Pediatric Ophthalmology- Strabismus and Amblyopia OPHTHALMOLOGY

Dr. Noel Atienza

March 19, 2021 7.1
Outline  When we do vision screening, we try to ask for subtle signs
I. Introduction regarding the child whether they seem to be having some
II. Vision screening
preference from one eye or whether they are exhibiting
III. Ophthalmologic Exam
a. Visual Acuity Test some symptoms suggestive of poor vision
b. External Eye Examination
c. Ocular Fixation OPHTHALMOLOGIC EXAM
d. Ocular Alignment
IV. Strabismus • Vision screening is recommended at least once in all
V. Amblyopia children aged 3-5 years.
 Even without problem, every children should be screened
LEGEND at least once before they enter preschool or toddler school
 Book  Recording  Previous Trans Must know  We try to observe if they have good fixation or if they have
Important Concept good visual acuity
 The question is: “How can we test visual acuity if they can’t
References: read, focus or sit on the chair?”
1. PowerPoint Lecture  For infants and older children, a general inspection may
2. 2021 trans reveal an identifiable deviation of 1 eye
3. Basic Ophthalmology  Having the patient look in the 6 cardinal positions of gaze
4. Video may reveal whether the deviation is
approximately the same in all fields indicating concomitant
INTRODUCTION strabismus or is significantly different in 1 field of gaze
*you may skip this part since this is just a brief introduction form doc about his
indicating a possible incomitant strabismus
lecture.
 Most of the cases in pediatric ophthalmology deals with
crossed eyed kid and lazy eye or amblyopia (which what VISUAL ACUITY
we prefer to call not lazy eye, but you can hear it a lot from  We try all sort of tests to detect visual acuity and some of
mothers) these are known to people who have background on
 Amblyopia is an urgent condition and must be treated psychology
actively and prevented or actively rehabilitated once it is • We have charts for children
diagnosed • To recognize:
 Strabismus or imbalance of the eye due to muscle o Refractive error
problems o Cataract
 We have to ask them (Parents) if it is seen familial or runs o Congenital glaucoma
in the family so when we do vision screening for children o Retinoblastoma
before they enter school we need to ask this conditions.  We have charts for children before they enter preschool
 Among this conditions, strabismus and amblyopia is the • Eye Charts
most common and luckily we do not have too many of the o Picture charts (Lea or Allen):
congenital glaucoma, but retinoblastoma we’re one of the ▪ Used in preliterate children
highest in the world and this is a familial and genetic  Lea chart consist of pictures of apple,
disease that is more prevalent in certain races and house, circle or square
countries in the world  Most kids can tell what you are showing
to them
VISION SCREENING o Matching charts (HOTV)
• Goal: to identify risk factors that require referral ▪ Preliterate children
o Family ophthalmologic history o Literate children:
▪ Strabismus ▪ Letter charts (Snellen)
▪ Amblyopia • Test each eye independently using charts with pictures of
▪ Retinoblastoma an apple, square then we try to show pictures that keeps
▪ Childhood glaucoma getting smaller until we get an estimate of a Snellen’s
▪ Childhood cataracts measurement.
▪ Ocular or genetic systemic disease  Usually the right eye is tested first
o Personal history • Occlude the opposite eye to discourage peeking
▪ Premature birth • Some kids cheat and peek through the occlude so you have
▪ Down syndrome to make sure that the other eye is properly covered. Some
▪ Cerebral palsy of them actually memorize the charts kaya right now mas
• At each visit the physician should ask about the child's preferred ang projector chart where you can isolate one
visual interactions and any eye or vision problems letter to discourage kids from memorizing the lines.

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 OPHTHALMOLOGY Pediatric Ophthalmology- Strabismus and Amblyopia LECTURE 7.1

EXTERNAL EYE EXAMINATION

 When we examine the eyes of children we inspect the same
structure that we will examine in an adult but in a different
way because some of these children cannot be easily
examine
 Sometimes you have to let them comeback and examine
them again until you are able to get the refraction
 The most difficult is the refractive part
• Inspect the following structures
o Eyelids
o Orbits
o Conjunctiva
o Sclera
o Cornea
o Iris
• Using a light, inspect for excessive tearing, watery or
Figure 1. (left) Snellen chart and (right) is the HOTV chart. Some purulent discharge, photosensitivity, conjunctival injection,
children who are already 4 years old can already do this, but you will and gross structural abnormalities.
have to go to the chart and point exactly what you are asking them
to read. LACRIMAL DUCT OBSTRUCTION
• Most common cause of persistent eye discharge in
infants
• Management:
o Lacrimal duct massage
o Topical antibiotics = if there are signs of infection
o Close follow-up for symptom resolution because
congenital glaucoma has a similar presentation
 Within the 1st year of life, majority of infants present with
nasolacrimal duct obstruction. So when you see tearing and
you suspect congenital NLDO within the 1st year of life, you
just observe because most cases spontaneously resolve.
If it persists BEYOND THE FIRST YEAR OF LIFE, that’s
the time you do some interventions

