Paediatric Squint

About Paediatric Squint (Strabismus)

Squint is a term used within ophthalmology for a misalignment between the two eyes. The medical term for this is ‘strabismus’. While one eye looks straight, a person can have one eye that turns inwards (esotropia), outwards (exotropia), upwards (hypertropia) or downwards (hypotropia). A child may be born with squint or it may be something that develops with age. Squints can appear suddenly or develop slowly, they can be constant or may only be present intermittently.

Types of Paediatric Squint (Strabismus)

Manifest squint: one eye constantly deviates from the direction of the other eye.
Latent squint: It is the most common. It appears when covering the eye or fatigue or at bedtime.
Alternating squint: In this type of strabismus, the right and left eye alternate at the same time.
Paralytic squint: This is more common in the elderly, especially those who suffer from high blood pressure or diabetes or stroke.
Pseudo-strabismus, which is the result of the development of facial features in infants, especially when there is wide nasal bridge between the eyes.

Causes

There are several causes and associations with squints, which include –

Need for glasses
Congenital (early onset) squint
Anything that obstructs the visual pathway; cataract or droopy lid can be associated with squints
Trauma
Squints are commonly associated with some genetic conditions or syndromes, such as Down’s syndrome, developmental delays and in children with cerebral palsy

Implications

Amblyopia

Amblyopia, also known as a ‘lazy eye’, is a childhood condition where a child’s eyesight does not develop in the way it should. If there is a squint in one eye the brain ignores the image in the squinting eye to avoid double vision. In this case the brain relies more heavily on the non-squinting eye, therefore the visual pathway in one eye is not stimulated enough and amblyopia develops.

Cosmetic appearance

Some squints are more noticeable than others and some children may become more aware of their eyes not looking straight than others. Family and friends may also notice the appearance of the eyes. In cases where the squint is noticed by the child or others, we can often look at surgical management or other treatments such as Botox injections. Careful measurements and vision assessments are taken to decide on the treatment plan.

Abnormal ‘binocular’ interaction

A squint may result in the eyes not working together as a pair. This can affect depth perception and normal ‘3D’ vision. In early onset squints, the main aim of early intervention is to align the eyes to given the best possible opportunity for the ability for the eyes to work together as a pair to develop. Patients without this ability may not have ‘3D vision’ (or stereopsis). However, for those with childhood squints, this is not usually a problem as their brain adapts to this situation and they learn to use cues in their environment to help perceive depth.

Examination

In case of suspicion of squint, a thorough examination of the child’s eyes must be carried out by the specialist with an orthoptist to confirm the type of squint and the best treatment for each case.

The examination begins with a detailed medical interview. The child is then examined by the orthoptist to check visual acuity and to diagnose strabismus, type and degree. In case of defective vision or squint, eye drops will be instilled to expand the pupil and relax the ciliary muscles. Only in this way, the entire retina can be examined and the refractive error diagnosed and its degree, if any.

Glasses

Some squints, usually inward turning squints, can be associated with ‘refractive error’ (need for glasses); often moderate degrees of hypermetropia (long-sightedness). You may notice the squint appears randomly and may be more noticeable when the child looks at things up close. In some children, glasses correct the squint fully. In other cases, there is an improvement in the size of the squint with the glasses on. With this type of squint, it is very normal for the squint to look more obvious when the glasses are removed, as the child tries to over focus and obtain a clear image. Some squints may not be affected by glasses. Given this potential for correction with glasses, in all squints, we start by checking if glasses are needed, then monitoring if glasses change the alignment of the eyes.

Active Monitoring

Some squints may not be constant. You may notice a squint when the child is very tired, in bright sunlight and or when they are unwell. In these cases we work closely with you to determine how often the squint is noticed. We observe how your child is able to control their eyes and keep them straight. We often monitor your child, ensuring things are stable. If the squint worsens to the point that it is noticed more often, we may then discuss further treatment.

Surgery

In cases of congenital (early onset) squints, we often aim to operate early. This is to give the child the best possible chance to develop binocular functions. In some cases, there is also the option of Botox injections to the eye muscles.

In children who have a squint that does not straighten fully with glasses, and has a significant measurement, we may discuss surgery. Surgery is normally a day case and is performed under general anesthesia so the child is asleep for the operation. It is performed on the muscles that attach to the eye to strengthen, weaken or reposition these muscles, to gain a straighter eye position postoperatively.

