Strabismus and

Amblyopia

Allen Habajab
Samantha Reyes
 Definitions

Visual Axis Heterotropia

● Fovea to point of fixation ● Visual axes do not intersect at point of
● Normal binocular single vision (BSV) fixation
○ Axes intersect at point of fixation ● Children -> image from deviating eye
○ Aligned by fusion reflex suppressed at cortical level
Orthophoria ● Anisometropia
● Perfect ocular alignment in absence of stimulus for ○ Difference in retraction in both eyes
fusion ● Horizontal deviation of eyes
Heterophoria ○ Most common form of strabismus
● Tendency of eyes to deviate when fusion is blocked ● Hypertropia, Hyperphoria and vice versa
● Slight phoria is normal Anatomical Axis
○ Inward (Esophoria) ● From posterior pole thru centre of cornea
○ Outward (Exophoria) ● Does not correspond to visual axis
● Decompensating phoria Angle Kappa → 5°; subtended by the V & A axes
○ Binocular Discomfort (Asthenopia) ● Positive (normal)
○ Double Vision (Diplopia) ○ Fovea is temporal to center of posterior pole
○ Nasal displacement of corneal reflex
 Anatomy of Extraocular Muscles

● The lateral and medial orbital walls are at an angle of 45°

● The orbital axis therefore forms an angle of 22.5° with both walls
○ regarded as being 23°
● Eye is looking straight ahead at a fixed point on the horizon with the head erect
○ visual axis forms an angle of 23° with the orbital axis

Primary Action of the Muscle

● major effect when the eye is in the primary position
Subsidiary Actions of the Muscle
● additional effects, which depend on the position of the eye

Listing Plane
● imaginary coronal plane passing through the centre of rotation of the globe
CLINICAL EVALUATION
● HISTORY
○ Age of onset, Symptoms, Variability, General Health, Birth History and etc.
● Visual Acuity
○ Fixation and Following, Comparison, Fixation Behaviour (steady or unsteady,
central or non-central), Rotation test, Preferential looking
● Tests for stereopsis
○ measured in seconds of arc (1° = 60 minutes of arc; 1 minute = 60 seconds)
○ The lower the value the greater the acuity
○ Titmus, three dimensional polarized vectograph comprising two plates in the
form of a booklet viewed through polarized spectacles
○ Lang stereotest, .Displacement of the dots creates disparity (1200– 200
seconds) and the patient is asked to name or point to a simple shape, such as a
star, on the card
CLINICAL EVALUATION
● Tests for binocular fusion in infants
without manifest squint
○ Base-out Prism, simple method for
detecting fusion in children;
displaces the retinal image tem
porally with resultant diplopia
CLINICAL EVALUATION
● Measurement of deviation
○ Hirschberg test, rough objective estimate of the angle of a manifest
strabismus and is especially useful in young or unco operative patients or
when fixation in the deviating eye is poor
○ Krimsky test, placement of prisms in front of the fixating eye until the corneal
light reflections are symmetrical
○ Cover-Uncover test, to detect heterotopia and heterophoria
(A) The right corneal reflex is near the temporal
border of the pupil indicating an angle of about
15°

(B) the left corneal reflex is near the limbus

indicating an angle of close to 45° –
convergent squint

(C) the right corneal reflex demonstrating both

divergence and hypotropia
CLINICAL EVALUATION
● Motility Test
○ Ocular movement
○ Near Point Convergence
○ Near point Accomodation
AMBLYOPIA
● decrease in best corrected visual acuity (VA) caused by form vision deprivation
and/or abnormal binocular interaction, for which there is no identifiable pathology
of the eye or visual pathway
● Strabismic amblyopia results from abnormal binocular interaction where there is
continued monocular suppression of the deviating eye.
● Anisometropic amblyopia is caused by a difference in refractive error between the
eyes and may result from a difference of as little as 1 dioptre.
● Stimulus deprivation amblyopia results from vision deprivation. It is typically
caused by opacities in the media or ptosis that covers the pupil.
● Bilateral ametropic amblyopia results from high symmetrical refractive errors.
● Meridional amblyopia results from image blur in one meridian.
AMBLYOPIA
● Diagnosis
○ Visual acuity in amblyopia is usually better when reading single letters than
letters in a row.
○ ‘crowding’ phenomenon is more marked in amblyopes
Pseudostrabismus

● Ocular deviation when no squint is present

● Epicanthic folds may stimulate esotropia
● Abnormal interpupillary distance
 Heterophoria

● Present clinically with associated visual

symptoms when the fusional amplitudes are
insufficient to maintain alignment, particularly
at times of stress or poor health.

Signs

● Both esophoria and exophoria can be

classified by the distance at which the angle is
greater: respectively, convergence excess or
weakness, divergence weakness or excess and
mixed.
 Vergence Abnormalities
Convergence Insufficiency
● individuals with high near visual demand
○ e.g. students
● Remote NPC independent of any heterophoria
and poor fusional convergence amplitudes
● Accommodative insufficiency (AI)
○ occasionally also present
○ may be idiopathic (primary) or post-viral
○ typically affects school-age children.
○ minimum reading correction to give clear vision
is prescribed but is often difficult to discard
Divergence Insufficiency
● Divergence paresis or paralysis
● associated with underlying neurological
disease, such as intracranial space-occupying
lesions, cerebrovascular accidents and head
trauma
● any age and may be difficult to differentiate
from sixth nerve palsy
● concomitant esodeviation with reduced or
absent divergence fusional amplitudes
 Vergence Abnormalities

Near Reflex Insufficiency Spasms of the Near Reflex

● Paresis ● Functional condition affecting patients of all

○ dual convergence and accommodation ages
insufficiency ● Diplopia, blurred vision and headaches
○ Mydriasis may be seen on attempted near
● Signs
fixation
○ Esotropia, pseudomyopia and miosis
○ difficult to eradicate
○ Spasm may be triggered when testing ocular
● Complete Paralysis movements
○ no convergence or accommodation can be
○ Observation of miosis is the key to the
initiated
diagnosis
○ may be of functional origin
○ Refraction with and without cycloplegia
■ midbrain disease or after head trauma
confirms the
○ Recovery possible
○ pseudomyopia
ESOTROPIA

● Concomitant esotropia the variability of the angle of

deviation is within 5 Δ in different horizontal gaze
positions
● Incomitant deviation the angle differs in various
positions of gaze as a result of abnormal innervation or
restriction

Early-onset esotropia
● Idiopathic esotropia developing within the first 6 months
● angle is usually fairly large (>30 Δ) and stable
● Fixation in most infants is alternating in the primary
position
● cross-fixating in side gaze
● Abduction can usually be demonstrated
● Nystagmus is usually horizontal
 Accommodative Esotropia

● Abnormalities of the AC/A ratio

Refractive Accommodative Esotropia Nonrefractive accommodative Esotropia

● AC/A ratio is normal ● AC/A ratio is high

● esotropia is a physiological response to excessive ● independently of refractive error
hypermetropia ● Convergence Excess
● manifest convergent squint ○ High AC/A ratio due to increased accommodative
● Fully accommodative convergence
○ Normal near PoA
○ Hypermetropia with esotropia when uncorrected
○ Straight eyes at distance
● Partially accommodative
○ Esotropia near
○ reduced but not eliminated by full correction
○ Amblyopia is frequent as well as bilateral congenital
● Hypoaccommodative convergence excess
○ High AC/A ratio due to decreased accommodation
superior oblique weakness
○ Remote near point
○ Straight at distance; esotropia at near
Exotropia

Intermittent Exotropia Sensory Exotropia