Figure 2. Lea Chart and Allen Chart. These are example of chart with
pictures, and of course if the child is alert enough, they will actively
say “house”, “apple” then going down “umbrella”, this is for the Lea
chart (left). If the child doesn’t know how to speak in English they
might be able to use the Allen chart (Right) as well, most especially if
you are having problem understanding the language of the patient.
Norms of Visual Acuity in Children
(Multi-ethnic Pediatric Eye Disease)
Age (in Months) Visual Acuity
30-35 months (2-3 years old) 20/60 or better
36-47 months (3-4 years old) 20/50 or better
48-59 months (4-5 years old) 20/40 or better
60-72 months (5-6 years old) 20/30 or better
 Normally, the patient’s visual acuity will improve over the
five to six years and you cannot expect them to have
20/20 vision like adults at a very early age but they will get
there along the way.
 The reason here is most children when they are young
they have some hyperopia or they have some refractive
errors because they do not really need that much vision
CONGENITAL GLAUCOMA
• Epiphora
 Excessive tearing
 Hindi yung basta basta lang sa eyes, dapat tumutulo
talaga sa cheeks
• Buphthalmos
 Enlarged eyes
 Kasi in children <3y/o elastic pa yung globe kaya nag
eexpand with very high pressure
• Photosensitivity / Photophobia
• Corneal clouding
 Some children has lacrimal duct problems or glaucoma
and we have to rule these things out to determine if the
patient just has strabismus or amblyopia
OCULAR FIXATION
 We also describe ocular fixation in an infant, meaning to
say they are able to look at the face of the examiner. Maybe
smile or fixate to objects like toys.
• Ocular fixation should be evaluated routinely to test vision
in an infant
• If at 3 months old, there is no binocular fix and follow
response → refer to an ophthalmologist.

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 OPHTHALMOLOGY Pediatric Ophthalmology- Strabismus and Amblyopia LECTURE 7.1

pupil so we call it orthophoric or normal. B. If the patient has

Age Response esotropia, the corneal light will be on the iris or the pupil or in very
6 weeks old Some response to an examiner’s severe it can be in the limbus or it will be on the lateral part of the eye
face because the eyes deviated inward. C. Other way around goes if it is
exotropia, the light reflex will be shifted medially. D. and if the patient
2 months old and Child should fix and follow a target
has hypertropia, in this case is deviated upward, naturally the light
older
reflex will be deviated downward. So wherever the deviation goes, the
corneal light deflections go to the other side and this would suggest a
OCULAR ALIGNMENT possible strabismus.
• To identify strabismus (eye misalignment), which may be
caused by
o Abnormal innervation of the EOMs
o Other pathology (ex: amblyopia, cataract,
retinoblastoma)
 Remember: Any condition resulting to poor vision
in one eye can lead to misalignment!
• Test the corneal light reflex in all children
o Done for both eyes
• Do basic cover tests in children (>3years old) to identify
strabismus
 If the patient cannot use that particular eye (s/t cataract or
other conditions), he will have a relatively poor vision in that
eye. The tendency of the affected eye is to deviate kasi di
naman siya makapag focus since wala siya halos makita.
Figure 4. Pseudostrabismus and Esotropia. A. Normal eye. B. Some
children they look “Duling” and occasional we have teenage patients
CORNEAL LIGHT REFLEX IN STRABISMUS that they still look like they have strabismus and when you examine
 Initially we use the corneal reflex to see if there is a mis the light is centered in the middle of the pupil and this is what we call
alignment in either one or both eyes. pseudo strabismus brought about by wide intercanthal bridge or
 The patient is directed to look at a penlight held directly in lacking nasal bridge. We just encourage them by saying when the child
front of the eyes by the examiner at a distance of 2 feet. grows, naturally the nasal bridge will develop and you will have a
 The examiner aligns his or her eye with the light source and loosening up of the skin but certainly you should be able to this from
compares the position of the light as reflected by the cornea the real Esotropia (C). C. Esotropia. Mukang “duling” and the light is
of each eye. deflected to the side and this would be the abnormal one.
 Normally, the light is reflected on each cornea
symmetrically and in the same position relative to the pupil  Hirschberg Test. You may use a penlight or an
and visual axis of each eye. ophthalmoscope. Ask the patient to fixate at a near target.
 In a deviating eye, the light reflection will be eccentrically A normal finding is the presence of the corneal light at the
positioned and, in a direction, opposite to that of the center of the pupil. An esotropic eye will present with a
deviation. light reflex that is temporal to the pupil. In exotropia, the
 The size of the deviation can be estimated by the amount light reflex is nasal to the pupil. In Pseudostrabismus,
of displacement of the light reflex, but this is a relatively minsan the broad nasal bridge or skin folds creates an
gross estimate illusion na merong esotropia pero pag chineck mow ala
naman. Pag ganito, advise the mom to observe lang kasi
as the child grows, mawawala din yan kapag nagdevelop
na yung facial bones.

STRABISMUS
• Bifoveal fixation
o In normal binocular viewing condition
o The clear image of any object or target object falls on
the fovea of each eye
 This is impossible when you have strabismus because one
eye is deviated, naturally the target object would be
visualized clearly on a fixating eye but it should be
suppressed on the other eye otherwise, the patient will see
double (diplopia).
 So the phenomenon that may be seen in children is the
Figure 3. Corneal Light Reflex in Strabismus. A. Take note of the absence of diplopia because the of suppression, and the
light here (whit pinpoint dot), normally it should be centered on both
suppression here is a reflex or something that will occur in
children less than 4 years old. Almost immediately after

