Why Do Squints Return in Adulthood? Causes & Treatment Options

Why Do Squints Return in Adulthood?

• Adult strabismus (squint) can occur as a new condition or as a recurrence of childhood strabismus, with causes including neurological conditions, trauma, thyroid disorders, and age-related changes.
• Common types of adult squint include esotropia (inward turning), exotropia (outward turning), and vertical deviations, each requiring specific treatment approaches.
• Childhood squint may return in adulthood due to breakdown of compensatory mechanisms, stress, illness, or age-related changes in muscle function.
• Key symptoms of adult strabismus include double vision, eye strain, headaches, visual confusion, and noticeable changes in eye alignment.
• Non-surgical treatments include corrective lenses, prism glasses, vision therapy, and Botox injections, which can be effective for many adults.
• Squint surgery is highly effective for adults, with 70-80% success rates after a single procedure and up to 90% with additional adjustments, regardless of patient age.
• Adult strabismus can significantly impact psychological wellbeing and social interactions, with successful treatment improving quality of life beyond visual function.
• Seek immediate medical attention for sudden double vision or eye misalignment, and consult specialists for progressive symptoms or psychological distress related to eye appearance.

Table of Contents

• Understanding Adult-Onset Strabismus: Causes and Risk Factors
• Common Types of Squint That Recur in Adulthood
• Why Does Childhood Squint Sometimes Return Later in Life?
• Recognizing the Signs: When Your Eye Alignment Changes
• Non-Surgical Treatment Options for Adult Squint
• Is Squint Surgery Effective for Adults? Success Rates Explained
• Living with Adult Strabismus: Psychological and Social Impact
• When to Seek Professional Help for Adult Squint Problems

Understanding Adult-Onset Strabismus: Causes and Risk Factors

Adult-onset strabismus (squint) occurs when the eyes become misaligned later in life, either as a new condition or as a recurrence of childhood strabismus. This misalignment happens when the six muscles controlling each eye’s movement fail to work in coordination, causing one eye to turn inward, outward, upward, or downward.

Several factors can contribute to squint eye causes in adults. Neurological conditions such as stroke, brain tumours, or multiple sclerosis may damage the nerves controlling eye muscles. Trauma to the eye or orbit can disrupt normal muscle function. Certain systemic diseases like thyroid disorders (particularly Graves’ disease) can affect the extraocular muscles, causing them to enlarge and restrict normal eye movement.

Age-related changes also play a significant role. As we age, the supportive tissues around the eyes may weaken, and the fusion mechanisms that keep our eyes aligned can deteriorate. Diabetes can damage blood vessels supplying the eye muscles or the nerves controlling them, leading to sudden onset strabismus in adults.

Risk factors include family history of strabismus, previous eye surgery, uncorrected refractive errors (particularly hyperopia or long-sightedness), and certain medications that affect neuromuscular function. Understanding these underlying causes is crucial for effective treatment planning and management of adult strabismus.

Common Types of Squint That Recur in Adulthood

Several types of squint can emerge or recur during adulthood, each with distinct characteristics and management approaches. Understanding these variations is essential for proper diagnosis and treatment.

Esotropia (convergent squint) is characterised by one or both eyes turning inward. In adults, this may develop due to uncorrected long-sightedness, cranial nerve palsies, or decompensation of a previously controlled childhood squint. Accommodative esotropia, common in children, can recur in adults who stop wearing their prescribed glasses.

Exotropia (divergent squint) involves the eye turning outward in adults. This type often develops gradually and may initially present as intermittent misalignment that worsens with fatigue or illness. Many adults with exotropia report that their symptoms worsen as the day progresses or during periods of stress.

Vertical deviations, where one eye is higher than the other, frequently result from cranial nerve palsies, thyroid eye disease, or previous eye surgery. These can be particularly troublesome as they often cause significant double vision (diplopia).

Duane syndrome, Brown syndrome, and fourth nerve palsy are less common forms that may become symptomatic in adulthood due to decompensation of fusion mechanisms. These complex forms of strabismus often require specialised evaluation and treatment approaches.

