A, a 7-year-old girl from a rural village in Northern Nigeria, was brought to the local health clinic by her mother, who noticed that A's eyes did not seem to align properly. The mother reported that this issue had been present since A was about 2 years old, but had recently become more noticeable, especially when A was tired or trying to focus on distant objects. A's teacher had also mentioned that she was struggling to read the blackboard at school.

On examination, A was found to have esotropia, where her right eye deviated inward while the left eye was aligned correctly. The deviation increased when she was focusing on near objects. A cover test confirmed that the strabismus was alternating, although the right eye was more affected.

Further assessment showed that A had a mild refractive error, and her visual acuity was reduced in the right eye, suggesting the development of amblyopia (lazy eye). There were no signs of neurological deficits, and her general health was good.

A’s family relies on subsistence farming, with limited access to healthcare. Eye care services are sparse, with the nearest specialist located several hours away by road. Due to cultural beliefs, her mother had initially attributed the condition to spiritual causes and sought traditional remedies before bringing A to the clinic.

Given the late presentation and the family's limited access to specialised care, the health clinic referred A to a regional hospital with an ophthalmologist. The proposed treatment plan included prescription glasses to correct her refractive error, patching therapy for the amblyopia, and possible surgical intervention if her condition did not improve with conservative management.

The main challenges included ensuring regular follow-up for A’s treatment, given the long distance to the hospital and the family's financial constraints. Additionally, addressing the cultural beliefs surrounding the condition was crucial to ensure compliance with the recommended treatment plan.

A’s mother agreed to take her to the regional hospital. Over the following months, A received glasses and underwent patching therapy, which led to some improvement in her visual acuity and alignment. However, the need for surgical correction remained under consideration due to persistent esotropia.

This case highlights the challenges of managing strabismus in rural sub-Saharan Africa, where late presentation, cultural factors, and limited access to specialised care complicate the treatment of a condition that, if addressed early, could have been managed more effectively.