Paediatric Squint Specialists

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Dubai
Abu Dhabi

Dr. Suhair Twaij

Consultant Ophthalmologist in Adult & Paediatric Strabismus Surgery, Paediatric Ophthalmology, Adult Cataract Surgery

Dr. Suhair Twaij is a Consultant Ophthalmologist with a subspecialist interest in adult and paediatric Strabismus surgery, Paediatric Ophthalmology, adult Cataract Surgery and General Ophthalmology at Moorfields Eye Hospital Dubai. Dr. Twaij recently relocated to the UAE from the UK, where she has worked as a consultant ophthalmologist at the Royal Victoria Hospital in Belfast since 2013. She was also the clinical lead for the adult motility service in Northern Ireland from 2014. She holds a graduate degree in medicine from the Baghdad University Medical School, obtained in 1994. Her areas of expertise include complex adult and paediatric squint surgery using the adjustable technique when needed, double vision correction, adult cataract surgery with an implant, Botox treatment for squints, double vision, blepharospasm and aesthetics. She has over 20 years of experience in general ophthalmology, including cataract surgery, anterior and posterior segments such as glaucoma and diabetic retinopathy. Dr. Suhair trained in the UK from 2004 in England and Northern Ireland and was awarded the certificate of completion of training (CCT) in ophthalmology in the UK in 2012. She was awarded the Royal College of Ophthalmologists Fellowship in the same year. Throughout her career, she has practised in leading medical institutions such as The Royal Victoria Hospital in Belfast, Northern Ireland, Altnagelvin Area Hospital, Northern Ireland, The Bristol Eye Hospital, England, and King Hussein Medical City Amman, Jordan. Dr. Suhair is an avid researcher and has Medline-published papers in various ophthalmology topics such as medical retina, paediatric ophthalmology and oculoplastics. She is a member of the Royal College of Ophthalmologists, the British & Irish Paediatric Ophthalmology and Strabismus Association (BIPOSA) and the European Association of Strabismus (ESA).

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Dr. Salma Yassine

Specialist Ophthalmologist in Paediatric and Neuro-ophthalmology

Dr. Salma Yassine is a specialist ophthalmologist in paediatric and neuro-ophthalmology at Moorfields Eye Hospital Dubai in Healthcare City Dubai. She holds a bachelor’s in science (2012) with high distinction and a medical degree (2016) from the American University of Beirut. She finished Her ophthalmology residency at the American University of Beirut Medical Center in 2020 before pursuing a fellowship in neuro-ophthalmology at the University of Minnesota in 2021, followed by another fellowship in pediatric ophthalmology and strabismus at Children’s National Medical Center in Washington DC. She has international experience in paediatrics and neuro-ophthalmology in countries including the USA and Lebanon. She has practised in leading medical institutions such as the University of Minnesota and the Children’s National Medical Center in the US. She has researched intracranial hypertension and nanophthalmos and published research papers on nystagmus and nanophthalmos in leading journals. She is a member of the American Association for Pediatric Ophthalmology and Strabismus Association (AAPOS) The North American Neuro-Ophthalmology Society (NANOS), and the Lebanese Ophthalmological Society (LOS)

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Dr. Imran Jawaid

Consultant Ophthalmologist in Paediatric Ophthalmology and Strabismus surgery

Dr. Imran Jawaid is a Consultant Ophthalmologist, specialised in Paediatric Ophthalmology and Strabismus, at Moorfields Eye Hospital Dubai in Dubai Healthcare City. He holds a Bachelor of Medicine, Bachelor of Surgery (MBChB) degree in Medicine from the University of Leicester, School of Medicine, graduating with honours in 2010. He is also dual qualified as an Optometrist with a Bachelor of Science (HONS) degree in 2003. Dr. Imran has completed his Fellowship with the Royal College of Ophthalmologists (FRCOphth) and obtained his Certificate of Completion of Training (CCT) in Ophthalmology in 2020. Dr. Imran has more than 15 years of experience in Ophthalmology in the United Kingdom and has completed a post-CCT fellowship in Paediatric Ophthalmology and Strabismus at Birmingham Children’s Hospital, UK. Most recently he was a Consultant Ophthalmologist and Head of Service for Ophthalmology at Nottingham University Hospitals, NHS Trust, a large tertiary centre for ophthalmic referrals. He has undertaken research in myopia, visual impairment, diabetic macular oedema and emergency ophthalmology, amongst other areas and has published over 10 research papers in leading journals. In addition to his research, Dr. Imran is a keen educator and has taught at different UK medical schools and contributed to book chapters in Ophthalmology. He is a member of the Royal College of Ophthalmologists (FRCOphth) and is the recipient of several internationally acclaimed awards and recognitions.

