What are the recommended referral criteria for a child with suspected strabismus to a specialist?

For a child with suspected strabismus (squint), the recommended referral criteria to a specialist depend on the presence of red flags or specific associated symptoms.

• Routine Referral:
  • Any child with a suspected or confirmed squint should be referred to the local paediatric eye service ¹.
  • A routine referral is indicated for most children ¹.
  • Children with non-paralytic squint should be referred to ophthalmology services ².
• Urgent or Immediate Referral (Red Flags):
  • Refer the child urgently to an ophthalmologist or other paediatric specialist if a serious underlying condition is suspected as the cause of the squint ¹.
  • Urgent referral (within a few days) is indicated in the presence of red flags such as double vision or headaches ¹. Other red flags include limited abduction and nystagmus (involuntary, repetitive, side-to-side oscillation of the eyes) ¹.
  • Immediate referral to ophthalmology services is required for children with new-onset squint that occurs together with loss of fundal ('red') reflex in one or both eyes ². This also relates to considering referral for ophthalmological assessment using a suspected cancer pathway for retinoblastoma ⁵.
  • Immediate referral to acute paediatric services is necessary for children with new-onset squint that occurs together with ataxia, vomiting, or headache ².
  • Urgent referral for neurological assessment is needed for children with paralytic squint, even without other signs and symptoms of raised intracranial pressure ².

Early treatment for squint can improve outcomes and help prevent or reduce the worsening of amblyopia (lazy eye) ¹.