Strabismus (Squint)

Anatomy of extraocular muscles:

Axes of Fick:
Axes around which the movements of eyeball are occur. They
are three; X (horizontal axis parallel to the iris plain), Y
(horizontal axis perpendicular to the iris plain and X-axis) & Z
(ve ical axis).
- Movements around X-axis are elevation and depression.
- Movements around Y-axis are Intorsion and extorsion.
- Movements around Z-axis are adduction and abduction.
For movement of one eye, we use terms "Adduction"
(for inward movement) and "Abduction" (For outward
movement).
*For simultaneous movement of both eyes, we use
terms "Dextroversion" (for movement to right) an
d "Levoversion" (for movement to left).
We have combined movement like: dextro-elevation,
dextro-depression, levo- elevation and levo-
depression.
Squint: is a misalignment of the visual axes.
Visual axis: is a line between the point of xation and
the fovea passing through nodal point. The normal
visual axes intersect at the point of xation.
Optical axis: line perpendicular to iris that falls on the
retina between the macula and the optic ne e. *The
angle between visual axis and optical axis is called
alpha (a) or kappa (x).
The squint is either: (-tropia): Manifested deviation
of the eyes ie squint present when both eyes are open.
Or: (-phoria): Latent tendency of the eye to deviate
(squint seen only when one eye is covered).
*Latent squint is not seen normally when both eyes are opened, but
when we occlude one eye it will deviate behind the cover, but as we
remove the occluder there will corrective movement which is not seen in
normal person.
Esotropia: inward deviation of eye Exotropia outward deviation of eye
Hype ropia Elevation of eye Hypotropia depression of eye
Manifested squint is of two types:
1- Comitant (or Concomitant): when the angle of squint is the same in
all directions of gaze.
2- Incomitant: when angle of squint varies in various direction of gaze

Comitant squint:
It can be:
1-Uniocular: same eye deviate all the time and the fellow eye always
xated.
2- Alternating: each eye xes and deviates alternately.
Esotropia: inward deviation of the eyes Classi cation of comitant
esotropia: which can be accommodative or non accommodative.
1- Accommodative esotropia: related to accommodation, sta s at
6m-Sy and mostly at 2y. It is divided into:
a- Refractive accommodative esotropia with a normal AC/A ratio, is a
physiological response to excessive hypermetropia (usually between
+4 and +7 Diopter). For example, a 4-year old boy has a refractive
error of +7 D in each eye.
Without spectacles there is esotropia measures 28 A (4 A/ID).
with spectacles →no deviation for distance and near.
In these cases the eyes usually remain straight with glasses and
surge is not required.
b- Non-refractive accommodative esotropia is associated with a
high AC/A ratio. The refraction is usually normal for the age of the
child (1.5-3.0 D) and there is little or no deviation for distance,
although there is a signi cant esotropia for near
C-Mixed accommodative esotropia
2- Non-accommodative esotropia:
- Essential infantile esotropia (congenital):
It is esotropia with onset since bi h or during the rst six months of life
-Convergence excess.
-Convergence spasm.
- Consecutive: patients with divergent squint who are underwent an
operation for correction of exotropia and ends with convergent squint due
to overcorrection.
- Divergence insu ciency.
Essential infantile esotropia (congenital):
Signs or criteria
( ):
b Alternating in prima position and cross xation in side gaze.
-
a Large angle
- .
e Usually associated with Nystagmus
- .
d Not associated with refractive error
- .
e Associated with inferior oblique overaction if we have convergence,
- (
then there will be elevation of the eye on adduction).
f-Usually it is squint per se, there is no neurological defect.
Aim of management of child with Squint:
1- Restore binocular single vision (BSV).
2- Cosmetic .
a Histo :
-
-Age of onset. Most of congenital need surge while
many cases of acquired can be treated with spectacles
because it is related to the use of accommodation. -
General health. Other systemic diseases should be
excluded prior to surge if needed and also other
neurological diseases which are can be associated with
squint.
- Family histo . We should search for any previous family
histo of squints and the way of their treatment because
the recent case is most likely corrected by the same way.
b- Visual acuity: it is the corner stone, as our aim in management of child with
squint is to restore his binocular single vision.
c-ocular motility examination: to exclude ne e palsy and other congenital
abnormalities of muscles.
d- Refraction: for assessment and determining its type and the way of treatment
(e.g. there is hypermetropia or not). This is done objectively be using retinoscope
instrument under complete cycloplegic e ect by using atropine or cyclopentolate or
homotropine.
e- Fundoscopy: to exclude retinal diseases e.g. retinoblastoma, congenital optic
disc anomaly, and macular hypoplasia.
f- Correction of amblyopia:.
i-Correction of refractive errors: by giving the patient spectacles.
ii- Occlusion of the fellow eye: this is done to enforce the amblyopic eye to send
stimulus to CNS by occlusion the xating eye in uniocular squint. In this method, we
occlude the normal eye for 1week/1year of age until improvement of VA to its normal level
(616)
iii-Penalization: it means pa ial occlusion to normal eye by daily instillation of cycloplegic
drugs (mostly atropine), this result in blurring of vision. This is done instead of occlusion if
the amblyopia is mild.
g-Surge : if the squint is not corrected or corrected pa ially by contiuous g-Surge of
spectacle, the residual angle should be corrected by surge (recession and resection).
Exotropia( Divergentsquint) : outward deviation of the eye
Classification:
1- Constant :seen when both eyes are open all the time.
- Congenital.
- Sensory :This is usually result from poor vision in the affected eye.
- Consecutive :duo to surgical overcorrection of esotropia.
2- Intermittent :present in some times of the day and sometimes the eyes
looks normal( no squint .)The diagnosis is just from the history taken
from parents and there may be no squint seen during the moment of
examination.
Congenital exotropia:
Signs:
1 -Normal refraction.
2-Large and constant angle.
3 -Usually associated with Neurological anomalies.
Treatment:
It is mainly surgical and done by bilateral lateral rectus recession +
resection of one or two medial recti.
Intermittent exotropia:
Management:
1- Spectacles if associated with myopia or any other
refractive errors.
2- Treatment of amblyopia.
3- Surge : recession of both lateral recti.
Paralytic squint (Incomitant squint):
1- Congenital.
2- Acquired: palsy of 3rd, 4th or 6th cranial ne e or
combination.
Surge should not attempt till there is no hope for
spontaneous recove and this is usually after 6
months to one year.
Pseudosquint: false appearance of squint
Causes: