My father's eye has turned since he was a child. Is it too late to straighten it? Squint in adults
One eye has turned for as long as the family can remember, and nobody has asked whether anything can be done. Here is what the evidence says about treating a squint in an adult, and which kinds cannot wait.
- An adult squint can be treated. AAPOS says many adults can have successful eye straightening with surgery, depending on the cause. No guideline sets an age limit for squint surgery.
- A squint since childhood usually does not cause double vision in adults, because the brain learned to ignore one eye. A new squint in an adult almost always does, and that needs a medical check this week.
- It is not only about looks. Adults with double vision mainly report functional problems, and those without it mainly report social and psychological ones.
- The AAO review reports successful realignment in 68% to 85% in large case series, new double vision in 1% to 14% and repeat surgery in up to 21%. Surgery may beat botulinum toxin for realigning the eyes, on low-certainty evidence.
- Before the first visit, write down which eye, in or out, since what age, any glasses or patch, and any double vision. Book an ophthalmologist who treats squint.
Yes. An adult can have a squint treated, whether it began in childhood or last week. What works depends on whether the two eyes can still be used together, and a squint that appears suddenly needs a check for its cause within the week. If your father, mother or grandparent has had one eye turning since childhood and the family long ago stopped talking about it, this page is for you.
My father's eye has turned since he was a child. Is it too late to straighten it?
No guideline sets an age at which squint surgery is too late. The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) says "Many adults can have successful eye straightening with surgery, depending on the cause." The American Academy of Ophthalmology (AAO) adds that you do not have to live with the discomfort and problems that misaligned eyes cause.
The phrase "depending on the cause" matters. A squint (mata juling) that has been there since childhood is a different problem from one that began after a stroke or with thyroid disease, and the plan differs. The first step is not an operation. It is a proper eye examination by an ophthalmologist who treats squint, to find out what kind it is and how the two eyes are working.
The action for the family: write down what you know. Which eye, turning in or out, since what age, whether he wore glasses or a patch as a child, and whether he has ever seen double. That page of notes saves half the first appointment.
Is an adult squint only a matter of looks?
No. It can be, but it often is not. A review of adult squint and quality of life (McBain and colleagues, 2014) found that adults with double vision have mostly functional worries, while adults without double vision have mostly social and psychological ones. Both are real, and neither is vanity.
The same review puts squint at about 4 in 100 adults. A later review (Gunton, 2014) notes that surgery was once labelled cosmetic when it could not promise better function, yet many studies show how heavily misaligned eyes weigh on people's lives. Hearing "it is only cosmetic" is part of why many fathers never ask.
Function can improve too. The AAO's own review of adult squint surgery lists, among the benefits reported, the end of double vision, binocular fusion (the two eyes working as a pair), a wider field of view with both eyes open, and an improved head position. Not everyone gains all of these.
Why does an adult with a childhood squint not see double?
Because the brain learned to ignore one eye long ago. AAPOS explains that a child's brain may ignore the image from the misaligned eye to avoid double vision, which is also how a lazy eye (amblyopia) forms. A squint that began in childhood therefore usually does not cause double vision in adult life, though it may become more noticeable over time.
This is the reverse of a new squint in an adult. The AAO says adults who develop strabismus after childhood often have double vision. That is why a squint that appears suddenly, with two images, is treated as a warning sign and not as a cosmetic matter. I cover it further down.
If your father's eye also sees poorly, that is the lazy eye, and what lazy eye treatment can still do when it is found late sets out what the trials show at older ages. A straight eye and a seeing eye are two separate questions.
What does squint surgery involve in an adult?
The surgeon moves the small muscles on the outside of the eyeball so that the eye points straight. The eye is not taken out and the skin is not cut. The steps are the same as in a child, which I describe in squint surgery, what happens on the day.
What differs is the anaesthetic. AAPOS notes that adults may have general anaesthesia, or conscious sedation with local anaesthesia, and the operation is typically done as a day case. The NHS says squint surgery usually takes less than an hour and the muscles are held in their new position with dissolvable stitches.
What are adjustable stitches?
A temporary knot that lets the surgeon fine-tune the eye's position after the operation, while the patient is awake. AAPOS describes the adjustable technique as a bow-knot or slip-knot on the muscle that can be changed, with the adjustment done after surgery once the eye is numbed. The NHS likewise says further adjustments may be made once you have woken up, using local anaesthetic drops.
This is a choice mainly open to adults, because it needs a patient who can cooperate while awake. It is not used for every squint or every surgeon, so ask whether it is planned. I have no figure for how much it improves results, and I will not guess one.
What are the risks, and how long is recovery?
