Strabismus

Dr. Manjoo S Reddy

East Point Medical College Hospital
Bengaluru
 Definition
• Orthophoria
• Eyes which are parallel without effort
• And maintain so in all positions of gaze

• When the visual axis is not parallel where one

eye is directed to the fixation object and the
other is deviated away from the object
• Condition is called Squint or Strabismus
Binocular Single Vision (BSV)
 Manifest Squint

Non paralytic
Concomitant

Convergent Divergent Vertical Tortional

Manifest Deviations
 Latent Strabismus

Latent

Esophoria Exophoria Hypophoria Hyperphoria

 Types
• Comitant:: Deviation does not change with
direction of gaze or fixing eye
• Incomitant. :Deviation varies with direction of
gaze or fixing eye
• Paralytic or restrictive
• Alternating
• Monocular
 Symptoms
• Small squints do not give rise to any symptoms

• When it is an obvious manifest squint

 Blurred vision
 Headache and eyestrain
 Intermittent diplopia
 Abnormal head posture
• Patient history and examination

• Assessment and diagnosis

• Assess Binocular vision status

 Evaluation
• Inspection
• Ocular movements
• Pupillary reaction
• Fundus exam
• Vision and refraction
• Cover tests
• Evaluation of deviation
• Tests for BSV and
• Sensory functions
(suppression/amblyopia/ARC/Diplopia)
 Extraocular Muscles
Muscle Primary Action Secondary Action
Lateral Rectus Abduction
Medial Rectus Adduction
Superior Rectus Elevation Adduction/intortion
Inferior Rectus Depression Adduction/extortion
Superior Oblique Depression Intortion/abduction
Inferior Oblique Elevation Extortion/abduction
• Ocular movements
• Uniocular …..Ductions
• Binocular…….Versions

• Vergences
Convergence
Divergence
 Tests
• Corneal reflex test . Hirschberg
• • Crude method
• • Deviated eye is blind
• • 1mm decenteration…7degrees
• • PBCT
• • Bruckner test
 Hirschberg Reflex
• Cornea light reflex

Central Corneal
45 Degrees Reflex

25 Degrees

15 degrees
 Measurement of deviation
• Cover uncover test
• Alternate cover test
• phoria+tropia
• Simultaneous prism cover test
• Tropia only
Prism Bar Cover Test (PBCT)
 Esotropia
• Infantile
• Accommodative
• Acquired Non accomodative
• Sensory
• Consecutive
 Esotropia
• Accommodative: associated with accommodation
Occurs due to excessive convergence
• Refractive
• Fully Accommodative associated with high hypermetropia

• Partially Accomodative

• B. Non Accommodative
• Convergence excess
• Accomodative weakness

• Mixed
 Acquired Non Accommodative
• Late onset esotropia
• Basic: Deviation is equal for distance and near

• Convergence Excess type

• Divergence insufficiency

• Acute concomitant
• Cyclic
• Nystagmus blocade

• Sensory: Cataract /optic atrophy / chorioretinitis / retinoblastoma

• Consecutive Esotropia Overcorrection of surgery for exotropia

 Exotropia
• Constant (early onset)
• Convergence insufficiency: deviation more for near than
distance
• Divergence excess: Exotropia more for distance than near
• Basic: Equal for distance and near
• Intermittent
• Sensory: Media opacities etc.
• Consecutive: post operative overcorrection
 Etiology
• Divergent squint

• Myopia starting at a later age

• Complete loss of vision Secondary divergent

squint
 Exotropia 70 PD
Corrected with Surgery
 Medical Treatment
• Treatment of Amblyopia
• Occlusion treatment
• Atropine
• Optical correction
• Spectacles
• Prisms
• Botulinum Toxin
• Orthoptics
 Surgical Treatment

