STRABISMUS &

AMBLYOPIA
STRABISMUS

• Definition :
• Ocular misalignment, whether due to abnormalities in binocular
vision or anomalies of neuromuscular control of ocular motility

• When the eyes become dissociated (not aligned) 

Strabismus
• The Advantages of Binocular Vision :
• Better visual acuity
• Exp. : - One eye  0,8 -- Both eyes  1,0
- One eye  1,0 -- Both eyes  1,2
• Wider field of view
• Stereoscopic vision

• Normal condition of muscle balance  Orthophoria  producing single

binocular vision
 EXTRA OCULAR MUSCLES
A TEAM OF SIX MUSCLES CONTROLS THE MOVE-
MENT OF EACH EYE and BALANCING THE EYE
• THE RECTUS MUSCLE
- THE MEDIAL RECTUS  adduction
- THE LATERAL RECTUS  abduction
- THE SUPERIOR RECTUS  supraduction
- THE INFERIOR RECTUS  infraduction
• THE OBLIQUE MUSCLE
- THE SUPERIOR OBLIQUE  intorsion
- THE INFERIOR OBLIQUE  extorsion
SINGLE BINOCULAR VISION

• Is a condition when retinal images from two eyes integrating into a single
three-dimensional visual perception
• Prerequisites for binocular vision :
• Visual acuity of the two eyes after corrected are the same or slightly different and
anisokonia not present
• Good coordination of eye muscles on the both eyes  same direction of viewing
• Fusion capabilities of the brain
NOMENCLATURE OF STRABISMUS

• Prefixes :
• Eso- : rotated nasally
• Exo- : rotated temporally
• Hypo- : rotated inferiorly
• Hyper- : rotated superiorly
• Incyclo-: torted nasally
• Exyclo- : torted temporally
NOMENCLATURE (CONT.)

• Suffixes :
• -phoria : A latent deviation that is controlled by
the fusional mechanism so that under normal
binocular vision of the eyes remain aligned
• Exp : Exophoria, Esophoria, etc
• -tropia : A manifest deviation that exceeds the
control of the fusional mechanism so that the
eyes are not aligned
• Exp. : Hypotropia, Esotropia, etc
CLASSIFICATION OF STRABISMUS

• According to fixation :
• Alternating : Spontaneous alternation of fixation from one eye to
the other
• Monocular : Definite preference for fixation with one eye

• According to age of onset :

• Congenital  prior of 6 months of age
• Acquired  after 6 months of age
CLASSIFICATION (CONT.)

• According to the type of deviation :

• Horizontal : Esodeviation or Exodeviation
• Vertical : Hyperdeviation or hypodeviation
• Torsional : Incyclodeviation or excyclodeviation
• Combined : Horizontal, vertical, and/or torsional
 CLASSIFICATION (CONT.)
• According to variation of the deviation with fixating eye :
• Comitant (concomitant) :does not vary with eye direction
• Incomitant : varies with eye direction
ETIOLOGY OF STRABISMUS

• Heterophoria :
• Muscle weakness :
• Congenital
• Acquired
• Muscle spasm
• Refraction anomalies
• Anomalies of anatomy of the eye muscle
ETIOLOGY OF STRABISMUS
(CONT.)
• Heterotropia :
• Congenital :
• Eye muscle or neural anomalies
• Disturbances of accommodation
• Infection
• Trauma
• Head/brain neoplasm
• Specific eye disease that attack macula  toxoplasmosis
CLINICAL SYMPTOM

• Subjective :
• Heterophoria :
• Blurred vision, especially when tired
• Headache after reading
• Heterotopia :
• Diplopia
• Eye ball’s range of movement  limited
• Changing the position of the head
ASSESSMENT OF STRABISMUS

• Patient’s eye ball appearance (simplest methods)

• Corneal light reflex test :
• Hirschberg test
• Modified Krimsky’s method test
ASSESSMENT (CONT.)

• Cover tests
• Cover-uncover test
• Alternate cover test
 THERAPY OF STRABISMUS
• Main goal of therapy  Single binocular vision
• Other goal  cosmetic reason
• Treatment :
• Congenital  strabismus surgery as soon as possible
• Refraction disturbances  correction
• Orthopic exercises
• Surgery
COMPLICATION

• Amblyopia
• Cosmetic
• Head posture
disturbances
AMBLYOPIA

• Definition :
• Unilateral or bilateral reduction of visual acuity (with best refractive
correction) that cannot be attributed directly to the effect of any
structural abnormality of the eye or the posterior visual pathway

• Caused by abnormal visual experience early in life

DEVELOPMENTAL PERIOD OF
THE EYE
• Period of development :
• Intra uterine development
• Period I : 0 – 6 months  critical
• Period II : 6 months – 2 years
• Period III : 2 years – 5 years
• Period IV : 5 years – 9 years
• Period V : 9 years – 12 years
• Good development  Macula lutea have to well trained by
rays that straight focused onto macula, before 6 years old
TYPES OF AMBLYOPIA

• Strabismic amblyopia
• Most common form

• Anisometropic amblyopia
• Isoametropic amblyopia
• Deprivation Amblyopia (amblyopia ex anopsia)
SEVERITY OF AMBLYOPIA

• Mild Amblyopia :
• Visual acuity : 0,6 or better

• Moderate Amblyopia :
• Visual acuity : 0,2 – 0,6

• Severe Amblyopia
• Visual acuity : 0,1 – 0,2
THERAPY OF AMBLYOPIA

• Goal of therapy :
• Normal visual acuity of both eye
• Perfect eye ball position of both of eye
• Streoscopic eye
• Prognosis of the therapy is depend on :
• Age onset of Amblyopia
• When the treatment begin
• Severity of amblyop
• Fixation type
• Patient’s compliance
THERAPY (CONT.)

• Principal of therapy  train the amblyopic eyes with :

• Occlude fellow eyes (the health eyes)
• Cyclopegic on fellow eye (Penalization)
• CAM stimulator (still controversial)

• Recurrence  50%