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Squint (crossed eyes)

Col (R) Dr Fazal Rabbi Consultant Ophthalmologist Department of Ophthalmology NIMS Medical College Abbottabad


One of the functions of the human eye is its ability to maintain
single binocular vision despite the two slightly dissimilar images formed on the retinas of two eyes. The appreciation of the

simple image is due to fusion at the higher level and this results
in stereopsis a 3D vision. There are three factors required for development of BSV.

1. Normal or nearly normal eyesight in each eye. 2. The ability of the visual area in brain to fuse the two
dissimilar images.

3. The accurate coordination of the two eyes for all directions

of the gaze. For retinal correspondence and achieving fusion, normally functioning extra ocular muscles are required.

Remember: BSV has advantages

1. 3D perception 2. Larger field of vision 3. Blind spot of each eye is overlapped.


In maintaining single binocular vision the extraocular muscles
play an important role. There are six extra ocular muscles in each eye which control there movement. Four of them are recti and two oblique.

1. 2. 3. 4. 5. 6.

Lateral rectus Inferior rectus Medial rectus Superior rectus Inferior oblique Superior oblique

supplied by 6th cranial nerve. supplied by 3rd cranial nerve.

supplied by 4th cranial nerve.

Actions of extra ocular muscles Muscle Main action primary Subsidiary action Secondary
Medial rectus Lateral rectus Superior rectus Inferior rectus Superior oblique Inferior oblique Adduction Abduction Elevation Depression Intorsion extorsion Intorsion Extorsion Depression Elevation adduction adduction abduction abduction


Yoke Muscles
It is a pair of muscles one from each eye, which moves the two
eyes in the same direction of gaze. E.g.

1. Medial rectus of one eye lateral rectus of the other eye. 2. Superior rectus of one eye is yoke muscle of inferior oblique
of the other eye and vice versa.

3. Inferior rectus of one eye is yoke muscle of superior oblique

of the other eye.

It is a condition when one eye deviates away from the fixation point.

Classification of squint
Apparent squint
Latent squint or Heterophoria

Manifest squint or

Concomitant squint

Paralytic squint







Apparent squint: It is a pseudo squint in which the visual axes are parallel but the eyes appear to have squint. This happens in epicanthus, broad based nose and high errors of refraction.

Latent squint: In this there is a tendency for deviation of

the eyes when the fusion is broken.

Esophoria There is a tendency for inwards deviation of the

Exophoria There is a tendency for outwards deviation of the


Hyperphoria There is a tendency for upwards deviation of

the eyeball.

Cyclophoria There is a torsional deviation of the eye.

Clinical Features:

1. Headache or eye ache is the most common. 2. Difficulty in changing focus from one distance to another is
often noticed.

3. Photophobia is very common, which is relieved by closing one


4. Blurring or crowding of words while reading. 5. Intermittent diplopia. 6. Intermediate squint.


Cover uncover test detects the presence of phoria. Maddox rod test to detect phoria for distance. Maddox wing test to detect phoria for near.


1. Correction of refractive error. 2. Orthoptic exercise to increase the fusional reserve and
convergence. the exercises are


Pencil exercises

ii. Exercise weak muscle aginst prism. iii. synoptophore

4. Prescription of prism in glasses. 5. Surgical treatment. 6. Improvement of health.

Manifest squint (Hetrotropia)

A visible deviation of the eye.

A. Concomitant Squint
In this the deviation remains the same in all directions of gaze. Etiology: Defect in afferent pathway due to defective vision. Types:

1. Uniocular concomitant squint: when one eye always deviates.

i. convergent

ii. divergent

2. Alternating concomitant squint


1. No symptoms only cosmetic embarassment. 2. No diplopia. 3. No binocular vision.


1. Primary and secondary deviations are equal. 2. No limitation of movements.

Investigations: 1. History:Ask i. age on onset ii. Any history of acute illness. iii. Any history of eye injury or head injury. iv. Is the squint intermittent or constant. v. Is deviation uniocular or alternating. iv. Family history of squint or refractive error.

2. 1.

Examination Inspection i. Right eye or left eye. ii. Deviation out or in or vertical. iii. Any opacity of the media.

iv. Pupilliary reaction.

v. Angle of squint.

2. 3. 4. 5. 6. 1. 2. 3. 4.

Cover test Movements of the eyeball.

V.A. recorded.
Ophthalmoscopy. Synoptophore (amblyoscope) for angle of deviation and B.V. Optical correction Occlusion Orthoptic training for B.V.



Paralytic squint:

Etiology: Cause by paralysis of extraocular muscles. Deviation is different in different directions. Efferent pathway defective. Symtoms:

1. Diplopia which is most marked in direction of action of the


2. Vertigo and nausea.


1. Limitations of movements. 2. False orientation. 3. Position of the head.


1. History 2. Examination
i. position of the eyes.

iii. iv. v. vi.

Position of the head.

Cover test: secondary deviation is more than primary deviation. Ocular movements uniocular and binocular. diplopia charting Worths four dot test.

vii. Hess screen. viii. Synoptophore for grades of B.V. (simultaneous perception, fusion, stereopsis)


1. Treat the basic underlying cause. 2. Occlusion of the eye with paralysis for allaying diplopia. 3. Operative treatment after 6 months.
i. recession of antagonist muscle in the same eye. ii. Recession of opposite synergist muscle.