• Procedures
• Recession
• Weakening an overacting
muscle

• Resection
• Strengthening a weak muscle

• Adjustable sutures
 Surgical management
Recession Resection
 Treatment
• Amblyopia should be detected and treated at
the earliest possible
• Occlusion of the good eye for varying periods
to 5 hours a day
• Best results when cjhild is young before years
of age
• Penalization of the normal eye with atropine
reducing vision
 Differences
Concomitant and Paralytic squint
Concomitant Paralytic
Developmental Acquired Trauma or Disease
Infants and Children Adults
Diplopia present Absent
Normal head posture Abnormal hed posture
No False projection False projection
Angle of squint constant Changes in diff. positions of gaze
Ocular movements no restriction Restriction
Primary and secondary angle same Secondary angle is greater than primary
Amblyopia present Amblyopia absent
Good surgical results Results vary
 Laws
• Hering’s Law
• During any conjugate movement Equal and
simultaneous innervation flows to yoke
muscles
• Eg. A palsy of the right lateral rectus will make
the left medial rectus receive more impulses if
made to look in right lateral gaze
• Sherington’s Law
• When a muscle is stimulated its antagonist
muscle is simultaneously and equally inhibited

• Eg. In right dextroversion (eyes looking to

right) the right medial and the left lateral
rectus are inhibited
 Causes
• Ocular deviation resulting from paralysis of
one or more extra ocular muscles

• Neurogenic
• Myogenic
• At neuromuscular junction
 Myogenic
• Chronic progressive ophthalmoplegia

• Myositis

• Trauma: lacerations or dis insertion of muscles (blow

out fracture)

• Inflammation influenza measles

• Myasthenia gravis
 SYMPTOMS
• Diplopia BINOCULAR

• Confusion

• Ocular deviation
 Signs
• Primary deviation (good eye fixing)
• Secondary deviation (paralysed eye fixing)

• Limitation of ocular movement in the direction

of action of the paralysed muscle
• Compensatory head posture
• False projection
 Sequelae of EOMS palsy
• Over action of contralateral synergistic muscle
• Contracture of direct antagonist
• Inhibitional palsy of contralateral
• antagonist muscle

• Paralysis of right lateral rectus

• Over action left medial rectus

• Contracture of right medial rectus
• Inhibitional palsy of contralateral left lateral rectus
Diplopia Chart

Red green goggles

6th Nerve (Abducens Palsy)
3 Nerve Palsy (Oculomotor nerve)
rd
4 Nerve Palsy (Troclear Nerve)
th
4 Nerve Palsy Signs
th
 Treatment

• Investigate the cause and treat

• Observation for 3 to 6 months or self recovery

• Diplopia to be managed by occlusion of paralysed eye

• Botulinum injection

• Surgical management
Restrictive myopathy Thyroid Eye Disease
 Restrictive Strabismus
• Congenital

• Mechanical
• Thyroid eye disease
• Blowout fracture of orbital floor
• Trauma

• Forced duction test

 Nystagmus
• Regular rhythmic to and fro movements of eyes
• Manifest or latent
• Horizontal/ vertical /rotatory

• Physiological nystagmus
• Optokinetic
• End gaze
• Vestibule – ocular reflex

• Pathological in brain tumours/CVA

 Amblyopia
• Visual acuity
• Difference of lines in Best corrected visual
acuity in the absence of an organic lesion

• Neutral density filter

• No change in visual acuity in the eye with amblyopia
• Normal eye has reduced vision by lines
 Types
• Strabismic amblyopia: Squinting eye is suppressed
• Anisometropic amblyopia: Unilateral high ref.error
esp. high hypermetropa or astigmatism
• Stimulus Deprivation amblyopia
(amblyopia ex anopsia) cataract, corneal opacity
• Ametropic amblyopia: Bilateral high refractive
error
 Treatment
• Amblyopia should be detected and treated at
the earliest possible
• Occlusion of the good eye for varying periods
to 5 hours a day
• Best results when cjhild is young before years
of age
• Penalization of the normal eye with atropine
reducing vision