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 OPHTHALMOLOGY Pediatric Ophthalmology- Strabismus and Amblyopia
strabismus developed in that eye, otherwise the patient
would be experiencing diplopia.
 In adults, if they have acute strabismus due to muscle
paralysis and the eye had been seeing clearly before, that
eye will have diplopia. Whereas in children, the diplopia is
counteracted by suppression.
 Normally, if the patient sees a chair, the image of the chair
should fall on the fovea of the right eye, ganun din dapat sa
left eye. Pero kapag yung image is outside the fovea of one
eye, negative na yung bifoveal fixation mo, baka may
strabismus na siya.
• Any deviation from perfect ocular alignment
o The target object is not visualized simultaneously by
fovea of each eye (not bifoveal fixation)
• Prevalence: 4% of children
• Strabismus is not outgrown
• Management: Treat ASAP to ensure best visual acuity and
binocularity→ may lead to amblyopia if not treated
 Treatment: mainly to prevent amblyopia.
 DEFINITION OF TERMS
• Angle Kappa- The main angle between the visual axis
and the central pupillary line. When the eye is fixing a
light, if the corneal reflection is centered on the pupil, the
visual axis and the central pupillary line coincide and the
angle kappa is zero. Ordinarily, the light reflex is 2°–4°
nasal to the pupillary center, giving the appearance of
slight exotropia (positive angle kappa). A negative angle
kappa gives the false impression of esotropia.
• Conjugate movement: Movement of the eyes in the
same direction at the same time.
• Deviation: Magnitude of ocular misalignment, usually
measured in prism diopters but sometimes measured in
degrees.
• Comitant deviation: Deviation not significantly affected
by which eye is fixing or direction of gaze, typically a
feature of childhood (nonparetic) strabismus.
• Incomitant deviation: Deviation varies according to
which eye is fixing and direction of gaze, usually a
feature of recent onset extraocular muscle paresis and
other types of acquired strabismus.
• Primary deviation: Incomitant deviation measured with
the normal eye fixing.
• Secondary deviation: Incomitant deviation measured
with the affected eye fixing.
• Fusion: Formation of one image from the two images
seen simultaneously by the two eyes. Fusion has two
aspects.
o Motor fusion: Adjustments made by the brain
in innervation of extraocular muscles in order to
bring both eyes into bifoveal and torsional
alignment.
o Sensory fusion: Integration in the visual
sensory areas of the brain of images seen with
the two eyes into one picture.
[Epoc, Gutierrez] EDITOR: [Corneta]
LECTURE 7.1
TYPES OF STRABISMUS
• Manifest strabismus (Heterotropia/Tropia)
o Present under binocular viewing condition (or
both eyes are open)
• Latent strabismus (Heterophoria/Phoria)
o Present only when binocular vision has been
interrupted (or 1 eye is occluded)
 Remember!
Manifest = Tropia. Obvious. Kita mo agad
Latent = Phoria. Mukhang normal. Makikita mo lang
pagtinakpan mo yung mata biglang may deviation
HETEROTROPIA (Paralytic or Non-paralytic)
 "Squints”
• Aka manifest deviation
 Squint is a term in layman “pinapaliit ang mata” but in
ophthalmologist is the same term as strabismus, and we
use the term “squint” to refer to either esotropia or exotropia
but we do not use the word “squint” for phorias.
 Pag sinabing squint meron ng inner or outward deviation
and we will see on what type of treatment will be given
TYPES
Exotropia Lateral Deviation, “wall-eyed”
Esotropia Medial Deviation, “cross-eyed”
Hypertropia Upward deviation
Hypotropia Downward deviation
PSEUDO ESOTROPIA
• Epicanthal folds give appearance of esotropia but
Hirschberg test is normal
• More common in Asians
• Resolves as the nasal bridge and bone structure develops
with age
 Some of the squints look like squints so pseudo squints.
 We try to identify which muscles are involved by proper
analysis of the child.
TROPIA: COVER TEST
 Easy to perform, requires no special equipment, and
detects almost every case of tropia
• Ask the patient to fixate on a distant target (as opposed
to Hirschberg test na NEAR TARGET)
• Cover the fixating eye, the deviated eye will then move to
fixate the target
• The deviation can be quantified using prism
 Occasionally we can quantify the deviation in the very
cooperative children using special lenses called prisms
 Prisms- these are lenses which will give us a number
corresponding to the amount of deviation brought
about by the muscle imbalance and these are better
way of measuring it rather than just drawing the
Hirschberg reflex in the cornea
 No shift on cover testing means there is no tropia, but a
phoria could still be present
 A phoria is detected by alternate cover testing
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 OPHTHALMOLOGY Pediatric Ophthalmology- Strabismus and Amblyopia
Figure 5. Classic Cover Test. Esotropia (Upper). So in cover test in
patient with esotropia, if you cover the good eye the eye with esotropia
will be move to the center. If its Exotropia (lower), if you cover the good
eye, that deviated eye will move to the center. So generally in esotropia
when you cover the bad eye, nothing will happen or it will not move
because the other eye is fixating. Same with exotropia, if you cover the
exotropic eye, the other eye will continue fixating and it will not move.
 Look at the picture. Remember, MANIFEST DEVIATION
to. When you cover the good eye, the affected eye will
move. Kasi tinanggal mo yung vision nung good eye, so
to compensate yung other eye yung magfifixate. Kapag
may movement, it confirms na tropic yung eye niya.
• Esotropia- OS left eye moves OUTWARD as the OD right
eye (initially fixating) is covered
• Exotropia- OS left eye moves INWARD as the OD right
eye (initially fixating) is covered
PARALYTIC STRABISMUS
• Incomitant strabismus
o The deviation varies in different positions of gaze
• Mostly in adults, acquired
• Due to reduction or restriction in range of eye movements
o Neural (CN III, IV, VI): ischemia (DM), Multiple
sclerosis, aneurysm, brain tumor, trauma
o Muscular: myasthenia gravis (neuromuscular
junction pathology), Graves’ disease
o Structural: restriction or entrapment of extraocular
muscles due to orbital inflammation, tumor, fracture of
the orbital wall
 One or more of the extraocular muscles or nerves may not
be functioning properly, or normal movement may be
mechanically restricted. This type of strabismus may well
indicate either a serious neurologic disorder, such as third
cranial nerve palsy, or orbital disease or trauma, such as
the restrictive ophthalmopathy of thyroid disease or a
blowout fracture.
 Generally, paralytic ‘squints’ cannot be subjected to
surgery, especially in an acute stage, but it can be done
much later on.
Figure 6. Right Lateral Rectus Paralysis
[Epoc, Gutierrez] EDITOR: [Corneta]
LECTURE 7.1
 On primary gaze, the patient is right esotropic. No deviation
on left gaze. But when he looks to the right, hindi maka
abduct yung right eye. Anong muscle ang affected? Right
Lateral Rectus
Figure 7. Right Medial Rectus Paralysis
 Eto naman right exotropic on primary gaze. No deviation
on right gaze. On left gaze, hindi naman maka- adduct yung
right eye. Ano ang affected? Right medial rectus
NON-PARALYTIC STRABISMUS
• Concomitant strabismus
o The deviation is equal in all directions of gaze
• Usually begins in infancy, up to age 8-10 years
• No restriction in range of eye movements
• Monocular, alternating, or intermittent
 The individual extraocular muscles are functioning
normally, but both eyes are simply not directed toward the
same target. Most concomitant strabismus has its onset in
childhood. In children, it often causes the secondary
development of suppression to overcome double vision and
thus leads to strabismic amblyopia.
 Remember!
o Paralytic= ORGANIC cause, adult onset
o Non-paralytic= NO ORGANIC cause, seen in children
HETEROPHORIA
• Aka latent deviation
 Latent strabismus
 It may not require treatment or it may just require
eyeglasses or careful observation which is also common or
sometimes sasabihin nila “doc pag antok yan, banlag na”
or if the patient is daydreaming or about to fall asleep their
eyes starts to deviate.
• Deviation corrected in the binocular state by the fusion
mechanism (the deviation is not seen when patient is using
both eyes)
• Normal Hirschberg test (symmetrical light reflexes)
• Very common, most are asymptomatic
• May present as asthenopia (eye strain, fatigue)
 So “tropia” is a term that says meron na talagang
deviation, but phoria it is latent or medyo nacocontrol pa
PHORIA: COVER-UNCOVER TEST
• In phoria, both eyes are straight on primary gaze
