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Strabismus

Strabismus is the misalignment of the eyes, affecting binocular vision and neuro-muscular control, with various classifications including pseudostrabismus, heterophoria, and heterotropia. The document discusses the anatomy of extra-ocular muscles, laws of ocular movements, and abnormalities of binocular vision, including suppression and amblyopia. It also covers the classification, diagnosis, and management of different types of squint, including comitant and incomitant strabismus, as well as treatment options such as prisms, surgery, and botulinum injections.

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7 views

Strabismus

Strabismus is the misalignment of the eyes, affecting binocular vision and neuro-muscular control, with various classifications including pseudostrabismus, heterophoria, and heterotropia. The document discusses the anatomy of extra-ocular muscles, laws of ocular movements, and abnormalities of binocular vision, including suppression and amblyopia. It also covers the classification, diagnosis, and management of different types of squint, including comitant and incomitant strabismus, as well as treatment options such as prisms, surgery, and botulinum injections.

Uploaded by

Garveesh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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STRABISMUS

Dr R K Bansal
Consultant, Ophthalmology
GMCH 32
Chandigarh
Strabismus

 Misalignment of eyes
 Abnormality of binocular vision
or neuro-muscular control of
eyes
 Orthophoria is ideal
 Small heterophoria is common
 Pseudostrabismus,
heterophoria, heterotropia
 Horizontal, vertical,
cyclovertical, or combination
Anatomy of Extra-ocular muscles

 4 Recti and 2 Obliques


 Origin at Annulus of Zinn, except for
IO
 Attached to sclera
 Nerve supply; 3,4 and 6th
 3 axis;x,y,z
 Actions:
 1. Ductions and vertions
 2. Conjugate; primary, secondary,
tertiary
 3. Disconjugate: Convergence and
Divergence
Law of ocular movements

 Hering’s Law: simultaneous and equal


innervation to yoke muscles
 Sherrington’s Law: law of reciprocal
innervation; agonist and antagonist, when
agonist contracts, antagonist relaxes
Actions of EOM

9 diagnostic positions of gaze


 Primary: straight primary position
 Secondary: up, down, right, left in straight position
 Tertiary: combinations of horizontal and vertical
muscle actions; dextroelevation, dextrodepression,
levoelevation, levodepression
 Cardinal positions: when yolk muscles work in their
main field of action: 2 horizontal and 4 tertiary
positions
CARDINAL POSITIONS OF GAZE
Binocular Vision

 Using two eyes for same target and perceiving it as one


 Develops during first 6 months of life
 Good distance vision and nearly equal vision in both
eyes, straight eyes, normal visual cortex
 3 grades: SMP, Fusion (convergence and divergence
range, Stereopsis
Abnormalities of BSV:Sensory adaptation

 Suppression
 Amblyopia
 Abnormal retinal correspondence
Suppression

 Binocular phenomenon
 One eye or alternate
 WFDT, Bagolini
 Facultative or obligatory
 Central or peripheral
Amblyopia

 Reduced form vision or abnormal binocular interaction


with normal eyes.
 Uniocular or binocular.
 Ocular structures are normal
 Prevalence 2-4% in school children
 Classification:Strabismic,
Anisometropic (isometropic, meridional),
Deprivation (cataract, ptosis, corneal
opacity)
 Treatment: Occlusion, pinlization, levodopa
Abnormal retinal correspondence

 Normal: bifoveal
 Abnormal : one fovea and other extra-foveal point to
achieve some grade of BSV
 Tests: WFDT, Bagolini striated glasses, after image
test, synaptophore test
Squint classificaton

 Pseudostrabismus : telecanthus, epicanthal fold,


negative and large positive angle kappa, less or more
IPD, hypertelorism
 Heterophoria
 Manifest squint
Heterophorias (latent squint)

 Fusion keeps the eyes straight


 Less fusional reserve
 Refractive error
 Eso/Exo/vertical/cyclovertical
 Asthenopia, diplopia, eye fatigue
 Cover/uncover test
 Meddox rod test for distance
 Meddox wing for near
 Measurement by prism cover test
 Fusional range: NPC/NPA
 Treatment: RE correction, exercises,
prisms, surgery
Manifest Squint:Heterotropia

 Most common form


 Eso/exo/vertical/cyclovertical
 Unilateral/alternate
 Unilateral associated with poor vision
 Cover/uncover test
 Hirschberg test, Krimsky reflex test, PBCT,
synaptophore
 Ocular movements
 Binocular vision status:SMP/Fusion/Stereopsis
 Supression/amblyopia/ARC
Hirschberg test PBCT