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Dr. Irfan Khan

Consultant Ophthalmic surgeon in Paediatric Ophthalmology and adult Strabismus

Dr. Muhammad Irfan Khan is a highly experienced consultant Ophthalmic surgeon specialising in Paediatric Ophthalmology at Moorfields Eye Hospitals in Abu Dhabi and Dubai. He earned three postgraduate degrees from the Royal College of Ophthalmologists London: DRCOphth, MRCOphth, and FRCOphth in 2013, along with a Paediatric Ophthalmology fellowship from the renowned Hospital for Sick Children, SickKids, Toronto, Canada. With over 20 years of clinical and surgical experience, Dr. Irfan has practised in several countries, including Ireland, the United Kingdom, Canada, and the UAE. His career includes roles at institutions such as the Royal Victoria Eye and Ear Hospital in Dublin, Manchester Royal Eye Hospital, SickKids in Toronto, and Sheikh Khalifa Medical City in Abu Dhabi. His subspecialty training includes managing complex paediatric eye conditions such as cataracts, glaucoma, and retinopathy of prematurity. He is also experienced in paediatric anterior segment reconstruction and common paediatric oculoplastics. For adult patients, Dr. Irfan is particularly adept in performing adjustable suture squint surgeries, a technique that allows for precise postoperative alignment adjustments. This approach significantly improves outcomes for adults undergoing strabismus surgery, enhancing both visual function and cosmetic results. He has undertaken research in the field of Ophthalmology and has published ten research papers and one book chapter in Childhood neurology. He is a member of the Royal College of Ophthalmologists London and an International member of the American Association of Pediatric Ophthalmology and Strabismus. In 2015, he received the JD Moran Award from the Hospital of Sick Children in Toronto, Canada.

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Dr. Alaa Bou Ghannam

Visiting Specialist Ophthalmologist in Neuro-Ophthalmology, Paediatric Ophthalmology, Paediatric Glaucoma & Adult Strabismus

Dr. Alaa Bou Ghannam is a visiting specialist in neuro-ophthalmology, paediatric ophthalmology, and adult strabismus at Moorfields Eye Hospital Dubai in Dubai Healthcare City. He holds a bachelor in science (2007) with high distinction and a medical degree (2011) from the American University of Beirut. He finished his ophthalmology residency at the American University of Beirut Medical Center in 2015 before pursuing a fellowship in pediatric ophthalmology and adult strabismus from Children's National Health System and George Washington Hospital in Washington DC in 2016. He also finished another fellowship in neuro-ophthalmology from The University of Colorado in 2017. He has over five years of regional/international experience in paediatric ophthalmology, adult strabismus, and neuro-ophthalmology in countries including Lebanon and The United States of America. In his career, he has practiced in leading medical institutions such as The American University of Beirut Medical Center. He has undertaken research in clinical ophthalmology and neurology and has published more than a dozen research papers and book chapters on strabismus, optic nerve diseases, paediatric glaucoma, paediatric ophthalmology, ocular electrophysiology, and nystagmus, in leading medical journals. He is a member of the American Academy of Ophthalmology (AAO), Lebanese Ophthalmological Society (LOS), North American Neuro-ophthalmology Society (NANOS), and The American Association for Pediatric Ophthalmology and Strabismus (AAPOS).

