ESTRABISMO

DOCENTE : Dr. ARTEMIO BURGA VALDIVIA ALUMNO: LENIN ZAVALETA RODRIGUEZ

Three directions of eye movement

Vertically
Upward SR & IO Downward IR & SO

Horizontally
Abduction LR Adduction MR

Torsionally
Intorsion (rotate nasally) SO Extorsion (rotate temporally) IO

Agonist Muscles
Receive equal innervation to ensure coordinated eye movements
Right MR activated to adduct the right eye, left LR equally activated to abduct left eye

Agonist/Antagonist Pairs (within each eye)

Receive reciprocal innervation
left MR muscle contracts to adduct left eye while the LR relaxes

 The movement of one eye by itself is called a duction The movement of the two eyes in the same direction is termed a version.
Vergences R binocular, disconjugate movements in opposite directions. They R convergence (ability of the eyes to turn inwards). Divergence (is their ability to turn outwards from the convergence

the nine diagnostic positions of gaze.

EOMs - The ability of the eyes to move to the Cardinal Points of Gaze is assessed to demonstrate paralytic strabismus

The SO is innervated by the trochlear nerve (CN IV). The animation demonstrates the three actions of the SO.

the eye is going to extort as it turns on the visual axis. This is the primary action of the IO the secondary action of the IO is elevation. The tertiary action of the IO is abduction

Strabismus.
Strabismus is the term for ocular misalignment or an underlying tendency toward misalignment. When the eyes are misaligned, one eye will fixate with the fovea and the fellow eye deviates, so the image fall on a peripheral retinal point.

Strabismus
Manifest
Heterotropia tropia

latent
Heterophoria phoria

False apparent

true

concomitant

incomitant

Direction
Eso nasal deviation Exo temporal deviation

Hyper superior deviation

Hypo inferior deviation

 Condition

Latent or phoria present only when fixation is Manifest or tropia present without interruption
of visual axis
Intermittent (when child is tired) v. Constant Monocular (always same eye) v. Alternating

interrupted

Comitant deviation same in all positions of gaze Incomitant deviation changes depending on position of gaze

MANAGEMENT OF STRABISMUS This involves 1. Confirming the presence of the Squint 2. Confirming the type of squint 3. Establishment of the cause of the squint 4. Eliminating the cause if possible eg: organic , refractive 5. Treat Amblyopia if present 6. Straighten the eye

Pseudostrabismus..
In young infants, strabismus must be differentiated from the more common pseudostrabismus

Pseudoesotropia as a result of a broad bridge of the nose. This is not a real eye crossing

Pseudo-deviations
Pseudo-esotropia Pseudo-exotropia

Epicanthic folds Short interpupillary distance Negative angle kappa

Wide interpupillary distance Positive angle kappa

Pseudostrabismus

Optical illusion - apparent esotropia Wide nasal bridge/large epicanthal folds The eyes look crossed, but the light reflection in each eye is identical (2 oclock in each eye)

Direction
Eso nasal deviation Exo temporal deviation

Hyper superior deviation

Hypo inferior deviation

History.
.Is there a family history of strabismus?. .Has the deviation been there since infancy? .When is the deviation present?
.Constantly? With fatigue? Only in certain positions of gaze?

.Is there a history of trauma? .Are there any other medical problems?
.Headaches

.Is there a history of toxin or medication exposure?

Subjective complaints:

Diplopia (binocular - monocular) Oscillopsia Asthenopia Getting worse or better Cosmetic issues Image tilt

How do children present ?

Lack of social smile or visual response in infants Squeezing of eyes while watching TV Inability to see blackboard Holding things close Frequent blinking and rubbing eyes Headache and eyestrain Poor school perfomance /attention Accidental on covering one eye or at school screening

Occlusion:
Which eyeHow longHow well

Orthoptics:
Type of exercisesHow longHow well Family history: Strabismus - parents, siblings, others Glaucoma Diabetes Other eye problems Trouble with anesthesia (malignant hyperthermia) General health: Trauma history Diabetes Fatigability Developmental delays

Special characteristics:
Head tilt (nodding) Preferred eye Variability of deviation Face turn Dancing eyes (nystagmus) Facial asymmetry

Prior treatment:
Glasses .When prescribedPrescription Bifocals Prisms

Ocular surgery:
When.What was done.By whom

 A convergent squint seen principally when reading will suggest an accommodative squint. An intermittent divergent squint is frequently worse for distance. An alternating squint suggests that there is no amblyopia present and makes an organic cause unlikely

The complications
1.Diplopia 2.Secondary contracture of extraocular muscles 3.Adverse psychosocial/vocational consequences 4.AMBLYOPIA

Physical Exam.
.General health and neurologic status .Assessment of development .Presence of a head tilt .Ophthalmologic exam:
Visual acuity Pupillary reactivity Eyelid position EOMs Corneal light reflex (Hirschberg Test) Cover Test Cover/Uncover Test Ophthalmoscopy Refraction

External Examination Examination Head posture . Facial asymmetry . Dysmorphic features Position of lids . Leukocoria .

Visual acuity.
is recorded as the smallest object a patient can see at a given distance. 20/20 vision (or 6/6 vision) means that at 20 feet (approximately 6 meters) a patient can see an object that subtends 5 minutes of arc with components of 1 minute. In the decimal system this is recorded as 1.0.
Visual acuity recorded as the viewing distance over the distance the smallest object seen subtends 5 minutes and is recorded: 20/60, 6/18, 0.3, etc.

VA in Preverbal children
The observation of behavioural patterns is the simplest method of assessment in this age group. .. Further information can be gained by fixation and pursuit patterns when appropriate visual targets are shown. ..Pupillary responses to light and optic kinetic nystagmus can also be used.

 At 2-4 weeks an infant will fixate and follow a light. By 5-6 weeks a large object will be followed. By 5-6 months small objects will receive attention. Small toys, attractive objects, or sweets may be used to determine visual responses Preference of fixation with one eye is an indication of better vision in that eye. A strabismic patient will alternate the fixing eye if vision is equal

Preferential looking test.

Teller cards

Leas paddles

Preferential Looking Observe patient eyes theory that gratings (stripes) will attract attention Difficult interpretation patients with nystagmus Limited interest

Cardiff Cards
pre-verbal (1 year+) Maintain interest Vertical separation Short distance (50cm/100cm) good interaction for babies/toddlers 11 acuity levels Overestimation of acuity

THE OBJECTIVE ASSESSMENT OF VISION

Visual acuity can be assessed objectively by using: .. The Visually Evoked Response Or . .. Preferential looking techniques

 If decreased vision is found in each eye when checked monocularly, vision should be checked binocularly. The examiner in this case should be looking for latent gross or micronystagmus. Fogging with a plus lens may be used to block vision in one eye but avoid nystagmus when determining monocular visual acuity in a patient with latent nystagmus. Near vision should be checked with E's, isolated letters or numbers, or sentence reading, depending on age.

 Visual acuity testing with neutral density filters can differentiate functional from organic amblyopia. Vision in an eye with functional amblyopia remains at or near the same level when neutral filters of increasing density are introduced. Vision in a normal eye or in an eye with an organic cause for poor vision decreases proportionally with the increased density of the filter.

Hirschberg test
Rough measure of deviation Note location of corneal light reflex 1 mm = 7 or 15

Reflex at border of pupil = 15

Reflex at limbus = 45

Hirschberg Test.
Used as an initial screen for strabismus How it works:
Stand several feet in front of child with penlight shining at eyes Light reflection will be at the same point in each eye

Normal

Exotropia

Esotropia

Krimsky Test..........

Bruckner Test..
Is performed by using direct ophthalmoscope to obtain a red reflex simultaneously in both eyes. If there is strabismus, the deviated eye will have a lighter and brighter reflex than the fixing eye. .Media opacities, Refractive errors, Strabismus

Evaluation of Motility.
Two principle methods of evaluating ocular motility are: 1. Observation of ocular ductions, which are the actual monocular movements of the eye, and 2. Observation of binocular ocular alignment, using cover/uncover and alternate cover testing.

Ocular movement examination.

 right esotropia (RET) right exotropia (RXT) right hypertropia (RHT)right hypotropia left esotropia (LET) left exotropia (LXT) left hypertropia (LHT)left hypotropia

alternating esotropia (ALT ET) alternating exotropia (ALT XT)

 E esophoria X exophoria

RH right hyperphoria LH left hyperphoria E(T) intermittent esotropia X(T) intermittent exotropia RH(T) intermittent right hypertropia LH(T) intermittent left hypertropia

Cover tests

Cover test detects heterotropia Uncover test detects heterophoria

Prism cover test measures total deviatio

Alternate cover test detects total deviation

Motility tests

Tests versions and ductions

Grades under/overaction

Left inferior oblique overaction

Left lateral rectus underaction

Tests for Stereopsis

Tests on stereopsis can be based on two principles 1..Using targets which lie in two planes, but are so constructed that they stimulate disparate retinal elements and give a three dimensional effect, for example: Circular perspective diagram such as the concentric rings Titmus fly test, TNO test, Random dot stereograms, Polaroid test Langs stereo test Stereoscopic targets presented haploscopically in major amblyoscope 2..Using 3 dimensional targets (e.g. Langs two pencil test).

