Strabismus

BY: SAYED HAMZAH

Introduction
Under normal binocular viewing
conditions, the image of the object of
regard falls simultaneously on the fovea of
each eye (bifoveal fixation), and the
vertical retinal meridians are both upright.
Any deviation from perfect ocular
alignment is called "strabismus.
Misalignment may be in any direction
inward, outward, up, down, or torsional.

Epidemiology
Strabismus is present in about 4%
of children.
Strabismus may also be acquired,
caused by cranial nerve palsies,
orbital masses, orbital fractures,
thyroid eye disease, or other
acquired disorders.

Physiology
Motor Aspects

Individual Muscle Functions

Field of Action
Synergistic & Antagonistic Muscles (Sherrington's
Law)
Yoke Muscles (Hering's Law)
Development of Binocular Movement

Physiology
Sensory Aspects
Binocular Vision
Sensory Fusion & Stereopsis
Sensory Changes in Strabismus:
These changes include diplopia, suppression,
anomalous retinal correspondence, and
eccentric fixation.

Diplopia
each fovea receives a different image.
The foveal image is localized straight
ahead, while the peripheral image of
the same object in the other eye is
localized in some other direction.
Thus, the same object is seen in two
places (diplopia).

Suppression
The images seen by one eye become
predominant and those seen by the
other eye are not perceived
(suppression).
Suppression is a common sensory
adaptation in childhood strabismus.
Suppression takes the form of a
scotoma in the deviating eye only
under binocular viewing conditions.

Amblyopia
This is reduced visual acuity in the absence of
detectable organic disease in one eye).
The three clinical causes of amblyopia include
amblyopia due to visual deprivation (eg,
congenital cataract or optic nerve hypoplasia),
amblyopia due to strabismus, and amblyopia
due to unequal refractive error
(anisometropia). Often, more than one
etiology is present.

Anomalous Retinal
Correspondence
This is a sensory adaptation that occurs
in strabismus under binocular viewing
conditions.
Heterotropia leads to suppression in the
nonfixating eye and a shift in the visual
direction of the deviated eye.
This shift in visual direction typically
offsets the amount of motor deviation
and prevents the perception of diplopia.

Eccentric Fixation
An eye with gross eccentric fixation will
not point toward the light source but
will appear to be looking in some other
direction (a positive or negative angle
kappa).
More subtle degrees of eccentric
fixation can be detected by an
ophthalmoscope that projects a small
fixation target onto the retina.

Examination
History
Family History
Age at Onset
Type of Onset
Type of Deviation
Fixation

Examination
Visual Acuity
Each eye is evaluated by itself, since
binocular testing will not reveal poor vision in
one eye.
The target should be as small as the child's
age, interest, and level of alertness allow.
Fixation is described as being normal if it is
centrally (foveally) and steadily fixated and
maintained while the eye follows a moving
object.

Inspection
Inspection alone may show whether the
strabismus is constant or intermittent,
alternating or nonalternating, and
whether it is variable.
The quality of fixation of each eye
separately and of both eyes together
should be noted.

Determination of Angle of
Strabismus (Angle of Deviation)
Prism and Cover Tests
Cover test
Uncover test
Alternate cover test
Prism and alternate cover test.

Objective Tests
Hirschberg Method
Prism Reflex Method (Correctly Known as the
"Reverse" Krimsky Test)

Cover testing. The patient is directed to look at a target at eye level 6 m (20
feet) away. Note: In the presence of strabismus, the deviation will remain
when the cover is removed.

Ductions (Monocular
Rotations)
With one eye covered, the other eye
follows a moving target in all directions
of gaze. Any decrease of rotation
indicates limitation in the field of action
of that muscle due to weakness of
contraction or failure of relaxation of its
antagonist.

Versions (Conjugate Ocular

Movements)
Hering's law states that yoke muscles receive
equal stimulation during any conjugate ocular
movement.
Difference in rotation of one eye relative to
the other is noted as overaction or
underaction.

Testing versions. Example of paretic left superior oblique.

Disjunctive Movements
Convergence
Convergence is an active process with a strong voluntary as well
as involuntary component. An important consideration in
evaluating the extraocular muscles in strabismus is convergence.