Sensory strabismus can develop when vision in one eye is significantly reduced, causing that eye to drift. This may occur following conditions like retinal detachment, macular degeneration, or traumatic eye injury in adults.

Why Does Childhood Squint Sometimes Return Later in Life?

Many adults who experience strabismus in later life are actually dealing with a recurrence of a childhood condition rather than a new onset. This phenomenon occurs for several interconnected reasons that relate to both the original causes of squint and changes that happen as we age.

The most common explanation for recurrence is the breakdown of compensatory mechanisms. Many children who undergo squint surgery or non-surgical treatments develop fusion abilities that help maintain eye alignment. However, these compensatory mechanisms can deteriorate over time, particularly during periods of stress, illness, or fatigue. The brain’s ability to suppress double vision or maintain fusion can weaken with age, revealing an underlying misalignment that was previously controlled.

Causes of strabismus in children often include muscle imbalances, refractive errors, or neurological factors. These underlying issues may never be completely resolved, only controlled. As adults age, the original muscle imbalances may become more pronounced, especially if there are changes in visual demands such as increased computer use or close work.

Additionally, adults who had childhood squint surgery may experience a gradual shift in muscle position over decades. The surgical corrections made in childhood may not maintain the same effectiveness throughout life, leading to a gradual drift in eye alignment. This is why long-term follow-up is recommended for individuals with a history of childhood strabismus.

Hormonal changes, particularly those occurring during pregnancy or menopause, can also influence eye muscle function and potentially trigger a recurrence of previously controlled strabismus. Understanding these mechanisms helps explain how squint affects vision differently in adults compared to children, particularly when it comes to recurrence patterns.

Recognizing the Signs: When Your Eye Alignment Changes

Identifying the early signs of changing eye alignment in adulthood is crucial for timely intervention. Unlike children, adults are typically more aware of subtle visual changes and can articulate their symptoms more precisely, which aids in diagnosis.

Diplopia (double vision) is often the most prominent and distressing symptom of adult strabismus. You may notice overlapping or side-by-side images, particularly when looking in specific directions or when tired. This occurs because the brain continues to process images from both eyes but can no longer fuse them into a single perception.

Eye strain and fatigue are common complaints, especially after prolonged visual tasks. You might experience headaches, particularly around the eyes or forehead, as your visual system struggles to maintain alignment. Some adults report a sensation of “pulling” or discomfort around the eyes when trying to focus.

Visual confusion can occur when the brain simultaneously perceives two different images that it cannot reconcile. This may manifest as difficulty reading, problems with depth perception, or challenges with tasks requiring hand-eye coordination. Many adults with developing strabismus report clumsiness or difficulty with spatial judgement.

Cosmetic changes may become apparent to you or others. Friends or family might comment that your eye appears to drift, particularly when you’re tired or unwell. You might notice changes in photographs or when looking in the mirror. Some adults report covering or closing one eye to alleviate visual discomfort, which can be a compensatory behaviour for underlying strabismus.

If you experience sudden onset of any of these symptoms, particularly double vision, it’s important to seek immediate medical attention as this could indicate serious underlying conditions requiring prompt assessment.

Non-Surgical Treatment Options for Adult Squint

For many adults with strabismus, non-surgical interventions can effectively manage symptoms and, in some cases, improve eye alignment. These approaches are particularly valuable for intermittent squints, recently developed misalignments, or cases where surgery is contraindicated.

Corrective lenses remain a cornerstone of squint eye treatment without surgery. Properly prescribed glasses or contact lenses can address underlying refractive errors that contribute to certain types of strabismus, particularly accommodative esotropia. In some cases, specially designed prism glasses for squint can realign images to eliminate double vision without changing the actual position of the eyes.

Vision therapy, a structured programme of visual activities, can help strengthen eye muscles and improve coordination. While more commonly used in children, evidence suggests that adults can also benefit from these exercises, particularly for convergence insufficiency or certain types of exotropia. These programmes typically involve regular sessions with a trained orthoptist and daily home exercises.