 Qualitative tests for Stereopsis:

Langs 2 pencil test Synaptophore

Quantitative tests for Stereopsis:

Random dot test TNO Test Langs stereo test

Tests for stereopsis

Titmus
TNO random dot test

Polaroid spectacles Figures seen in 3-D

Red-green spectacles Hidden shapes seen

Frisby

Lang

No spectacles Hidden circle seen

No spectacles Shapes seen

Sensory Fusion . Present each eye with different stimulus If sensory fusion intact patient will report a combined percept. Variety of different test Bagolini glasses Constant squint supn/diplopia(double vision)

Measurements of ocular misalignment

Measurement of squints/misalignments

Synoptophore - picture test Measure - misalignments,sensory and motor fusion and stereopsis Predict BV post-surgery Measure misalignments 9 positions of gaze

Prism Cover Test

Measure squint/misalignment Single prism/prism bar Primary position or in all positions of gaze

Refractive accommodative esotropia

Presents between 18 months - 3years Initially intermittent Normal AC/A ratio Excessive hypermetropia Fully accommodative Partially accommodative

Esotropia greater for near

Straight for distance

Straight for distance and near

Esotropia for near

Four-year old girl with accommodative esotropia. Farsighted glasses control all of the eye crossing

This six month old child with esotropia measured to be significantly farsighted. With the appropriate glasses in place, the eye crossing resolved.

A patient with a right accommodative esotropia which only becomes manifested when looking at a fixating object close-up

A patient with accommodative esotropia corrected with plus lenses

Management of accommodative esotropia

Refraction - prescribe full cycloplegic refraction under age 6 years

Treatment of amblyopia

Surgery - if spectacles do not fully

correct deviation

Recession

Resection

Constant exotropia
Congenital

Sensory

Presents at birth Large angle Alternating fixation Normal refraction for age

Disruption of binocular reflexes by acquired lesions, such as cataract

Consecutive - follows previous surgery for esotropia

Intermittent exotropia
Signs
Basic

Angle greater for near

Convergence weakness

Angle greater for near

Presents - usually prior to 5 years

Divergence excess

May be associated with myopia

Usually alternating (amblyopia uncommon)

Treatment - surgery

Angle greater for distance

May be true or simulated

Three-year old girl with an intermittent exotropia. The photo on the left demonstrates her exotropia. Moments later, her eyes spontaneously became well aligned as illustrated in the photo on the right.

Bilateral in about 20% On attempted adduction - retraction of globe and narrowing of palpebral fissure On attempted abduction - opening of palpebral fissure and normal globe position

Duane syndrome
Left type I (left)

Primary position - straight Adduction- normal or mildly limited or mild esotropia

Abduction - limited or absent

Type II

Abduction - normal or mildly limited Adduction - limited Primary position - straight or mild exotropia

Type III (left)

Abduction - limited

Primary position - straight or mild esotropia

Adduction - limited

Hypertropia

This child has an obvious left hypertropia. Unbeknownst to her and her family, her doll has a right hypertropia.

Head tilt before eye muscle surgery

No head tilt after eye muscle surgery.

Brown syndrome (right)

Normal elevation in abduction

Straight in primary position Limited elevation in adduction

Double elevator palsy (right)

Unilateral elevation failure in all positions

Mobius syndrome
Signs

..

Bilateral sixth nerve palsies - Primary position - 50% patient looking left straight, 50% esotropic

Bilateral, usually asymmetrical facial Horizontal gaze palsy in palsies sparing lower fac 50% Paresis of 9th and 12th cranial nerves

V pattern deviation
Signs Treatment

V pattern esotropia

Bilateral medial rectus recessions + downward transposition

Difference between up- and downgaze is 15 or more

V pattern exotropia
Bilateral lateral rectus recessions + upward transpositions

A pattern deviation
Signs Treatment

Difference between up- and A pattern esotropia Bilateral medial rectus recessions downgaze 10 or more + upward transposition

A pattern exotropia

Bilateral lateral rectus recessions + downward transposition