Divergence
Electromyography has established
that divergence is an active process,
not merely a relaxation of
convergence. Clinically, this function is
seldom tested except in considering
the amplitudes of fusion.

Sensory Examination

Stereopsis Testing
Suppression Testing
Fusion Potential

Medical Treatment
Nonsurgical treatment of
strabismus includes
treatment of amblyopia
the use of optical devices (prisms and
glasses)
pharmacologic agents
orthoptics

Surgical Treatment
Surgical Procedures
Resection and Recession
Shifting of Point of Muscle Attachment
Faden Procedure

Esotropia (Convergent
Strabismus, "Crossed Eyes")
Esotropia is by far the most common type of
strabismus.
It is divided into two types: paretic (due to
paresis or paralysis of one or both lateral
rectus muscles) and nonparetic (comitant).
Nonparetic esotropia is the most common
type in infants and children; it may be
accommodative, nonaccommodative, or
partially accommodative.

Nonparetic Esotropia
Nonaccommodative Esotropia
Infantile Esotropia
Acquired Nonaccommodative Esotropia

Accommodative
Esotropia
Accommodative esotropia occurs when there
is a normal physiologic mechanism of
accommodation with an associated overactive
convergence response but insufficient relative
fusional divergence to hold the eyes straight.
There are two pathophysiologic mechanisms
at work, singly or together:
a. Accommodative esotropia due to hyperopia
b. accommodative esotropia due to a high (AC/A
ratio),

Partially
Accommodative
Esotropia
A mixed mechanismpart muscular
imbalance and part
accommodative/convergence imbalance
may exist.

Paretic (Incomitant)
Esotropia (Abducens Palsy)
Incomitant strabismus results from paresis or
restriction of action of one or more extraocular
muscles.

Incomitant esotropia is usually due to paresis of

one or both lateral rectus muscles as a result of
unilateral or bilateral abducens nerve.
Other causes of incomitant strabismus are
fracture of the medial orbital wall with
entrapment of the medial rectus muscle, thyroid
eye disease with contracture of the medial rectus
muscles, and Duane's retraction syndrome

Incomitant strabismus (paralytic). Paralysis of

right lateral rectus muscle, with left eye fixing.

Pseudoesotropia
Pseudoesotropia is the illusion of crossed eyes in an infant or
toddler when no strabismus is present.

This appearance is usually caused by a flat, broad nasal

bridge and prominent epicanthal folds that cover a
portion of the nasal sclera, giving the impression that
the eyes are crossed.

Exotropia (Divergent
Strabismus)
Exotropia is less common than esotropia,
particularly in infancy and childhood.
Its incidence increases gradually with age.
Not infrequently, a tendency to divergent
strabismus beginning as exophoria
progresses to intermittent exotropia and
finally to constant exotropia if no
treatment is given.

Alternative Classification of
Exotropia
Basic Exotropia
Divergence Excess
Pseudodivergence Excess
Convergence Insufficiency

Intermittent Exotropia
Intermittent exotropia accounts for well
over half of all cases of exotropia.
The onset of the deviation may be in the
first year, and practically all have
presented by age 5.
A characteristic sign is closing one eye
in bright light.
The manifest exotropia first becomes
noticeable with distance fixation.

Child with intermittent exotropia squinting in sunlight.

Constant Exotropia
Constant exotropia is less common than
intermittent exotropia.
It may be present at birth or may occur when
intermittent exotropia progresses to constant
exotropia.

Right exotropia.

A & V Patterns
A horizontal deviation may be vertically
incomitant, ie, the deviation is different
in upgaze versus downgaze (A or V
pattern).
An A pattern is diagnostically
significant when greater than 10 PD
and a V pattern when greater than 15
PD.

Hypertropia
Vertical deviations are customarily named
according to the high eye, regardless of which
eye has the better vision and is used for
fixation.

Right hypertropia.

Head tilt test

(Bielschowsky test).

Special Forms of
Strabismus
Duane Retraction Syndrome

Dissociated Vertical Deviation

Brown's Syndrome (Superior Oblique
Tendon Sheath Syndrome)

Heterophoria
Heterophoria is deviation of the eyes
that is held in check by binocular
vision.
The symptoms of heterophoria may be
clear-cut (intermittent diplopia) or
vague ("eyestrain" or asthenopia).

Thank you