Literature Review

Examination and Management Large

Exotropia with Amblyopia
Anisometropia
Dezca Nindita*

Consultant* :
dr. Linda Trisna Sp.M(K)

Medical Staff Group of Ophthalmology

INTRODUCTION
 Exotropia is a form of Amblyopia Anisometropia is
divergent strabismus. the second most common
cause of amblyopia.

The causes isn’t fully Anisometropic amblyopia

understood but can be occurs when unequal focus
caused by anatomic, between the two eyes causes
mechanic, and neurogenic chronic blur on one retina.

Occupied 32 of 100.000 Occupied 2-4% in North

birth America
 Amblyopia
Exotropia
Anisometropia

can affect patient’s future and

quality of life
Aim
To know and understand about anatomy of
extraocular muscle and physiology of binocular
vision

To know and understand about exotropia and

amblyopia anisometropia

To know and understand about examination and

management related to exotropia and amblyopia
anisometropia
Anatomy and
Physiology
EXTRAOCULAR MUSCLE
MONOCULAR MOVEMENTS
Muscle Primary Secondary Tertier
Rectus medial Adduction - -

Rectus lateral Abduction - -

Rectus inferior Depression Extorsion Adduction

Rectus superior Elevation Intorsion Adduction

Oblique inferior Extorsion Elevation Abduction

Oblique Intorsion Depression Abduction

superior
Levator Elevation of - -
palpebra upper eyelid
superior
BINOCULAR MOVEMENTS
GRADES OF BINOCULAR VISION
EXOTROPIA AND
ANISOMETRIC
AMBLYOPIA
EXOTROPIA

Exophoria

a manifest divergent
strabismus.
Intermitten Exotropia

Constant Exotropia
Intermitten Exotropia

Consist of Good Control, Fair

Control, Poor Control

Classified by Burian and Kushner as

Basic, Convergence Insufficiency, True
Divergent Excess, and Pseudo-
divergence excess.
Constant Exotropia
most often in older patients with sensory exotropia or
in patients with a history of long- standing intermittent
exotropia, which has decompensated.

Classified by Burian and Kushner as

Consist of Infantile Exotropia,
Basic, Convergence Insufficiency, True
Sensory Exotropia, and
Divergent Excess, and Pseudo-
Consecutive Exotropia
divergence excess.
Classified by Burian and Kushner
Infantile Exotropia
Infantile exotropia is an
exodeviation that develops within
the first few months of life and
persists.

Caused by disrupts development

of vergence, leading to strabismus
and to functional deficits, loss of
fusion, asymmetric monocular
smooth pursuit and monocular
motion perception
Sensory Exotropia

The mechanisms for the

development of exotropia :
Binocular Rivalry
Decompensation of exophoria
Mechanical factors.
Sensory exotropia
develops as a result of
loss of vision or chronic
poor vision in one eye.
Consecutive Exotropia Risk Factor

simultaneous excessive
multiple
Consecutive surgery for three amount of
surgeries
or more muscles surgery
Exotropia is Exotropia
occurring in patients
with a previous postoperative absence of high
limitation of fusion, hypermetropic
history of esotropia adduction amblyopia error
either spontaneously
or following optical
and surgical vertical
anisometropia
treatment incomitance
Amblyopia

unilateral or, less commonly,

bilateral reduction of best-
corrected visual
strabismic acuity

Visual
Deprivation

Refractive
Strabismic Amblyopia

visual cortex becomes

nonfusible
strabismu dominated
input from
s by input from the fixating
the 2 eyes
eye

inhibition of the retino-striate

development
pathways of visual projections originating
of amblyopia
in the fovea of the deviating eye
Visual Deprivation Amblyopia

visual cortex becomes

Visual nonfusible
dominated
deprivatio input from
by input from the fixating
n the 2 eyes
eye

inhibition of the retino-striate

development
pathways of visual projections originating
of amblyopia
in the fovea of the deviating eye
Refractive Amblyopia

Isometric Anisometric
Amblyopia Amblyopia
Isometric Amblyopia

Severe symmetric
Hyperopia in excess of
refractive error
about 5 to 6 D
(isoametropia)

Myopia, unless
High extremely high, usually
degrees of does not cause
astigmatism bilateral amblyopia
Anisometric Amblyopia amblyopia is caused by a
difference in refractive error
between the eyes
EXAMINATION
 Visual Acuity

Preverbal Verbal

• Observation • Allen Card

• Visual Behavior • HOVT Card
• Optokinetic Nystagmus • LEA Symbol
Test • E chart
• Preferential Looking
Test
• Visual Evoked Potential
Observation

• Observe how the child interact with his

parents or his own hands

Visual Behavior

• Place attention-grabing targets in front

• Observe the child with CSM method
• (Central/non central, steady/unsteady,
maintan/non maintain))
Optokinetic Nistagmus Test
Preferential Looking Test
The child’s response to a visual stimulus
is observed to assess visual acuity .

For toddler which less than 1 year,

A 38 cm test distance is
recommended.

