Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 7 Sept 2026Clinical review pending
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New squint with a concerning associated feature
A new squint with an absent red reflex may indicate serious ocular disease; headache, vomiting or ataxia can signal a neurological cause.
Action: Follow NICE's immediate referral routes: ophthalmology for new squint with loss of red reflex, and acute paediatrics for new squint with headache, vomiting or ataxia. A paralytic squint also needs urgent neurological assessment.
Synopsis
Use the history, corneal reflections and cover tests to assess ocular alignment, recognise the limits of each test and identify children needing urgent ophthalmic or neurological referral.
Describe the direction, constancy and onset of the deviation.
Measure vision in each eye before assuming equal function.
Corneal reflections provide a rapid estimate of alignment.
Key red flags
New squint accompanied by headache, vomiting or unsteadiness.
Investigation priorities
01
Corneal light-reflex comparisonFirst step
Obtain an initial alignment estimate when fixation is possible.
Management branches
Initial assessmentBuild a reliable description
A child presents with a suspected or intermittently observed squint.
Ask about onset, frequency, direction, visual symptoms and relevant family or developmental history.
Measure each eye's vision using an appropriate test and observe fixation and posture.
Stable non-paralytic squintArrange ophthalmic and orthoptic care
Misalignment is present without an emergency feature or movement palsy.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 7 Sept 2026; clinical approval remains outstanding.