Eye Care Orthoptists

Overview

An orthoptist is a specially trained eye health professional. They test and treat problems with how the eyes move and how they work together as a pair. This includes eyes that turn in or out (a squint), a lazy eye, and double vision. Orthoptists are not doctors, but they work closely with eye doctors (ophthalmologists) and optometrists. You often do not need a referral to see one in a hospital eye clinic or a community eye service.

Very common. Squints and lazy eye are among the most frequent eye problems in childhood, and eye strain or double vision brings many adults to an orthoptist each year.

Anyone can be seen, but orthoptists mostly work with three groups: young children (squint, lazy eye, vision screening), working-age adults (eye strain, double vision, eye muscle problems) and older adults (double vision after stroke, thyroid eye disease, or nerve problems). A family history of squint or lazy eye raises the chance a child will need a check.

Symptoms

Common symptoms

• Seeing two images instead of one (double vision)
• One eye turning in, out, up or down, all the time or only when tired
• Closing or covering one eye to see more clearly
• Tired, aching eyes after reading, screens or close work
• Headaches around the eyes or forehead after using your eyes
• Words or lines seeming to jump or blur when reading
• Poor sense of depth, so stairs, parking or ball games feel harder
• Eyes feeling 'pulled' or strained when you look at things up close

Symptoms in children

• A squint noticed by a parent, teacher or health visitor
• Tilting or turning the head to look at things
• Screaming or fussing when one eye is covered, but not the other
• Rubbing the eyes, blinking a lot, or closing one eye to watch TV
• Bumping into things or seeming clumsy with hand-eye tasks
• Not enjoying 3D films or puzzles that need two eyes working together
• A referral from a school vision check or a newborn eye check

Symptoms in older adults

• New or changing double vision
• Eyes that feel tired or strained when reading or driving
• Eyes that look misaligned after a stroke or a thyroid problem
• A drooping eyelid or one eye sitting differently from the other
• Difficulty judging steps, kerbs or doorways because of double vision

Causes

Main causes

• The eyes needing different strengths of glasses (refractive error), which can pull the eyes out of line
• A weakness or imbalance in the muscles that move the eyes
• The brain and eyes not learning to work together in early childhood (the usual cause of lazy eye and childhood squint)
• Nerve problems, such as a nerve palsy affecting one eye muscle
• Thyroid eye disease, where the tissues around the eye become swollen
• Stroke, head injury or other brain conditions
• Scarring or damage to an eye muscle after injury or surgery
• Convergence problems, where the eyes struggle to turn in for close work such as screens and reading

Risk factors

• Family history of squint, lazy eye or wearing strong glasses as a child
• Being born early or with a low birth weight
• Needing strong glasses, especially at a young age
• Thyroid disease
• Diabetes or other conditions that affect nerves
• A previous head injury or stroke
• Long hours of close work or screen use without breaks

When to see a doctor

See a doctor urgently if:

• Double vision that has just started, or that goes away when you cover one eye
• A squint that appears suddenly in a child or adult
• Any sudden change in vision, or new flashing lights or floaters
• Eye pain, redness or a drooping eyelid with a change in vision
• A child with a head tilt, or who cries when one eye is covered

Book a routine appointment if:

• You or your child have a squint that has been there for a while
• Your child has not had a vision check and has a family history of squint or lazy eye
• Eyes feel strained, tired or headachey after reading or screens
• You find it hard to judge depth, or you avoid driving at night because of your eyes
• You have thyroid disease and notice your eyes look or feel different
• Glasses no longer seem to keep your eyes comfortable

Diagnosis

An orthoptist diagnoses these problems by watching how your eyes move and how well they work together. There is no need for needles or scans in most cases. The appointment is relaxed and can be adapted for young children, people who do not speak much English, or anyone who finds the tests hard. If something more serious is found, the orthoptist refers you to an eye doctor.

Tests that may be done

• A vision (letter or picture) test for each eye on its own
• The cover test: covering one eye at a time to see how the eyes line up
• Watching the eyes follow a light or a toy in different directions
• 3D vision tests, using special glasses and picture books
• Prism tests, where a small glass is held in front of the eye to measure the size of the turn
• Tests with coloured filters or lenses to check for double vision
• A glasses check (refraction), usually by an optometrist
• Sometimes eye drops to widen the pupil so the back of the eye can be checked
• In some clinics, photographs or a scan of the eye muscles

What to expect at your appointment

Appointments usually last 20 to 45 minutes. Your child may be asked to sit on your lap or play a short game, and the orthoptist will explain each step. Bring any glasses you wear and, for a child, anything that helps them feel calm. You may be given exercises or a patch plan to try at home, and a follow-up appointment to see how things are going.