Botox for strabismus has emerged as an effective non-surgical option. This treatment involves injecting botulinum toxin into specific eye muscles to temporarily weaken them, allowing opposing muscles to pull the eye into better alignment. While the effects are temporary (typically lasting 3-6 months), repeated injections can sometimes lead to more permanent improvements. Botox is particularly useful for recent-onset strabismus, small-angle deviations, or as a diagnostic tool before surgery.

Eye patching may be recommended in certain situations to prevent double vision, though this addresses symptoms rather than correcting the underlying misalignment. Prism lenses incorporated into glasses can realign images on the retina, eliminating double vision while maintaining the use of both eyes.

For adults with thyroid eye disease-related strabismus, managing the underlying thyroid condition is essential and may lead to improvements in eye alignment as inflammation subsides.

Is Squint Surgery Effective for Adults? Success Rates Explained

Many adults with strabismus wonder about the effectiveness of surgical intervention, particularly if they’ve been told in the past that they were “too old” for correction. Modern evidence overwhelmingly demonstrates that squint surgery can be highly effective for adults, with success rates comparable to those in children.

Studies indicate that successful alignment (defined as alignment within 10 prism dioptres of orthophoria) is achieved in approximately 70-80% of adult patients after a single surgery. This success rate increases to over 90% when including patients who undergo additional adjustments or secondary procedures. These statistics challenge the outdated notion that adult strabismus is less responsive to surgical intervention.

The type of strabismus significantly influences success rates. Acquired paralytic strabismus (resulting from nerve palsies) has slightly lower single-surgery success rates (60-70%) compared to non-paralytic forms. Recurrent childhood strabismus typically responds well to surgical correction in adulthood, with success rates of 75-85% after a single procedure.

Age itself is not a limiting factor for surgical success. Research has demonstrated successful outcomes in patients well into their 80s and 90s. The duration of strabismus, however, can impact results, with more recent-onset squints generally responding better than those present for many decades.

Functional improvements extend beyond eye alignment. Approximately 60-67% of adults with pre-operative diplopia experience complete resolution after surgery, while another 20-25% report significant improvement. Binocular vision (the ability of both eyes to work together) can be restored or improved in 20-50% of adult patients, depending on the type and duration of their strabismus.

It’s important to note that while cosmetic improvement is often dramatic and immediate, functional improvements such as reduced diplopia and enhanced depth perception may develop gradually over weeks or months following surgery as the brain adapts to the new alignment.

Living with Adult Strabismus: Psychological and Social Impact

The effects of adult strabismus extend far beyond visual function, often having profound psychological and social implications. Research consistently demonstrates that visible eye misalignment can significantly impact quality of life, self-perception, and social interactions.

Studies have shown that adults with noticeable strabismus report higher levels of anxiety, depression, and social avoidance compared to the general population. Many describe feelings of self-consciousness during face-to-face interactions, with some developing compensatory behaviours such as avoiding eye contact, turning their head to hide the affected eye, or limiting social engagements altogether.

Professional and economic consequences can be substantial. Research indicates that individuals with visible strabismus may face unconscious bias during job interviews and workplace interactions. Some adults report that their eye condition has limited career advancement or influenced their choice of profession, particularly in fields requiring significant public interaction.

The psychological burden often relates to misconceptions about strabismus. Many people incorrectly associate eye misalignment with intellectual disability or lack of attention, creating additional social challenges. Adults with sudden onset strabismus may experience particular distress as they adjust to changes in both appearance and visual function simultaneously.

Importantly, successful treatment of adult strabismus—whether surgical or non-surgical—has been shown to significantly improve psychosocial functioning. Studies measuring quality of life before and after strabismus correction demonstrate marked improvements in social confidence, interpersonal relationships, and overall mental wellbeing.

Support groups, both online and in-person, can provide valuable emotional resources for adults living with strabismus. Connecting with others who understand the unique challenges of the condition can help reduce feelings of isolation and provide practical coping strategies for managing both the functional and psychological aspects of strabismus.