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 OPHTHALMOLOGY Pediatric Ophthalmology- Strabismus and Amblyopia
Figure 8. Cover-Uncover Test. In Esophoria (upper image), at
baseline they see well but once you do the cover-uncover test you will
actually elicit the defect. So, in this case, the middle picture, when you
cover the eye with latent esophoria it will start to deviate and once you
remove the cover the eye can actually remain straight in primary gaze.
 Look at the picture, Phoria naman to. Ang gumagalaw
naman dito is yung eye UNDER the occlude. So paano
mo makikita yung eye kung natatakpan diba? Ganito.
Kapag nilagay mo yung occluder at hindi nagmove yung
uncovered eye, pwedeng normal to. Kapag may phoria,
makikita mo yung REFIXATION MOVEMENT once you
remove the occluder. Meaning pag tinanggal mo na yung
occluder mukhang magfofocus/gagalaw yung tinakpan
mong eye para mag-focus
ALTERNATE COVER TEST
Figure 9. Alternate Cover Test. We do the cover test repeatedly and
we ask them to comeback then we do it again until we are convinced
that the patient has either tropia or a phoria. For patients who have a
tropia (esotropia or exotropia) its another kind of decision whether they
will need eyeglasses or surgery to correct the squint.
 This test is performed after single cover testing as it is the
most dissociative of cover tests. It involves covering one
eye and holding the occluder for several seconds to
suspend fusion, then shifting the occluder to the other eye
and rapidly alternating back and forth without allowing the
patient to become binocular and being careful to always
keep one eye occluded. The eye under the occluder is
observed as the occluder is removed and placed over the
fellow eye in order to determine the direction of deviation. If
there is an outward, or lateral, refixation in the nasal to
temporal direction- this represents an esodeviation. If
there is an inward, or medial, refixation in a temporal to
nasal direction – this represents an exodeviation. If there
[Epoc, Gutierrez] EDITOR: [Corneta]
LECTURE 7.1
is a vertical refixation movement – this represents either a
hyper or hypo deviation. There can be both horizontal and
vertical deviations present at the same time.
SENSORY CHANGES IN STRABISMUS
• If strabismus starts early (<7 or 8 years old), abnormal
binocular vision may occur
1. DIPLOPIA
o The same object is seen in 2 different places
o 1 fall on fovea, 1 fall in peripheral retina
 Can be suppressed in children via cortical
suppression
2. VISUAL CONFUSION
o Localization of spatially separate objects to the same
location
Figure 10. A. Confusion, B. Diplopia.
3. ABNORMAL (ANOMALOUS) RETINAL
CORRESPONDENCE (ARC)
o In the presence of manifest strabismus, an
extrafoveal retinal locus may become the preferred
point of fixation in the deviating eye, resulting in
abnormal (anomalous) retinal correspondence
(ARC).
o ARC is present only under binocular viewing
conditions, in contrast to eccentric fixation (see
below). ARC avoids diplopia and visual confusion
because the extrafoveal retinal locus of fixation in the
deviating eye is localized straight ahead during
binocular viewing. It also facilitates binocular
function, possibly resulting in low-grade stereopsis
4. SUPRESSION
o In binocular vision, images seen by 1 eye becomes
predominant while those seen by the other eye is not
perceived
▪ Dominant eye: seen
▪ Strabismic/amblyopic eye: not perceived
“suppressed”
o In the absence of strabismus, a blurred image in 1
eye may also lead to suppression
▪ The lack of simultaneous perception in the
central retina prevents fire stereopsis (from
the peripheral retina) may still be present
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 OPHTHALMOLOGY Pediatric Ophthalmology- Strabismus and Amblyopia
5. AMBLYOPIA
• Decreased visual acuity without any organic disease
in 1 eye
 Occasionally, there is no definite explanation why
we would see children with a very poor vision on
one eye compared to one eye, luckily it is very rare
 The three main causes of amblyopia are strabismus,
unequal refractive error (anisometropia), and visual
deprivation (eg, congenital cataract, ptosis or optic
nerve hypoplasia). Often, more than one etiology is
present.
 In esotropia, amblyopia is common and often severe,
whereas in exotropia it is uncommon and usually
mild. If spontaneous alternation of fixation is present,
amblyopia does not develop.
AMBLYOPIA
• Also known as “Lazy Eye”
 Decreased visual acuity in the absence of sufficient organic
eye disease to explain the level of vision.
 Reduction in visual acuity in the absence of detectable
organic disease (such as cataract, retinoblastoma, or other
inflammatory or congenital ocular disorders) that results
from a disruption of the normal development of vision.
• Reduction of best-corrected visual acuity due to
cortical suppression of sensory input from an eye that is
receiving blurred or conflicting visual info, leading to
disruption of the normal development of visual pathways
serving that eye.
 Loss of vision brought about by suppression of sensory
input from an eye that is either deviated or is receiving
blurred information because of a high refractive error.
 Remember: Kapag may poor vision ang bata, eventually
nagkakaroon ng suppression of visual input sa cortex. Kaya
kahit macorrect yung visual problem later in life, hindi na
helpful kasi suppressed na yung cortical pathways
• Etiologies include:
o Strabismus
o Anisometropia
 The grade of the left and right eye is different
usually with a grade of more than 200. So yung
grado ng isa might be 600 yung isa 300, so we
could say that patient has anisometropia.
o Any ocular pathology that prevents proper light
transmission and transduction
▪ Congenital or infantile cataracts
 Yung pinanganak na may ptosis can develop
amblyopia very rapidly within the first month of
life – urgent condition
▪ Retinal lesions
▪ Neurologic disease
▪ Ocular injury
• Amblyopia must be suspected if with the following:
o Resistance to monocular occlusion
▪ The child seems to consistently resist covering of
one eye more than the covering of the other eye
o Head tilt
▪ The child tilts his head frequently
o Nystagmus
▪ The child has nystagmus
[Epoc, Gutierrez] EDITOR: [Corneta]
LECTURE 7.1
 Generally, amblyopia is reversible within the first 4
years of life, any residual amblyopia found after the
4th year is generally considered permanent or
irreversible
• Leads to permanent vision loss if left untreated
• Difficult to detect in pre-literate children
• The presence of amblyopia always warrants referral to
an ophthalmologist
• General Treatment of all types of amblyopia:
o Correct the underlying cause
o Occlusion therapy (patching) or atropine
cycloplegia (optical degradation therapy) of the good
eye
 Always Patch the good eye! Para ma force yung bad eye
na umayos. PUT ATROPINE ON THE GOOD EYE! Mag
didilate yung pupil ng good eye. This way, you induce BOV
(ang effect nito is 2 weeks na blurred vision) of the good
eye so ganon din, mapipilitang umayos ang bad eye
TYPES OF AMBLYOPIA
1. STRABISMIC AMBLYOPIA
• Due to Strabismus
 The eye used habitually for fixation retains normal acuity
and the nonpreferred eye often develops decreased
vision. Adult-onset strabismus generally will cause diplopia
(double vision) because both eyes are not aligned on the
same object. The brain of a child, on the other hand, is
more adaptive. In a similar strabismic situation, the child’s
brain ignores suppresses) the image from one of the
eyes—usually the one that provides the blurrier image.
• Management:
o Correct with spectacles
o Patching – occlusion of unaffected eye
o Surgery:
▪ Recession (weakening)- moving muscle
insertion further back on the globe
▪ Resection (strengthening)- shortening the
muscle
 In the case of Esotropia, you weaken the medial
rectus. Kasi pinupull ng MR yung eyeball papunta
sa gitna.
o Botulinum toxin for single muscle weakening after
ocular alignment is restored (via spectacles,
surgery, or botulinum toxin)
2. REFRACTIVE (ANISOMETRIC) AMBLYOPIA
• Ambylopia usually occurs in the more hyperopic eye
• Due to anisometropia
 The eye with the lesser refractive error provides the
clearer image and usually is favored over the other eye;
consequently, amblyopia develops. Children with
asymmetric hyperopia are susceptible, because
unequal accommodation (focusing) is impossible; the
child can bring only 1 eye at a time into focus. Refractive
amblyopia may be as severe as that found in strabismic
amblyopia.
• Management:
o Treat with glasses to correct refractive error
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 OPHTHALMOLOGY Pediatric Ophthalmology- Strabismus and Amblyopia LECTURE 7.1

