Strabismus and Medicolegal Risk: Failure to Act, Refer, or Treat

Srtabismus due to various forces on the eye

Strabismus is far more than a cosmetic misalignment. In childhood it represents a time-critical neurovisual emergency where prompt recognition and appropriate management are essential to prevent permanent loss of binocular function and amblyopia. For solicitors, strabismus cases raise important questions about breach of duty, causation, and long-term functional impact.

This article explains why strabismus is a high-risk area in paediatric ophthalmology claims and the clinical standards a reasonably competent practitioner is expected to follow.

1. Why Strabismus Matters in Litigation

Strabismus disrupts the development of coordinated binocular vision. If untreated or recognised too late, it can lead to:

• irreversible amblyopia

• loss of stereopsis

• impaired depth perception

• difficulties with reading, sports, and coordination

• psychosocial impact

• long-term functional impairment

In many medico-legal cases the question is not whether the strabismus existed, but whether clinicians acted quickly and correctly in response.

2. Early Recognition Is Crucial

Competent recognition of strabismus requires:

• assessment of fixation and following

• Hirschberg or cover testing

• accurate acuity measurement appropriate for age

• awareness of parental concerns

• recognition of risk factors such as hypermetropia or family history

A common breach in litigation is the failure of a GP, optometrist, or community practitioner to identify an abnormal deviation or to recognise that an apparent intermittent deviation was increasing in frequency or angle.

A subtle esotropia that is missed at age two may lead to lifelong consequences. The window for preventing amblyopia and developing stereopsis is narrow.

3. Failure to Refer: A Major Medicolegal Pitfall

Strabismus should prompt referral to paediatric ophthalmology or orthoptics without delay. Breach occurs when:

• symptomatic children are observed instead of referred

• referrals are delayed despite parental concern

• alignment abnormalities are attributed to “normal variation”

• children are reassured without proper examination

• practitioners assume the child will outgrow the condition

Referral pathways exist precisely because strabismus requires early, specialist assessment. Litigation often arises when referral was delayed beyond the stage at which amblyopia could still be reversed.

4. The Role of Cycloplegic Refraction in Strabismus Cases

Uncorrected refractive error is a significant driver of strabismus, particularly esotropia. Standards of care require:

• cycloplegic refraction for all esotropias

• recognition of accommodative component

• accurate optical correction as first-line management

Failure to perform cycloplegia or misinterpretation of the results is a recurrent breach in negligence cases relating to strabismus.

Optical correction alone may realign the eyes and resolve the deviation. When it is omitted, delays are magnified and harm becomes avoidable.

5. Monitoring and Follow Up: Essential for Safe Practice

Clinicians must:

• review regularly

• monitor acuity and ocular alignment

• adjust treatment when improvement plateaus

• escalate to atropine penalisation or patching when required

• involve paediatric ophthalmology or orthoptics early

Litigation frequently arises when children are lost to follow up, or when long intervals allow amblyopia to become irreversible.

Documentation of follow up plans is essential.

6. Surgical Intervention: Timing and Indications

For non-accommodative deviations or residual strabismus after optical correction, timely surgery may be required.

Breach of duty may occur when:

• surgery is delayed despite stable deviation

• clinical concerns raised by orthoptists are not actioned

• pre-operative planning is inadequate

• post-operative follow up is insufficient

Although surgical technique rarely forms the basis of litigation in strabismus, the timing of surgery is frequently challenged.

7. Causation: What the Expert Must Establish

Causation in strabismus cases requires the expert to determine:

• whether earlier recognition or referral would have prevented amblyopia

• whether the delay allowed stereopsis to be lost

• the extent of binocular vision achievable with timely treatment

• whether the deviation would have required surgery regardless

• the long-term impact on function and occupational choices

The court relies on the expert to explain how neurovisual development interacts with clinical decisions.

8. Prognosis and Long-Term Consequences

Permanent strabismus or loss of stereopsis can influence:

• depth judgement and spatial awareness

• reading and learning speed

• driving eligibility

• performance in sport and practical tasks

• future occupational limitations

• psychosocial confidence and peer interaction

Experts must articulate these consequences in a clear, structured manner that assists the court in quantifying future risk and loss.

9. Practical Guidance for Solicitors

When assessing a strabismus case, solicitors should:

• obtain all orthoptic and optometry records

• review referral timelines

• analyse visual acuity progression

• assess whether cycloplegic refraction was performed

• identify missed opportunities where deviation increased

• seek early specialist opinion to determine whether harm was avoidable

Timelines are critical. A few months can determine the difference between reversible and irreversible harm.

Conclusion

Strabismus is one of the most time-sensitive conditions in paediatric ophthalmology. When primary practitioners fail to recognise or refer promptly, or when follow up is inadequate, irreversible harm can result. For solicitors, understanding the medicolegal framework around strabismus is crucial to identifying breach and establishing causation.

Expert evidence must explain clearly how the child’s visual system develops, what should have happened clinically, and how delays influenced the final outcome. When done correctly, it provides the court with a transparent and reliable foundation on which to assess liability.