When to Seek Professional Help for Adult Squint Problems

Knowing when to consult a specialist for adult strabismus is crucial for optimal outcomes. While some may hesitate due to misconceptions about treatability in adulthood, early intervention often leads to better results.

Seek immediate medical attention if you experience sudden onset of double vision or eye misalignment. These symptoms can indicate serious underlying conditions such as stroke, aneurysm, or cranial nerve palsy that require urgent assessment. Even if the double vision is intermittent or occurs only when looking in certain directions, prompt evaluation is essential.

If you notice gradual changes in eye alignment or increasing frequency of visual symptoms such as eye strain, headaches after visual tasks, or difficulty with depth perception, consult an ophthalmologist specialising in strabismus. These progressive symptoms may indicate decompensation of a previously controlled squint or the development of a new problem that could benefit from early intervention.

Adults who had childhood strabismus should consider regular evaluations, even if they believe their condition was fully corrected. Long-term follow-up can identify subtle changes before they become functionally or cosmetically significant. This is particularly important during periods of significant visual demand changes, such as starting a new job requiring extensive computer work.

If you’re experiencing psychological distress related to the appearance of your eyes or functional limitations caused by strabismus, this alone is sufficient reason to seek professional help. Modern treatment approaches consider both the functional and psychosocial aspects of strabismus equally important.

When consulting a specialist, seek a comprehensive strabismus service with experience in adult cases. The evaluation should include detailed measurements of eye alignment in different gaze positions, assessment of binocular vision potential, and thorough discussion of both surgical and non-surgical treatment options tailored to your specific situation.

Frequently Asked Questions

Can adults develop squint suddenly?

Yes, adults can develop squint (strabismus) suddenly. Sudden-onset squint in adults is often caused by serious conditions like stroke, cranial nerve palsy, brain tumors, or trauma. Other causes include thyroid eye disease, diabetes, and certain medications. Any sudden eye misalignment or double vision requires immediate medical attention as it may indicate an underlying neurological emergency.

Is squint surgery worth it for adults?

Squint surgery is generally worth it for adults, with success rates of 70-80% after a single procedure and over 90% with additional adjustments. Benefits extend beyond cosmetic improvement to include functional improvements like reduced double vision (in 60-67% of cases), better depth perception, and enhanced peripheral vision. Studies also show significant improvements in psychological wellbeing, social confidence, and quality of life following successful surgery.

Can squint be corrected at any age?

Squint can be corrected at any age, including in older adults. Research shows successful outcomes in patients in their 80s and 90s. While childhood intervention offers advantages for developing binocular vision, adult correction can still provide substantial functional and cosmetic benefits. Treatment options include surgery, prism glasses, vision therapy, and Botox injections, with approach determined by the type and cause of strabismus rather than age.

Why would an adult develop a squint?

Adults develop squint due to various factors including neurological conditions (stroke, MS, brain tumors), cranial nerve palsies, thyroid eye disease, diabetes, trauma, age-related tissue degeneration, decompensation of childhood strabismus, uncorrected refractive errors, and certain medications. Stress, fatigue, and illness can also trigger squint in adults with previously controlled eye alignment issues. The specific cause determines treatment approach and prognosis.

How long is recovery from adult squint surgery?

Recovery from adult squint surgery typically involves 1-2 weeks for initial healing, with most patients returning to desk work within 7-10 days and physical activities within 2-4 weeks. Eye redness gradually resolves over 4-6 weeks. While cosmetic improvement is immediate, functional benefits like reduced double vision may develop gradually over 2-3 months as the brain adapts to the new alignment. Complete stabilization of the eye position can take up to 6 months.

Can glasses correct adult squint?

Glasses can correct certain types of adult squint, particularly accommodative esotropia caused by uncorrected hyperopia (farsightedness). Prism glasses can also help manage double vision by realigning images without changing eye position. However, glasses alone cannot correct squint caused by muscle or nerve problems, which may require surgery, Botox injections, or vision therapy. An ophthalmologist can determine if glasses are a suitable treatment option for your specific condition.