitive, side-to-side oscillation of the eyes ¹.
• New-onset squint occurring with loss of the fundal ('red') reflex in one or both eyes ².
• New-onset squint accompanied by ataxia or vomiting ².