OPHTHALMOLOGY

LECTURE
SOFIA SIPIN, MD
PEDIATRIC OPHTHALMOLOGIST
Extraocular Muscle

And-a-1!
And-a-2!
And-a-3!
Extraocular muscles
 EOM actions, innervations

◦ RAd Sin
◦ SO↓ IO↑
◦ SO4 LR6 (LA SOT)

Muscle Primary Secondary Tertiary

Medial rectus Adduction - -
Lateral rectus Abduction - -
Inferior rectus Depression Extorsion Adduction
Superior rectus Elevation Intorsion Adduction
Inferior oblique Extorsion Elevation Abduction
Superior oblique Intorsion Depression Abduction
 EOM functions and relationships

 Agonist – the muscle producing the movement

 Antagonist – the muscle producing the opposite

movement of the agonist

 Synergists – two muscles moving the eye in the

same direction (in the same eye)

 Yoke – muscles in the 2 eyes producing a particular

gaze
Sherrington’s Law of reciprocal
innervation (agonist-antagonist)
◦ Impulse to contract (agonist) = inhibitory impulse to
relax (antagonist)

Hering’s Law of motor correspondence

(yoke muscles)
◦ Yoke muscles in the 2 eyes receive the same amount
of innervation to contract
DUCTIONS VERSIONS
Observation of Binocular eye
monocular eye movements of 6-9
movement with the cardinal gazes
opposite eye occluded

*Grade Over and Underactions

 Normal versions preclude the need to
check ductions.

 If versions are abnormal, duction testing

should be performed, esp in the field of
limited ocular rotations.
 MOTILITY TESTING

Versions
 Binocular Eye Movement
EXTRAOCULAR MUSCLES
SR IO IO SR

IR SO SO IR
SR IO IO SR

IR SO SO IR
SR IO IO SR

IR SO SO IR
SR IO IO SR

IR SO SO IR
SR IO IO SR

IR SO SO IR
SR IO IO SR

IR SO SO IR
SR IO IO SR

IR SO SO IR
 MOTILITY TESTING

Ductions
 Monocular Eye Movements
 Supraduction or sursumduction
 Infraduction or dorsumduction
 Adduction
 Abduction
 Incycloduction or Intorsion
 Excycloduction or extorsion
MOTILITY TESTING
1. Primary position
◦ ET
◦ XT
◦ HT

2. R and L gaze
◦ Adduction
◦ Abduction

3. Up and Down
gaze
◦ A pattern
◦ V pattern

4. Obliques
◦ Overaction
◦ Underaction
 STEPS IN EXAMINATION

 Composites
 The 9 Cardinal Gazes – analyzing composite pictures

Primary (ET?, XT? fixating eye? Hirschberg)

Horizontal (Limitations? Oblique overaction?)
Vertical (A or V pattern?)
Oblique (Oblique over or underaction?)
Grading scheme for Over/Underactions
IO +1 +2 +3 +4

-1 -2 -3 -4
SO +1 +2 +3 +4

-1 -2 -3 -4

Photos from Clinical Strabismus Management. Rosenbaum/ Santiago

Oblique muscle function was estimated on a
grading scale of 4- to 4+ (1- to 4-,
underaction; 1+ to 4+, overaction) based on
eye movements in an upward, a downward
and a side gaze.

Grade 1+ represented 1 mm of higher

elevation of the adducting eye in gaze up and
to the side.

Grade 4+ indicated 4 mm of higher

elevation.
UNaOVSKA E., VANaUROVA J. ANTERIOR TRANSPOSITION VERSUS MYECTOMY OF THE INFERIOR
OBLIQUE MUSCLE IN THE TREATMENT OF DISSOCIATED VERTICAL DEVIATION.SCRIPTA MEDICA
(BRNO) – 76 (2): 111–118, April 2003
HIRSCHBERG
TEST
(CORNEAL
LIGHT REFLEX
TEST)
• 1 mm = 7
degrees of ocular
deviation

• Prerequisites
• Attention
• Useful Visual
Acuity
• Ability to fixate

• Disadvantage
• NOT precise
• Large angle
kappa may be
misleading
 KR IM SK Y T ES T
(P RIS M
REF LEX TES T,
PRIS M
• Prism is placed on the
REF LEC TIO N
FIXATING Eye/DEVIATING TES T)
Eye