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Dr. Christiane Al Haddad

Visiting Consultant Ophthalmologist in Paediatric Ophthalmology and Adult Strabismus

Dr Christiane Al- Haddad is a visiting associate professor of Ophthalmology, Specialised in Paediatric Ophthalmology and adult Strabismus at Moorfields Eye Hospital Dubai in Dubai Healthcare City. She holds an MD degree from the American University of Beirut in 2000, an Ophthalmology degree from the American University of Beirut in 2004, a fellowship in paediatric ophthalmology from Children’s National Medical Center, Washington DC in 2005, and a fellowship in paediatric ophthalmology and adult strabismus from Duke Eye Center, Durham, North Carolina, USA in 2006. Dr Al-Haddad has more than 15 years of regional/international experience in all aspects of Paediatric Ophthalmology and Strabismology in leading medical institutions: the American University of Beirut Medical Center (Lebanon), Children’s National Medical Center (USA) and Duke Eye Center (USA). She has undertaken research in the field of Paediatric Ophthalmology & strabismus and has published more than 50 research papers on amblyopia, strabismus, genetic eye diseases, retinoblastoma, congenital glaucoma and eye tracking technology in leading journals including British Journal of Ophthalmology, American Journal of Ophthalmology, Journal of the American Association for Paediatric Ophthalmology and Strabismus, Journal of Paediatric Ophthalmology and Strabismus, and Canadian Journal of Ophthalmology among others. Dr Al-Haddad is a member of the American Association for Paediatric Ophthalmology and Strabismus, the International Strabismological Association and the Costenbader Society. She is the director of the Paediatric Ophthalmology division in the Ophthalmology department at the American University of Beirut and established the retinoblastoma program with the oncology team at the Children’s Cancer Center in collaboration with St Jude Children’s Research Hospital, Memphis USA.

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Dr. Ayesha Khan

Consultant Ophthalmologist in Paediatric Ophthalmology

Dr. Ayesha Khan is a Consultant Ophthalmologist in Paediatric Ophthalmology at Moorfields Eye Hospital Dubai in Dubai Healthcare City. She is an experienced Ophthalmologist, specialising in the clinical and surgical treatment of a full range of Children’s Eye Diseases, including Retinopathy of Prematurity, Retinoblastoma, Cataracts, Glaucoma, Squints, and eye injuries, amongst others. She is also experienced in the surgical treatment of adult squints & cataracts. After doing her fellowships in Ophthalmology from the College of Physicians & Surgeons, Pakistan (FCPS), & Royal College of Surgeons, Edinburgh, UK (FRCSEd), Dr. Ayesha completed her clinical & surgical training in Paediatric Ophthalmology & Strabismus from University of Toronto, Canada. After that, she headed the Department of Paediatric Ophthalmology at a tertiary care Eye Hospital in Pakistan before moving to Canada in 2010. She served as an Associate Professor and Consultant Paediatric at the prestigious Montreal Children’s Hospital of the McGill University Health Centre. After that, she did a short stint in the UK before moving to UAE in January 2020. Since then, she has been actively practising Paediatric Ophthalmology in Dubai. Dr. Ayesha has done extensive research work in Paediatric Ophthalmology and has several publications to her credit. She is a member of the American Association for Paediatric Ophthalmology & Strabismus.

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Dr. Syed M. Asad Ali

Consultant Ophthalmologist in Paediatric Ophthalmology and Strabismus and Cataract Surgery

Syed Ali is a Consultant Paediatric Ophthalmologist with extensive experience in the management of all paediatric eye conditions including congenital eye diseases, paediatric cataracts, paediatric glaucoma, trauma and all types of squints in children and adults. Syed works with advanced technology and techniques. He has over 10 years of extensive experience in screening and treating retinopathy of prematurity with retinal laser and intravitreal anti VEGF injection. He has wealth of experience in phacoemulsification procedures. Syed Ali trained and has practiced in the UK and Pakistan and has over 18 years of experience in ophthalmology. After completing his basic specialist training, he undertook a fellowship in paediatric ophthalmology and ocular motility at the world renowned Wolverhampton Eye Infirmary, UK. His training in Pakistan and the UK is recognised by the General Medical Council (GMC) and was placed on specialist register. In addition to his clinical experience, Syed has undertaken published original research and teaching in his specialist area, including as an assistant professor of ophthalmology at the Pakistan Institute of Ophthalmology. He is a member of several professional bodies including The Royal College of Ophthalmologists, American Academy of Ophthalmology, The British Medical Association, Medical Defense Union and Royal College of Surgeons Edinburgh.

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