Treatment

Treatment depends on what is causing the problem. The aim is to help the eyes work together, keep vision strong in each eye, and get rid of double vision. Orthoptists lead many treatments themselves, such as eye exercises and patch plans, and work with optometrists for glasses and with eye doctors for medicine or surgery.

Self-care at home

• Wear your glasses as advised — they are often the first and most important step
• Take regular breaks from close work: every 20 minutes, look at something far away for 20 seconds
• Set up screens at eye level, an arm's length away, with soft lighting and no glare
• Do your eye exercises as shown, little and often, rather than all at once
• If your child wears a patch, build it into a routine and use a sticker chart or small reward
• Keep follow-up appointments, even when things seem fine
• Tell your child's teacher or nursery about the patch or glasses so they can support them

Medical treatments

Common approaches include glasses to correct focusing, patching or special eye drops (prescribed by your eye doctor) to strengthen a lazy eye, and eye exercises to improve how the eyes turn in and work as a team. Prisms built into glasses can help stop double vision. Some adults with double vision are offered a medicine injected into an eye muscle by a specialist to relax it. If vision is affected by another condition, such as thyroid disease or a nerve problem, treating that condition is part of the plan. Your eye team will explain the choices and what is likely to work for you.

When is surgery considered?

Surgery is not needed for most people. It may be discussed when glasses, patching or exercises have not straightened the eyes enough, or when a squint is long-standing and causes problems. An eye doctor (ophthalmologist) does the operation, which adjusts the eye muscles so the eyes sit straighter. It is usually a day-case procedure, and some people still need glasses or further treatment afterwards.

Living with this condition

Most people carry on with work, school and hobbies as normal. You may need to plan around appointments, patch time or exercises, and you might need to avoid driving while you have double vision until your eye team says it is safe. It helps to tell family, friends, teachers and your employer what you need — for example, a seat where you can see the board clearly.

Lifestyle tips

• Keep up good lighting at home and at work to reduce eye strain
• Follow the 20-20-20 habit during screen use
• Wear sunglasses outdoors if light makes your eyes uncomfortable
• Use a patch or glasses plan consistently — short, regular sessions work better than occasional long ones
• For children, keep play active and outdoors where possible; this is good for general health and eye development
• Tell your optometrist or orthoptist if your vision or double vision changes

Diet and exercise

No diet or exercise can straighten the eyes or cure a lazy eye, but a healthy lifestyle supports your eyes and the nerves and blood vessels that feed them. Eat a balanced diet with fruit and vegetables, stay active, avoid smoking and keep up with checks for conditions like diabetes and high blood pressure. Ask your clinician before starting any new exercise if you have double vision, so you can stay safe.

Mental health and emotional wellbeing

Eye problems can affect how you feel. Children may be teased about a patch or glasses, and adults with double vision can feel anxious, tired or less confident, especially about driving or going out. These feelings are common and worth talking about. If low mood, worry or stress is lasting or getting in the way of daily life, speak to your doctor — support is available, and you do not have to manage alone.

Prevention

Not all eye team problems can be prevented, but early detection makes a big difference. Some cases linked to head injury, diabetes or thyroid disease can be reduced by managing those conditions well. For children, the key is checking vision at the recommended ages so problems are found while treatment still works best.

Screening programmes

Newborn and early childhood eye checks, plus school vision screening where it is offered, help find squints and lazy eye early. If you are not sure whether your child has been checked, ask your health visitor, family doctor or school. Adults should have an eye test at least every two years, or sooner if their optometrist advises it, and anyone with diabetes should attend regular diabetic eye screening.

Complications

If left untreated

• A lazy eye can become permanent if it is not treated in early childhood
• Losing the ability to see in 3D, which affects depth judgement and some sports and jobs
• Double vision that continues, making reading, driving and walking safely harder
• Falls or injuries in adults whose depth vision is poor
• Eye strain, headaches and tiredness that affect school, work and mood
• A child falling behind at school because they cannot see the board clearly

Long-term outlook

The outlook is good for most people. Glasses, patching, exercises and, where needed, surgery help many people see comfortably and keep their eyes working together. Early treatment gives the best results, especially for children, but adults can also be helped with double vision and eye strain. Your eye team will tell you what to expect for your situation and review your progress as you go.

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