STRABISMUS

Name : Kholilah
NPM : 19360190
Definition of strabismus
Strabismus, squint, or crossed eyes, is a condition in which
both eyes do not look in the same direction at the same time. I
t occurs because the eyes do not move in synchrony with eac
h other, resulting in different positions of the two eyes when
looking at an object.
One or more of the six muscle pairs that control eye movemen
t are out of harmony. One eye fixates on the object the person
wants to look at, the other eye turns in another direction. Often
both eyes alternate in fixing on the object. In other cases, it is
always the same eye which fixates, and the other eye has
poorer vision.
Anatomy of the eye muscles
Eyeball position
The normal position of the eyeball is parallel (orthophoria) and can be checked in various
ways such as cover test, Hirschberg test and others. In a situation where the position of the
eyeballs is not parallel (heterophoria as in exophoria, esophoria or hyperphoria), it should be
investigated whether this is due to a parese, mechanical thrust or resistance or non-paretic
strabismus.

There are several forms of eyeball position :

1 Primary position, the eye looks straight ahead

2 Secondary position, the eye looks straight up, straight down, left and right

33 Tertiary position, the eye looks up right, up left, down right and down left.
Movement of two eyes (version)

The movement of the two eyes is checked by asking the patient to follow a
movement The object held by the examiner which is moved in the desired
direction is usually carried out in 6 main directions. In a state of strabismus
(heterophoria), the examination is carried out on each eye.

Etiology
1. Heredity factor
The "genetic pattern" is not
certain, but the consequences
are clear. If a parent suffering
from strabismus with surgery is
successful, then if the child has
strabismus and the operation
will be successful too.
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2. Anatomical Abnormalities
Extraocular muscle disorders
- Over development
- Under development
- Disorders of muscle
insertio
3. Abnormalities of the orbital
bones
• Abnormalities in the formation
of orbital bones cause
abnormal shapes and orbitals
, resulting in eyeball
distortion.
• Abnormalities in the central
nerve that cannot synthesize
stimuli.
• The fovea cannot capture
shadows.
• Abnormalities in the quantity
of stimulus in the eyeball
muscles.
• Sensory Abnormalities
Pathogenesis

If there is one or more eye muscles that cannot keep up with the movement of the
other muscles, there will be a disturbance in the balance of movement of the two
eyes, the axis of vision will cross, the eye will become strabismus & double vision
(diplopia)

Eye movement disorders:

1. Excessive tone.
2. Paretik / paralytic.
3. Mechanical resistance
 Physical Disorders of the Eyeball Movable Muscles

The eyeballs are moved by the external eye muscles in such a way that the image of
the object of interest will always fall right over the two central fovea. The muscles that
move the eyeballs totaling twelve will always move regularly; one muscle movement
will get a balance of motion from other muscles. The ideal balance of all the
muscles that move the eyeball causes we can always see binoculars.

If there is one or more eye muscles that cannot keep up with the movements of the
other muscles, there will be a disturbance in the balance of movement between the
two eyes, so that the axis of vision crosses the place outside the object that is of
concern to him and is called a 'squint' (crossed eyes).
Disorders of the balance of movement of the eyeballs (muscle imbalance)
can be caused by the following:
1. When the activity and
tone of one or more of the
driving muscles becomes
excessive; in this case the
muscle concerned will pull
the eyeball from its normal
position. If the hyperactive
muscle is the muscle that
functions for convergence,
a convergent squint
(esotropia) occurs.
2. The opposite of the first,
when one or more of the
muscles moving the eyeball
activity or tone become
weakened or paretic. When
this occurs in the muscle
used for convergence, a
divergent squint (extropia)
occurs.
Classification
Foria

There are two forms of foria, namely:

• Orthophoria
Orthophoria is the second eye of the eye where the work of the muscles outside
the eyeball is balanced, allowing fusion to occur without any effort. In orthophoria the position of
the eyeball does not change even though the fusion reflex is disturbed. A perfect orthophoria is
actually a rare condition and the position of the eye is shifted by 3-5 degrees in the horizontal
plane or 2 degrees in the vertical plane is still considered normal. Vision with both eyes is
necessary in everyday life because with binocular vision, simultaneous perception with both eyes,
fusion and spatial vision (stereopsis) is obtained.
Classification
• Heterophoria
Heterotrophy is a condition where the eyeball is normally positioned but there will be deviation
(deviation) if the fusion reflex is disturbed. Deviation is lost when the dissociation factor is remove
d due to the influence of the fusion reflex.

The kinds of heterotrophy depend on the area of ​deviations;

o in the horizontal plane, there are esophory and exophoria
o in the vertical plane, hypo or hyperforia is found
o while in the frontal plane, there are insiclofory and exiclofory.

The cause is the result of imbalance or insufficiency of the eye muscles.

Classification
b. According to its manifestations.
1) manifest = heterotropia
Tropia 2) latent = heterophoria: deviation occurs when
can be divided into various categories the fusion mechanism is disconnected.

a. According to the direction of deviatio

n.
1) Outward: exptropia
2) Into: esotropia
3) Down: hypotropia
4) Up: hypertropia
Classification
c. According to the angle of deviation
1) comitment strabismus: the angle of deviation remains constant at various positions.
2) non comitant strabismus: the angle of deviation
is not the same, in most cases due to extraocular muscle paralysis, hence it is often referred to as
"paralytic strabismus".

d. According to eye fixation ability

1) Unilateral strabismus: when one eye is constantly deviating.
2) Alternating strabismus: when both eyes deviate alternately.

e. According to the timing of strabismus

1) Permanent: the eyes appear constantly deviated.
2) Intermittent: in certain circumstances such as fatigue, anxiety,
etc.the eyes sometimes appear deviated, sometimes normal.
 Limited eye movement
Clinical in the area where the paralyzed muscles work. This becomes
evident in total paralysis and less pronounced in parese. This
symptoms can be seen, if the patient is asked to follow an object that is
moved to the 6 cardinal directions, without moving his head
(excursion test).

