What to do for a patient with sudden onset of convergent squint and no history of trauma?

Immediate Ophthalmology Referral Required for Sudden-Onset Convergent Squint

A patient presenting with sudden-onset convergent squint without trauma requires urgent ophthalmology referral now to rule out space-occupying lesions and other serious neurological causes. 1, 2

Critical Distinction: Acute vs. Chronic Presentation

Sudden-onset strabismus in any patient—particularly without trauma—is fundamentally different from longstanding or childhood-onset squint and demands immediate evaluation for potentially life-threatening causes 2:

• Acute convergent squint can indicate increased intracranial pressure, posterior fossa lesions, or other CNS pathology 1, 3
• The possibility of restrictive, paralytic, or neurologic causes (especially increased intracranial pressure) must be addressed promptly 1
• Differentiating sudden-onset concomitant squint from paralytic squint can be difficult but is critical due to neurological implications 2

Why Immediate Referral is Essential

Neuroimaging is Frequently Indicated

• Acquired symptomatic diplopia with sudden onset may herald serious pathology including tumors, demyelination, or stroke 1
• Brain and/or orbital MRI with contrast should be performed for new-onset strabismus with poor fusional amplitudes 1
• Neuroimaging should always be performed if there are additional CNS signs or symptoms 1

Time-Sensitive Conditions Must Be Excluded

The American Academy of Ophthalmology emphasizes that conditions threatening vision or the eye should be treated before any other manifestation 3:

• Space-occupying lesions (tumors, abscesses) 1
• Increased intracranial pressure 1, 3
• Vascular events (stroke, aneurysm) 1
• Demyelinating disease 1
• Giant cell arteritis (in appropriate age groups) 1

Comprehensive Ophthalmologic Evaluation Required

The initial examination by an ophthalmologist should include 1, 3:

• Visual acuity testing to detect vision-threatening pathology 3
• Pupillary examination to identify afferent defects or neurologic involvement 3
• Intraocular pressure measurement 3
• Binocular alignment testing at distance and near in all gaze positions 1
• Extraocular muscle function assessment (ductions and versions) to distinguish paralytic from concomitant deviations 1
• Cycloplegic refraction 1
• Dilated funduscopic examination to assess for papilledema or other posterior segment pathology 1

Why Reassurance or Delayed Referral is Inappropriate

Reassurance alone is never appropriate for sudden-onset strabismus 1, 2:

• Binocular vision can degrade rapidly in young children, resulting in suppression and anomalous retinal correspondence 1
• Early diagnosis and treatment are essential 1
• The distinction between benign and serious causes cannot be made without comprehensive ophthalmologic examination 2

Delayed referral ("after a while") risks missing time-sensitive diagnoses 1, 3:

• Neurological causes may progress rapidly 1
• Visual development in children is time-sensitive 1
• Amblyopia risk increases with delayed treatment 1

Common Pitfall to Avoid

The most critical error is assuming sudden-onset convergent squint is benign without proper evaluation. Unlike gradual-onset or childhood strabismus that may be monitored, acute presentation mandates urgent assessment to exclude serious neurological pathology 1, 2. The American Academy of Ophthalmology guidelines consistently emphasize that new-onset strabismus requires comprehensive evaluation including consideration of neuroimaging 1.