Synaptophore test
Squint work up

 Pseudostrabismus, Heterophopia or Tropia


 Cover and uncover test and alternate cover test
 Squint measurement; Hirschberg, Krimsky, PBCT,
synaptophore
 Measurement for distance and near
 Ocular movements
 Cyclolegic refraction: atropine/homatropine
 Fundus examination
Classification of Manifest Squint

COMITANT

INCOMITANT

SECONDARY

Esotropia, Exotropia, Hypertropia, Cyclotropia


Comitant Esotropia

 Most common type


 Types:Primary
Accommodative;
refractive,
non-refractive (High AC/A ratio)
partial accommodative
Non-accommodative;
Essential Infantile Esotropia (congenital esotropia)
Late on set basic
Microtopia
Cyclic esotropia
 Secondary
 Consecutive
Essential Infantile Esotropia

 Most common
 Onset <6 months
 Small refractive error
 Large angle >30 PD
 Alternate
 Nystagmus
 Limited abduction
 Cross fixation
 IOOA or DVD associated
 Needs surgery
Accommodative

 Onset after 2 years


 Deviation more for near
 Large refractive error in refractive
 High AC/A ration in non-
refractive
 Correction by glasses; refractive
 Bifocals for high AC/A ratio
 Surgery for partial
accommodative
Accommodative Esotropia:
AC/A ratio high
Basic Esotropia

 Late on set
 Small refractive error
 Same for distance and near
 A or V phenomenon
 Cycloplegic refraction
 Surgery
Exotropia

 Outward deviation of eye


 Intermittent or constant
 Primary
 Secondary
 Consecutive
Primary exotropia

Four types
 Divergent excess
 Convergent insufficiency
 Basic
 Simulated divergent excess type
 Initially intermittent later constant
 A or V pattern, DVD, IOOA, SOOA
 Treatment: glasses, fusional exercises, prisms,
surgery
Incomitant Strabismus

 Paralytic: any nerve palsy,


myopathies, Myasthenia
Gravis
 Restrictive: DRS, Brown
syndrome, thyroid
myopathy, floor fracture,
fibrosis syndrome
 Special types: A/V
phenomenon, DVD
Paralytic

 Sudden onset
 Headache, nausea, vomiting
 Diplopia
 Associated neurological features
 Primary deviation< secondary deviation
 Head posture
 Restricted movement
 False pointing
Paralytic Vs Comitant

 Onset: Sudden  Gradual


 Precipatating event: present  Absent
 Age: Late  Pediatric
 Symptom: Diplopia  Usually no diplopia
 Ass sym: headache  No headache
 Other neurological signs  Absent
present
 Head posture: present  Absent
 Cyclotropia: present  No
 Past pointing: present  No
 Sensory adaptation: absent  Present
Sequales of Muscle Palsy

 Overaction of contralateral synergist (yoke muscle) MR


of other eye in LR palsy

 Contracture of direct anatgonist; MR of same eye

 Secondary inhibitional palsy of contralateral


antagonist;LR of other eye
Types of Palsies

 Single muscle palsy; LR or SO


 Multiple muscles palsy; 3rd N, complete
ophthamoplegia; all nerves
 Pupil sparing or involved; external/internal
 Total ophthalmoplegia
 Internuclear ophthalmoplegia;MLF lesions
 Accommodation paralysis; drugs
Etiology of paralytic

 Congenital
 Inflammatory
 Neoplastic
 Vascular; DM, hypertension, aneurysms
 Trauma
 Toxic; poisoning, diptheria, alcohol, lead
 Demyelination; MS
 Myaesthenia Gravis
Work up

 Examination for cause


 Blood investigations, CT scan
 Tensilon test for MG
 Diplopia charting
 Lees Charting
 FDT
 Management: cause, prisms, patching, surgery
Management

 Treatment of cause
 Temporary measures for diplopia; prisms, occlusion
 Botulinum A injection
 Surgical: recession/resection, transposition once
deviation stable.
Special forms of squint

 Duane’s retraction syndrome


 Brown syndrome
 Double elevator palsy
 Progressive external ophthalmoplegia
DRS SYND
LEFT EYE 4TH N PALSY
Nystagmus

 To and fro movement of eye; regular and rhythmic


 Involuntory movements of eye
 Pendular or jerk type
 Latent or manifest
 Horizontal or vertical (up-beat, down-beat)), see-saw
 Physiological, pathological
 Vestibular
 Ocular causes, Brain stem lesions, cerebellar, drug
toxicity
Muscle surgeries

 Weakening;
recesssion, Z plasty,
myectomy
 Strengthening;
resection,
advancement, tucking
 Transposition; attach
normal muscle to
week muscle

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