o Patching is required if difference in the visual acuity o Elevation – Directing the eye UP
persists after 4-8 weeks of using spectacles o Depression – Directing the eye DOWN
o Intorsion – Directing the TOP of the eye TOWARD the
3. DEPRIVATION AMBLYOPIA (FORM AND OCCLUSION) nose
• Due to visual deprivation o Extorsion – Directing the SUPERIOR aspect of the eye
• Ex. Congenital Cataract, Periocular hemangioma, AWAY from the nose
Ptosis, Retinoblastoma, Occlusion (from patching the • Movement of both eyes together also have two distinct
good eye) types:
• Management: o Version – Movement of both eyes in SAME direction
o Manage or treat the etiology of the occlusion o Vergence – Movement of both eyes but each eye
moves in an OPPOSITE direction
▪ Convergence – directing the left and right eyes
• Preferred Eye – retains normal visual acuity
TOWARD the nose
• Non-preferred Eye – develops amblyopia (decreased
▪ Divergence – directing the left and right eyes
visual acuity)
AWAY from the nose
RED REFLEX EXAMINATION
Muscle Primary Secondary Tertiary
• To identify:
o Retinoblastoma Medial Adduction __ __
o Congenital or Infantile cataracts Rectus
o Other ocular opacities and ocular abnormalities Lateral Abduction __ __
• ROR asymmetry or absence (leukocoria) may suggest: Rectus
o Error of refraction Inferior Depression Excycloduction Adduction
o Retinoblastoma Rectus /Extorsion
o Congenital or Infantile Cataract Superior Elevation Incycloduction Adduction
o Retinopathy of prematurity (ROP) Rectus /Intorsion
o Retinal detachment Inferior Excycloduction Elevation Abduction
o Coat’s disease (exudative retinitis) Oblique /Extorsion
o Toxocariasis Superior Incycloduction Depression Abduction
o Retinal coloboma Oblique /Intorsion
o Persistent Hyperplastic Primary Vitreous (PHPV)
o These may all lead to amblyopia  Mnemonics:
 In the presence of leukocoria during the first 2 years or even • Lahat ng Superior, Laging INtorsion
first 6 months we would actually put the child on general • Inferior ang EXtorsion mo
anesthesia, dilate the pupil complete and find the etiology, • Lahat ng may oBlique laging aBduction
especially retinoblastoma since it is a life-threatening • Primary Action – Principal effect the EOM has on eye
tumor. rotation
• Secondary Action – Less effect
• Tertiary Action – Least effect