• Advantages
• Provides estimate of
the deviation

• Disadvantage
• NOT precise
Esotropia
 Esotropia
Pseudoesotropia
Congenital/Infantile
Accommodative
– Refractive
– High AC/A Esotropia
– Partially accommodative
Sensory Esotropia
Incomitant Esotropias
 Esotropia
Pseudoesotropia
– Flat, broad nasal
bridge
– Prominent epicanthal
folds
– Central Hirschberg
– Cover testing: normal
– Reassessment if
deviation does not
improve
 Esotropia
Congenital/Infantile
– Onset by 3-6 months
– Deviation > 30 PD ET
– Cyclo ref: 1-2 D hyperopia
– Associated abnormalities:
• IO overactions
• DVD
• Latent nystagmus
– Surgery
• BMR recessions
• 3 muscle surgery if >50PD*, IO weakening if present
 Esotropia
Accommodative
– Characteristics
• 6 months -7 years
– Ave: 2 ½ years
• Intermittent  constant
• Hereditary
• Trauma/ illness
• Amblyopia
• Diplopia in older children
 Esotropia
Accommodative
TYPES:
Refractive
High AC/A Esotropia
Partially accommodative
 Esotropia
• Accommodative
 Refractive:
– Mechanisms
• Uncorrected hyperopia
• Accommodative
convergence
• Insufficient fusional
divergence
 Esotropia
• Accommodative
Refractive:
– 20 -30 PD ET
(distance and near)
– Ave: +4.00 D
– Give full cycloplegic
refraction worn full time
 Esotropia
• Accommodative
 High AC/A Esotropia:
– Angle of ET > near
– EOR variable
*nonrefractive accommodative ET
*refractive accommodative ET
– Mgt options:
• Bifocals
– Adds should bisect pupil!
• Cholinesterase inhibitors
• Surgery
• Observation
 Esotropia
• Accommodative
 Partially accommodative:
– Residual ET following:
• Amblyopia treatment
• Full hyperopic therapy
– Decompensation
– New accommodative
component
 Esotropia
• Accommodative
Partially accommodative
– Mgt:
• Full hyperopic correction
• Amblyopia therapy
• Surgery
– For non accommodative
component
 Esotropia
Incomitant Esotropias
– Congenital dysinnervation disorders
• Duane syndrome
• Mobius syndrome
• Congenital fibrosis syndrome
– CN VI palsy
– High myopia
 Esotropia
• Incomitant Esotropias
Mobius Syndrome
– Rare
– CN VI and VII palsies
– Masklike fascies
– ET or straight on primary
– Limited abduction
– Limited adduction
 Esotropia
• Incomitant Esotropias
CN VI palsy
– Adults> Children> Infants
– Causes
• Ischemic mononeuropathy most common cause
• 1/3 intracranial lesions
– Characteristics
• Horizontal diplopia worse on ipsilateral gaze
• Face turn toward paralytic side
• VS Duane syndrome
 Esotropia
• Incomitant Esotropias
CN VI palsy
 Esotropia
• Incomitant Esotropias
CN VI palsy
– Management
• History
– Infection, trauma, vasculopathies, etc
• Neurologic exam
• Medical evaluation, Diagnostics as indicated
• Patching
• Prisms
• Botulinum injections
• Surgery
Exotropia
Exotropias
1. Intermittent Exotropia
a. Basic (X)T
b. Pseudo Divergence
Excess
c. True Divergence Excess
2. Convergence Insufficiency
3. Sensory Exotropia
4. Congenital Exotropia
 Exotropias

1. Intermittent Exotropia
a. Basic (X)T
b. Pseudo Divergence Excess
c. True Divergence Excess
2. Convergence Insufficiency
3. Sensory Exotropia
4. Congenital Exotropia
 Exotropias

1. Intermittent Exotropia
a. Basic (X)T
b. Pseudo Divergence Excess
c. True Divergence Excess
2. Convergence Insufficiency
3. Sensory Exotropia
4. Congenital Exotropia
 Exotropias

1. Intermittent Exotropia
a. Basic (X)T
b. Pseudo Divergence Excess
c. True Divergence Excess
2. Convergence Insufficiency
3. Sensory Exotropia
4. Congenital Exotropia
 Exotropias

1. Intermittent Exotropia
a. Basic (X)T
b. Pseudo Divergence Excess
c. True Divergence Excess
2. Convergence Insufficiency
3. Sensory Exotropia
4. Congenital Exotropia
 Exotropias

1. Intermittent Exotropia
a. Basic (X)T
b. Pseudo Divergence Excess
c. True Divergence Excess
2. Convergence Insufficiency
3. Sensory Exotropia
4. Congenital Exotropia
 Exotropias

1. Intermittent Exotropia
a. Basic (X)T
b. Pseudo Divergence Excess
c. True Divergence Excess
2. Convergence Insufficiency
3. Sensory Exotropia
4. Congenital Exotropia
 Non Surgical Management of
Exotropias
Convergence
insufficiency
small angle exophoria
interim treatment prior to
surgery
High hypermetropia with
Exotropia
 Indications for Surgical
Management

• X(T) more than 50% of waking hours

• Poor control of X(T)

• Deterioration of control

• Severe asthenopia

• Visual Confusion / diplopia

 Surgical Procedures

• Bilateral Lateral Rectus Recessions

• Recess-Resect Procedures

• Bilateral Medial Rectus Resection

 Pattern Strabismus
• A Pattern
• difference in measurement between upgaze and
downgaze is 10 PD
• V Pattern
• difference in measurement between upgaze and
downgaze is 15 PD

Courtesty of Dr. Melissa Agulto

Pattern Strabismus

Causes:
1. Oblique Muscle Dysfunction
2. Horizontal Rectus Muscle Dysfunction
3. Vertical Rectus Muscle Dysfuntion
4. Orbital Abnormality
Pattern Strabismus

Management
1.Oblique Muscle Weakening
2.Vertical Transposition of the Horizontal Rectus
Muscles - M - A - L - E
Pattern Strabismus

Complications of Surgery
1.Consecutive Pattern
2.Asymmetric Result
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