The main risks are that the eyes are not fully aligned and a second operation is needed, and that double vision appears or stays. Serious problems are rare. In the AAO's review, new double vision after surgery occurred in 1% to 14% of adults, a hole in the white of the eye (scleral perforation) in 0.8% to 1.8%, and unplanned repeat surgery in up to 21% of large series, and up to 50% in thyroid eye disease.
The NHS lists further surgery (quite common, particularly if the squint is severe), permanent double vision that may need special glasses, and loss of vision, which is very rare. The surgeon should go through these figures with him before he consents.
Recovery is shorter than most families fear. AAPOS says most people return to normal activities within a few days, with swimming and heavy exercise held back for a few weeks. The NHS gives about a week for work, four weeks for swimming and six for contact sport. The white of the eye stays red for weeks, sometimes months, which is expected. Our page on the first weeks after squint surgery covers the details, written for children but the eye behaves the same.
As for results, the evidence is steadier for alignment than for feeling. The AAO review reports successful realignment in 68% to 85% in large case series. One small study of 20 adults aged 18 to 63 with long-standing childhood squint found that 13 reached satisfactory alignment and that quality-of-life scores rose. It had no comparison group, so I would not treat it as proof for any one person.
Are there treatments other than surgery?
Yes: glasses, prisms, eye exercises and botulinum toxin, and the right one depends on the squint. The AAO says prisms can help some people with mild double vision see one image instead of two.
Botulinum toxin (the medicine often called Botox) is injected into an eye muscle to weaken it for a while. The NHS says the effect usually lasts less than 3 months. A Cochrane review of four trials found low-certainty evidence that surgery may be more likely than the toxin to improve or correct a squint, and the AAO review found surgery realigned 76.9% against 29.4% in its one randomised comparison.
If a squint runs in the family and you are wondering about the children, squint runs in families sets out what is known.
When is a new squint in an adult urgent?
When it comes on suddenly. AAPOS lists the causes of new adult squint as cranial nerve palsies, thyroid eye disease, stroke, head injury, myasthenia gravis and convergence insufficiency, and says it almost always causes double vision. The NHS advises getting medical advice if a squint or double vision develops later in life.
The test is simple: cover one eye. If the double vision goes, misaligned eyes are the likely cause. Either way, a new squint or double vision with headache, a drooping lid, weakness, speech changes or after a knock to the head needs medical attention at once, not an appointment next month.
Not every double image is a squint. Dr Catherine Chow, an oculoplastic surgeon, explains when double vision is mechanical, from thyroid eye disease or an orbital fracture and why one eye can look different in thyroid eye disease. For a grandchild who says they see double, see when a child says they see double.
How do I help my father take the first step?
Ask for an appointment as a family check, not as a verdict on his eye. Many people who have lived with a squint for fifty years expect to be told it is too late, so say that you only want to know the options. Book with an ophthalmologist, a doctor who treats squint, and bring the notes you wrote down. See also eye checks for the whole family and squint surgery in Malaysia: the wait and what to ask covers waiting times and the questions to put to the surgeon.
Whatever he decides is his to decide, and "not now" is a fine answer.
- A squint or double vision begins suddenly in an adult.
- Double vision comes with a drooping lid, headache, weakness or speech changes, or after a knock to the head. Go the same day.
- Double vision goes away when one eye is covered. That points to misaligned eyes and needs a check.
- An eye has started to bulge or look different in someone with thyroid disease.
Common questions
Can an adult squint be corrected?
Is it too late to fix a squint I have had since childhood?
Is squint surgery in adults only cosmetic?
What are adjustable stitches?
What are the risks of squint surgery in an adult?
Does botulinum toxin work as well as surgery for a squint?
When is a new squint in an adult an emergency?
- American Academy of Ophthalmology · What is strabismus? · www.aao.org
- AAPOS · Adult strabismus · aapos.org
- AAPOS · Strabismus surgery · aapos.org
- NHS · Squint · www.nhs.uk
- NHS · Squint surgery · www.nhs.uk
- Ophthalmology 2004 · Strabismus surgery for adults: a report by the American Academy of Ophthalmology · pubmed.ncbi.nlm.nih.gov
- Survey of Ophthalmology 2014 · The impact of strabismus on quality of life in adults with and without diplopia: a systematic review · pubmed.ncbi.nlm.nih.gov
- Current Opinion in Ophthalmology 2014 · Impact of strabismus surgery on health-related quality of life in adults · pubmed.ncbi.nlm.nih.gov
- J AAPOS 2013 · Improved sensory status and quality-of-life measures in adult patients after strabismus surgery · pubmed.ncbi.nlm.nih.gov
- Cochrane 2023 · Botulinum toxin for the treatment of strabismus · pubmed.ncbi.nlm.nih.gov