GENERALIZATIONS
• Horizontal recti only adduct & abduct
• Vertical recti – main elevators & depressors of the eye
• Obliques – mostly for the torsion
• All recti are adductors.
• The oblique muscles are abductors.
• The superior muscles are intorters.
• The inferior muscles are extorters
• Mnemonics: RAD SIN = Rectus Muscles Adduct,
Superior muscles (SO/SR) Intort
Figure 11. Types of ROR. Lifted from ppt.

EXTRAOCULAR MUSCLES FIELD OF ACTION

MOTOR PHYSIOLOGY
• The precise action of a muscle depends on the orientation
of the eye in the orbit & the influence of the orbital
connective tissues
• Gross extraocular muscle movements:
o Adduction – Directing the eye TOWARD the nose
o Abduction – Directing the eye LATERALLY
 The position of the eye is determined by the equilibrium
achieved by the pull of all six extraocular muscles
 The eyes are in the primary position of gaze when they
are looking straight ahead with the head and body erect
• 1° position of gaze – eyes look straight ahead with head
and body erect

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 OPHTHALMOLOGY Pediatric Ophthalmology- Strabismus and Amblyopia LECTURE 7.1

• Field of action of EOM – direction of gaze where the EOM
exerts its greatest contraction force as an agonist
• Synergist Muscle – EOMs within the same eye with the
same field of gaze
• Yoke muscle – paired EOMs in both eyes that work
together to a certain gaze direction
same time, meron equal inhibition sa right medial rectus
and left lateral rectus para hindi naman sila istorbo sa
smooth movement ng eye to the right
MOTOR FUSION
• The process by which the activity of the extraocular
muscles is adjusted to maintain the necessary ocular
alignment for sensory fusion.
• Stimulated by disparity in images received from the two
eyes, such as results from the object of regard moving
toward or away from the subject

DEVELOPMENT OF BINOCULAR MOVEMENT

• The neuromuscular system of an infant is immature, so that
it is not uncommon in the first few months of life for ocular
alignment to be unstable.
• Transient exodeviations are most common and are
associated with immaturity of the accommodation-
convergence system.
• Gradually improving visual acuity together with maturation
of the ocular motor system allows a more stable ocular
alignment by age 2 to 3 months.
• Any ocular misalignment after this age should be
investigated by an ophthalmologist.

-------------------------------END OF TRANS------------------------------

RECALLS/NUGGETS
Retinoblastoma treatment to avoid ?
enucleation
*if detected
earlier, the eye
can be preserved
Incomplete CN3 palsy Absence of ptosis
Figure 12. Yoked EOMs movement in cardinal position. Lifted from Trans:
ppt. (See appendix) Complete CN3 palsy – (+)
Vision screening recommended 3-5 years old
LAWS IN MOTOR PHYSIOLOGY atleast once in all children in which
SHERRINGTON’S LAW age
• “Share” an eye Group?
• Synergistic and Antagonistic Muscles Enlarged eyes Buphthalmos
• Reciprocal innervations of antagonistic EOMs Evaluate infant’s ocular fixation Child should fix
• Antagonist is inhibited, while agonist is stimulated and follow a target
 Eto yung law for one eye lang. If the patient is looking to the Exotropia
right, right lateral rectus ang nagwowork. Ang sinasabi lang
ng law na most of the nerve stimulation goes to the right
lateral rectus while inhibited naman yung antagonist (right
medial rectus)

HERING’S LAW
• Yoke’s Muscles
• Corresponding agonist EOMs receive equal innervations
for eye movement in the same direction
• Example: Left LR & Right MR for a left horizontal gaze
 For both eyes na to. Pag tingin niya sa right, equal
innervation ang nakukuha ng right lateral rectus and left
medial rectus to allow eye movement to the right. At the Hirshberg test Latent deviation/
heterophoria

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OPHTHALMOLOGY Pediatric Ophthalmology- Strabismus and Amblyopia LECTURE 7.1