Deviation
If the eye is moved towards the ground where the paralyzed
muscle is working, the healthy eye will lead in this direction well,
while the sore eye is left behind.

Diplopia
Occurs at the work of the paralyzed muscle and becomes more
pronounced when the eye is moved in this direction.

.
 Ocular torticollis (head tilting)
Clinical The patient usually rotates towards the work of the paralyzed
muscle. The tilted head position helps diagnose paralytic
symptoms strabismus. By tilting his head, his diplopia was noticeably
diminished

Vertigo, nausea
caused by diplopia and incorrect projections. This
situation can be relieved by closing the sore eye

.
Diagnostic Checks
a. E-chart / Snellen Chart Examination with e-chart is used on children from 3 - 3.5
years old, while over 5 - 6 years old, Snellen chart can be used.
b. For children under 3 years old method can be used
• Objectively with optical moschope
• By observing the child's attention to their surroundings
• With occlusion
c. Determine refraction anomalies Retroscopy after anthropination with atropine 0.5%
- 1%
d. Retinoscopy Until the age of 5 years the refractive anomaly can be determined
objectively by retinoscopy after atropinization with atropine 0.5% - 1%, above the
age of 5 years is determined subjectively as in adults.
 Diagnostic Checks
e. Examination of light reflex from a flashlight on the
surface of the cornea (Hisch Berg test) How:
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Sufferers are instructed to see light at a distance of 12

inches (30cm). note the light reflex on the pupil. If it is
located on the edge of the pupil, the deviation is 15
degrees, but if it is located between the pupil and
limbus, the deviation is 30 degrees and if it is in the
limbus, the degree of deviation is 45 degrees.
(Note: 1 degree = 2 prism diopter)
f. Krimsky test

How:
The sufferer sees a light source whose distance is determined. Pay attention to the light reflex in
deviated eyes. The largest power of the prism is placed in front of the deviating eye, until the light
reflex is located in the center of the cornea

g. Eye movement examination

• Examination of monocular movements

One eye is closed and the other eye follows the light moved in all directions of view, so that any
rotational weakness can be identified. Such weakness is usually due to muscle paralysis or mechanical
anatomic abnormalities.
• Examination of binocular movements
In each eye, the image captured by the fovea subjectively looks like it is located straight in front. If there
are 2 different objects captured by 2 fovea, the two objects will appear as if they are located straight in
front, if there are 2 objects will appear to overlap each other, but if there are differences, the fusion does
not give a single impression.
 Additional test
1. Maddox Cross
Test Maddox Cross consists of one crossbar with a hand from its cross 1 m. at a distance of
1m from the Maddox cross, the eyes of the sufferer, the lamp that is located in the middle of
the Maddox cross and the Maddox cross ends to form an isosceles triangle with a point of
view of 45o Tell the patient to see the muscle light, if there is no strabismus, the light reflex is
located in the middle of the pupil, but if it is strabismus, it is almost eccentric

2. Monocular Rotation Examination Test

How: Checked with one eye closed, while the other eye follows the light or object that is directed.
Weakness in deduction is not known to be caused by muscle weakness or anatomical
abnormalities of the muscles.
Treatment
The occurrence of strabismus is a result of not fulfilling the requirements for normal vision binoculars,
therefore the goal of strabismus treatment is to get good binocular vision. 3 stages of strabismus
treatment:

1. Improve the vision of each eye:

• By closing a good eye
• Giving glasses
• Exercise (by orthoptist)

2. Fixing cosmetics:
• The eye is surgically straightened
• Giving glasses
• The combination of the two
 Treatment
3.Binocular vision:

• Orthoptic exercises One of the non-surgical therapeutic options in strabismus is by training the eyes with
coordination problems.
• Surgery & orthoptic
• Eye glasses & orthoptic

So the treatment of strabismus can be concluded:

A. Non operative
• Eye glasses
The most important optical tool in the treatment of strabismus is the accurately prescribed glasses.
Treatment
• Occlusion orthoptics
The use of an eye patch (blindfold) on the normal eye, thus training the eye with strabismus to try
to see normally. This therapy is quite effective in children up to 8 years of age

• Drugs
Injection of botulinum toxin type A (Botox) into an intraocular muscle causes muscle paralysis,
which is dose dependent.

• Synoptophore Exercises
- Manipulate accommodation
1. Lens plus / with miotik Lowering the burden of accommodation
and accompanying convergence
2. Minus lenses and siklopegic drops stimulate
accommodation in children
Treatment
B. Operative

The goal is to correct eye disorders by changing function of the muscles or

muscle mechanics.
1. Double vision that gets worse
2. Cosmetics
3. To correct a curved face with strabismus incominant or nystagmus
Complications
Complications with strabismus can include:

1. Suppression
It is a patient's unconscious effort to avoid diplopia that occurs due to deviations. The mechanism by which
this occurs is unknown.

2. Amblyopia
Namely lowering the vision in one / two eyes with / without glasses correction & without any organic
abnormalities.

3. Head position adaptations include: Head Tilting, Head Turn.

This situation can arise to avoid using the defective or paralyzed muscle to achieve binocular vision. The
adaptation of the head position is usually towards the action of the paralyzed muscle.
Example: Lateral Paralyse Rectus of the right eye, there will be a head turn to the right.
Prognosis

The prognosis for strabismus is good if promptly treated further, so as not to

cause permanent complications.
Thank you