Congenital or Acquired Muscle Weakness

Sixth, third or fourth cranial nerve palsies are sometimes seen after head injuries and the surgeon must always bear in mind the possibility of a sixth or other cranial nerve palsy being associated with raised intracranial pressure. Myasthenia gravis is extremely rare in children but it can present as a squint. In some cases of squint there is a degree of facial asymmetry. These patients might also have "asymmetrical eyes", one being myopic or hypermetropic relative to the other. Sometimes there is no refractive error but there might be an asymmetry of the insertions of the extraocular muscles as a possible cause of squint. There is a group of conditions, known as musculofascial anomalies, in which there is marked limitation of the eye movements from birth in certain directions. They are accompanied by abnormal eye movements, such as retraction of the globe and narrowing of the palpebral fissures on lateral gaze.

Overaction of muscles can cause a squint. This is seen in school children sometimes with a background of domestic or other stress. The eyes tend to overconverge and overaccom-modate, especially when being examined.

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