Most common cause of Lacrimal duct Advice on patient with esotropia but Resolves as the
persistent eye discharge in obstruction with normal Hirschberg test nasal bridge and
infants bone structure
Not part of management of Recession and develops with age
anisometric amblyopia? Resection Amblyopia Reduction of
best-corrected
Management: Treat visual acuity due
with glasses to correct to cortical
refractive error; suppression of
patching is required if sensory output
difference in visual Patch Test Cover the
acuity persists after 4 - unaffected eye
8 weeks of using Primary action of superior Intort
spectacles oblique
Strabismus quantifies by using? Prism Red Reflex examination identify the Congenital
Recession Moving muscle following except: glaucoma
insertion further back
on the globe

Resection – shortening
the muscle

APPENDIX

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OPHTHALMOLOGY Pediatric Ophthalmology- Strabismus and Amblyopia LECTURE 7.1

SUMMARY
*please see photos in the main trans
VISION SCREENING
• Goal: to identify risk factors that require referral
o Family ophthalmologic history
▪ Strabismus, Amblyopia, Retinoblastoma, Childhood glaucoma, Childhood cataracts, Ocular or genetic
systemic disease
o Personal history
▪ Premature birth, Down syndrome, Cerebral palsy
• At each visit the physician should ask about the child's visual interactions and any eye or vision problems.

OPTHALMOLOGIC EXAM • Vision screening is recommended at least once in all children aged 3-5 years.

VISUAL ACUITY • We have charts for children

• To recognize refractive error, cataract, congenital glaucoma, retinoblastoma
• Eye Charts
o Picture charts (Lea or Allen):
▪ Used in preliterate children
o Matching charts (HOTV)
▪ Preliterate children
o Literate children:
▪ Letter charts (Snellen)
• Test each eye independently using charts with pictures of an apple, square then we try to
show pictures that keeps getting smaller until we get an estimate of a Snellen’s
measurement.
• Occlude the opposite eye to discourage peeking.
EXTERNAL EYE EXAM • Inspect the following structures: Eyelids, Orbits, Conjunctiva, Sclera, Cornea, Iris
• Using a light, inspect for excessive tearing, watery or purulent discharge, photosensitivity,
conjunctival injection, and gross structural abnormalities.
OCULAR ALIGNMENT • To identify strabismus (eye misalignment), which may be caused by
o Abnormal innervation of the EOMs
o Other pathology (ex: amblyopia, cataract, retinoblastoma)
 Remember: Any condition resulting to poor vision in one eye can lead to
misalignment!
• Test the corneal light reflex in all children
o Done for both eyes
• Do basic cover tests in children (>3years old) to identify strabismus
STRABISMUS
• Bifoveal fixation
o In normal binocular viewing condition
o The clear image of any object or target object falls on the fovea of each eye.
• Any deviation from perfect ocular alignment
o The target object is not visualized simultaneously by fovea of each eye (not bifoveal fixation)
• Prevalence: 4% of children
• Strabismus is not outgrown
• Management: Treat ASAP to ensure best visual acuity and binocularity→ may lead to amblyopia if not treated
TYPES OF STRABISMUS • Manifest strabismus (Heterotropia/Tropia)
o Present under binocular viewing condition (or both eyes are open)
• Latent strabismus (Heterophoria/Phoria)
o Present only when binocular vision has been interrupted (or 1 eye is occluded)
• Remember!
Manifest = Tropia. Obvious. Kita mo agad
Latent = Phoria. Mukhang normal. Makikita mo lang pagtinakpan mo yung mata
biglang may deviation

HETEROTROPIA • Aka manifest deviation

• TROPIA: COVER TEST
o Ask the patient to fixate on a distant target (as opposed to Hirschberg test na
NEAR TARGET)

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OPHTHALMOLOGY Pediatric Ophthalmology- Strabismus and Amblyopia LECTURE 7.1

o Cover the fixating eye, the deviated eye will then move to fixate the target
o The deviation can be quantified using prism
▪ Esotropia- OS left eye moves OUTWARD as the OD right eye (initially
fixating) is covered
▪ Exotropia- OS left eye moves INWARD as the OD right eye (initially
fixating) is covered

• PARALYTIC STRABISMUS
o Incomitant strabismus
▪ The deviation varies in different positions of gaze
o Mostly in adults, acquired
o Due to reduction or restriction in range of eye movements
▪ Neural (CN III, IV, VI): ischemia (DM), Multiple sclerosis, aneurysm, brain
tumor, trauma
▪ Muscular: myasthenia gravis (neuromuscular junction pathology),
Graves’ disease
▪ Structural: restriction or entrapment of extraocular muscles due to orbital
inflammation, tumor, fracture of the orbital wall
• NON-PARALYTIC STRABISMUS
o Concomitant strabismus
▪ The deviation is equal in all directions of gaze
o Usually begins in infancy, up to age 8-10 years
o No restriction in range of eye movements
o Monocular, alternating, or intermittent
HETEROPHORIA • Aka latent deviation
• Deviation corrected in the binocular state by the fusion mechanism (the deviation is not seen
when patient is using both eyes)
• Normal Hirschberg test (symmetrical light reflexes)
• Very common, most are asymptomatic
• May present as asthenopia (eye strain, fatigue)
• PHORIA: COVER-UNCOVER TEST
o In phoria, both eyes are straight on primary gaze
SENSORY CHANGES IN • If strabismus starts early (<7 or 8 years old), abnormal binocular vision may occur
STRABISMUS DIPLOPIA
o The same object is seen in 2 different places
o 1 fall on fovea, 1 fall in peripheral retina
VISUAL CONFUSION
o Localization of spatially separate objects to the same location
ABNORMAL (ANOMALOUS) RETINAL CORRESPONDENCE (ARC)
o In the presence of manifest strabismus, an extrafoveal retinal locus may become the
preferred point of fixation in the deviating eye, resulting in abnormal (anomalous)
retinal correspondence (ARC).
o ARC is present only under binocular viewing conditions, in contrast to eccentric
fixation (see below). ARC avoids diplopia and visual confusion because the
extrafoveal retinal locus of fixation in the deviating eye is localized straight ahead
during binocular viewing. It also facilitates binocular function, possibly resulting in low-
grade stereopsis
SUPRESSION
o In binocular vision, images seen by 1 eye becomes predominant while those seen by
the other eye is not perceived
▪ Dominant eye: seen
▪ Strabismic/amblyopic eye: not perceived “suppressed”
o In the absence of strabismus, a blurred image in 1 eye may also lead to suppression
▪ The lack of simultaneous perception in the central retina prevents fire
stereopsis (from the peripheral retina) may still be present
AMBLYOPIA
• Decreased visual acuity without any organic disease in 1 eye
AMBLYOPIA
• Also known as “Lazy Eye”