For 1-3 years, 55 cm is recomended

Movement of the eyes toward the stripes

indicates that the child can see them.
Seeing narrower stripes denotes better
vision
Visual Evoked Potential
Verbal

Allen Card HOVT

Verbal

LEA symbol E Chart

Cover/ Uncover Test
Alternate Cover Test
 Deviation Measurement

Hirschberg test Krimsky test

Alignment Of the Eye

Maddox Rod
Alignment Of the Eye

Double Maddox
Rod
Motility Test

Duction and
Version
Motility Test

Duction and
Version
 Sensory Test

Diplopia Test
Sensory Test

Bagolini
Lenses
Sensory Test

Worth Four-
Dot Test
Stereoacuity Test

Titmus Test
MANAGEMENT
Management of Exotropia with Amblyopia
Anisometropia

Refractive Correction

Surgery

Occlusion Therapy

Penalization Therapy
Refractive Correction
A follow-up interval
It is reasonable to
of 6 to 8 weeks, until
start amblyopia
improvement in the
treatment with the
amblyopic eye VA
refractive correction
plateaus

Some children (i.e., those with

amblyopia resolution) may not need
additional
amblyopia treatment beyond optical
correction.
Surgery

Aims of surgery on the extraocular muscles are

to correct misalignment to improve appearance, and if possible to
restore BSV

Recession Resection

Recession slackens a muscle

Resection shortens a muscle
by moving it away from its
to enhance its effective pull
insertion
Surgery
Occlusion Therapy
Occlusion therapy
Patching Dosage
has been the
may vary depends
mainstay of
on age of patient.
treatment

In young children, using an adhesive

patch should be strongly considered
so that
peeking is less likely to occur
Penalization Therapy
Both pharmacologic and
Penalization is an optical means are used
alternative to occlusion to blur the vision in the
therapy for better eye for near
amblyopia. and/or distance

Pharmacologic penalization involves the

instillation of
a long-acting cycloplegic agent into the
fellow eye.
CONCLUSION
Binocular Single Vision is the highest of Fusion
that only can be formed if there are perception
simultan and Fusion

The purpose of examination is to know about

whether the component of BSV is present

The management of exotropia on amblyopia

anisometropia should be comprehensive and
holistic
Thank You
Patophysiology of Amblyopia

Amblyogenic Factor

Role of Retina

Active Cortical Inhibition

Amblyogenic Factor
VISUAL DEPRIVATION

• monocular Seen in strabismic , anisometropia, stimulus deprivation

amblyopia
• Binocular Seen in bilateral cataract, ametropia and bilateral high
refractive errors

LIGHT DEPRIVATION.

• Usually seen in children with unilateral or bilateral complete cataracts.

ABNORMAL BINOCULAR INTERACTION

• produces profound amblyopia due to competition amblyopia. -seen in

strabismic, anisometropic and unilateral stimulus deprivation amblyopia.
RETINA IN THE DEVELOPMENT OF AMBLYOPIA

Decreased sensitivity of foveal cones in amblyopia

The reduced input from rods and cones in the

affected eye causes certain neurophysiologic
changes, transmitted to the CNS which triggers
amblyopia.
ACTIVE CORTICAL INHIBITION
A developmental defect of spatial visual processing occurring in
the visual pathway.

Poor transmission from the fovea, optic nerve to the Striate

Cortex of the affected eye.

LGB & Striate cortex develop abnormally.

Ganglion cells in foveal area are affected; Shrinkage of LGB

Nucleus & Striate cortical fibres in the amblyopic eye.

Loss of binocularly driven cells in LGB & Striate Cortex

Teller Aquity Chart (Start Card)
Cover / Uncover Test
Accomodative convergence / Accomocative Ratio
Visual Acuity Development
Dosis Patching
Umur Dosis Patching

Bayi < 3 bulan oklusi selama ¼ dari waktu bangun

Bayi 3 – 6 bulan oklusi selama ¼ - 1/3 dari waktu
bangun
Bayi 6 – 9 bulan oklusi selama ½ dari waktu bangun

Bayi 9 – 12 bulan oklusi selama ¾ dari waktu bangun

Pada anak 1-2 tahun oklusi 1 minggu

Pada anak 2-3 tahun oklusi 2 minggu
Pada anak 3-4 tahun oklusi 3 minggu
Pada anak 4 – 6 tahun oklusi 4 minggu
Diatas 6 tahun 6 minggu
Penalisasi
1. Penalisasi dekat : paling sering digunakan
Mata dominan diberi atropin + koreksi penuh untuk penglihatan jauh.
Mata ambliop : koreksi lebih, ditambah S+2 atau S+3D dipaksa untuk penglihatan dekat.
2. Penalisai jauh :
Mata dominan diberi atropin dan koreksi ditambah S+3 D untuk penglihatan dekat.
Mata ambliop : koreksi penujh untuk lihat jauh.
3. Penalisasi total :
Mata dominan diberi atropin : koreksi dikurangi 4 sampai 5 D. Mata ambliop diberi koreksi penuh.
Dengan cara ini mata dominan tidak dapat digunakan untuk penglihatan jauh dan dekat.
4. Penalisasi alternans:
Dengan dua kaca mata yang dipakai bergantian setiap hari.
I. Koreksi dilebihkan S+2 sampai S+3 D pada mata kanan.
II. Koreksi dilebihkan S+2 sampai S+3 D pada mata kiri.
Synoptophore / major amblyoskop
surgery
Recession
• The muscle is exposed and two absorbable sutures are
tied through the outer quarters of the tendon.
• The tendon is disinserted from the sclera, and the amount of
recession is measured and marked on the sclera with callipers.

Resection
• The muscle is exposed and two absorbable sutures are tied
through the outer quarters of the tendon.
• The tendon is disinserted from the sclera, and the amount of
recession is measured and marked on the sclera with callipers.
Komplikasi operasi