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OPHTHALMOLOGY Pediatric Ophthalmology- Strabismus and Amblyopia LECTURE 7.1

• Reduction of best-corrected visual acuity due to cortical suppression of sensory input from an eye that is receiving blurred
or conflicting visual info, leading to disruption of the normal development of visual pathways serving that eye.
 Remember: Kapag may poor vision ang bata, eventually nagkakaroon ng suppression of visual input sa cortex. Kaya kahit
macorrect yung visual problem later in life, hindi na helpful kasi suppressed na yung cortical pathways
• Etiologies include:
o Strabismus, Anisometropia, Any ocular pathology that prevents proper light transmission and transduction (Congenital
or infantile cataracts, Neurologic disease, Ocular injury)
• Amblyopia must be suspected if with the following:
o Resistance to monocular occlusion, Head tilt, Nystagmus
• Leads to permanent vision loss if left untreated
• Difficult to detect in pre-literate children
• The presence of amblyopia always warrants referral to an ophthalmologist
• General Treatment of all types of amblyopia:
o Correct the underlying cause
o Occlusion therapy (patching) or atropine cycloplegia (optical degradation therapy) of the good eye
TYPES OF AMBLYOPIA STRABISMIC AMBLYOPIA
• Due to Strabismus
• Management:
o Correct with spectacles
o Patching – occlusion of unaffected eye
o Surgery:
▪ Recession (weakening)- moving muscle insertion further back on the globe
▪ Resection (strengthening)- shortening the muscle
o Botulinum toxin for single muscle weakening after ocular alignment is restored (via
spectacles, surgery, or botulinum toxin)
REFRACTIVE (ANISOMETRIC) AMBLYOPIA
• Ambylopia usually occurs in the more hyperopic eye
• Due to anisometropia
• Management:
o Treat with glasses to correct refractive error
o Patching is required if difference in the visual acuity persists after 4-8 weeks of using
spectacles
DEPRIVATION AMBLYOPIA (FORM AND OCCLUSION)
• Due to visual deprivation
• Ex. Congenital Cataract, Periocular hemangioma, Ptosis, Retinoblastoma, Occlusion
(from patching the good eye)
• Management:
o Manage or treat the etiology of the occlusion
RED REFLEX EXAMINATION • To identify:
o Retinoblastoma, Congenital or Infantile cataracts, Other ocular opacities and
ocular abnormalities
• ROR asymmetry or absence (leukocoria) may suggest: Error of refraction,
Retinoblastoma, Congenital or Infantile Cataract, Retinopathy of prematurity (ROP),
Retinal detachment, Coat’s disease (exudative retinitis), Toxocariasis, Retinal coloboma,
Persistent Hyperplastic Primary Vitreous (PHPV)
• These may all lead to amblyopia
EXTRAOCULAR MUSCLES Muscle Primary Secondary Tertiary
Medial Adduction __ __
Rectus
Lateral Abduction __ __
Rectus
Inferior Depression Excycloduction Adduction
Rectus /Extorsion
Superior Elevation Incycloduction Adduction
Rectus /Intorsion
Inferior Excycloduction Elevation Abduction
Oblique /Extorsion
Superior Incycloduction Depression Abduction
Oblique /Intorsion


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OPHTHALMOLOGY Pediatric Ophthalmology- Strabismus and Amblyopia LECTURE 7.1

 Mnemonics:
• Lahat ng Superior, Laging INtorsion
• Inferior ang EXtorsion mo
• Lahat ng may oBlique laging aBduction
• Primary Action – Principal effect the EOM has on eye rotation
• Secondary Action – Less effect
• Tertiary Action – Least effect
GENERALIZATIONS • Horizontal recti only adduct & abduct
• Vertical recti – main elevators & depressors of the eye
• Obliques – mostly for the torsion
• All recti are adductors.
• The oblique muscles are abductors.
• The superior muscles are intorters.
• The inferior muscles are extorters
• Mnemonics: RAD SIN = Rectus Muscles Adduct, Superior muscles (SO/SR) Intort
FIELD OF ACTION • 1° position of gaze – eyes look straight ahead with head and body erect
• Field of action of EOM – direction of gaze where the EOM exerts its greatest contraction
force as an agonist
• Synergist Muscle – EOMs within the same eye with the same field of gaze
• Yoke muscle – paired EOMs in both eyes that work together to a certain gaze direction
LAWS IN MOTOR SHERRINGTON’S LAW
PHYSIOLOGY • “Share” an eye
• Synergistic and Antagonistic Muscles
• Reciprocal innervations of antagonistic EOMs
• Antagonist is inhibited, while agonist is stimulated
HERING’S LAW
• Yoke’s Muscles
• Corresponding agonist EOMs receive equal innervations for eye movement in the same
direction
• Example: Left LR & Right MR for a left horizontal gaze

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