‫‪Strabismus‬‬

‫الدكتور‬
‫حسن عبد األمير المعمار‬
‫اختصاص طب و جراحة العيون‬
 Introduction
* Orthophoria  perfect ocular alignment in the
absence of any stimulus for fusion (uncommon).

* Heterophoria  tendency of the eyes to deviate

when fusion is blocked (latent)..slight phoria is
present in most normal individuals and is
overcome by the fusion reflex.

* Heterotropia  manifest deviation.

 Extra-ocular muscles
* There are 6 EOM  4 recti muscles (medial,
lateral, superior and inferior) and 2 obliques
muscles (superior and inferior).
* Innervations  3rd CN, 4th CN and 6th CN (L6
SO4).
* 5 of the 6 EOM (inferior oblique excepted)
originate at the orbital apex.
EOM
 Position of gaze
* There are 9 diagnostic position of gaze those
in which deviations are measured ( primary
position , elevation , depression , dextro-
version , levo-version , dextro-elevation , levo-
elevation , dextro-depression and levo-
depression ).
* The primary position is defined as the
position when the eye and head are both
directed straight ahead.
Gaze
 Strabismus adaptation
1. Sensory  the ocular sensory system in
children has the ability to adapt to anomalous
status (confusion and diplopia) by 2
mechanisms (suppression and abnormal
retinal correspondence).

2. Motor  adoption of an abnormal head

posture ( face turn / head tilt / chin elevation
or depression ).
AHP
 Amblyopia
* It is the developmental defect in the central visual pathways result in unilateral or rarely bilateral decrease in best
corrected visual acuity for which there is no identifiable pathology of the eye or visual pathway (absence of organic lesion).

* Causes :
1. Strabismus.
2. Anisometropia (difference in refractive error between the eyes).
3. Stimulus deprivation (opacities in the media like congenital cataract).
4. Bilateral ametropia (high symmetrical refractive errors and usually hypermetropia  bilateral amblyopia ).

* Diagnosis :
1. Difference in the VA between the 2 eyes by 2 Snellen lines.
2. Crowding phenomenon  reading single letter clearly.

* Treatment : ( the sensitive period during which acuity of an amblyopic eye can be improved is usually up to 7-8 years
).
(correction of significant refractive errors is an essential preparation for active amblyopia treatment).

1. Occlusion or patching of the better-sighted eye  is the most effective treatment…if there has been no improvment after
6 months of effective occlusion , further treatment is unlikely to be fruitful.
2. Penalization by atropine or fogging  for mild amblyopia 6/24 or better.
3. Low dose of oral Levodopa have been shown to augment the effect of occlusion therapy.
Amblyopia
Occlusion therapy
Clinical evaluation of strabismus
1. History (age of onset, …..).
2. Visual acuity (according to age …..).
3. Tests for stereopsis (like titmus fly test).
4. Tests for sensory anomalies (like Worth 4-dot test).
5. Measurement of deviation (like Hirschberg test and cover test).
6. Motility tests (ocular movements).
7. Investigation of diplopia (like Hess chart).
8. Refraction and fundoscopy.

* The earlier the onset strabismus, the more likely the need for
surgical correction.
Snellen charts
 Esotropia
* It is a manifest convergent squint (inward deviation) which is the most common form of strabismus, either concomitant
( same angle of deviation in horizontal gaze position) or incomitant ( the angle differs in various positions of gaze).

A. Accommodative  Refractive (hypermetropia between +2 to +7 DS that presented between age of 18 months till 3 years
which is treated by plus glasses) or non-refractive (high AC/A ratio which may require bifocal glasses).

B. Non-accommodative :

1. Infantile  within 6 months, no refractive errors, large angle, alternating and no limitation of ocular movement…
treatment ideally surgical by age of 1 year(even though bifoveal fusion is not achieved)…(sometime may require further
second session of surgical corrections).

2. Microtropia.
3. Convergence spasm.
4. Sensory.
5. Consecutive.
6. 6th cranial nerve palsy.
7. Duane syndrome type 1.
8. Mobius syndrome .
Esotropia
 Pseudo-squint
* It is a clinical impression of ocular deviation
when no squint is present.
Causes :
1. Epicanthal folds  may simulate an
Esotropia as in Orientals persons.
2. Abnormal interpupillary distance.
Pseudo-ET (epicanthal folds)
 Exotropia
* It is a divergent squint (outward deviation).

* Types :
1. Early onset (constant)  normal refraction, large and constant angle of deviation and
usually associated with neurological abnormalities … treatment mainly surgical.
2. Intermittent  around age of 2 years, exophoria breaks down to exotropia under
conditions of visual inattention…treated either by over-minus lenses to stimulate
accommodation and convergence with near exercise and training or surgical (the
exodeviation is rarely completely eliminated by surgery and results found to be
unsatisfactory to the patient or physician).

3. Sensory.
4. Consecutive.
5. Duane type 2.
6. 3rd cranial nerve palsy.
Exotropia
 Special types of strabismus
* Duane syndrome  (congenital anomalous innervation of LR by
fiber from 3rd cranial nerve).

* Brown syndrome  ( congenital mechanical restriction result in

impaired movement of the SO tendon through the trochlea).

* Mobius syndrome  multiple bilateral cranial nerves palsy like 7th

and 6th ).

* Paralytic Strabismus :
1. 6th cranial nerve palsy  esotropia.
2. 3rd cranial nerve palsy  exotropia.
3. 4th cranial nerve palsy  hypertropia.
4th CNP-Hypertropia
 Surgery
* To improve appearance and if possible to restore binocular single vision and also be
used to reduce an abnormal head posture.

1. Weakening procedures  like recession.

2. Strengthening procedures  like resection.
3. Vector adjustment  like transposition.

* Surgical results vary depending on criteria for success and length of follow-up.
Cosmetic success is often defined as an esotropia or exotropia of less than 15 prism
diopter and functional success is often defined as a small asymptomatic phoria less
than 10 prism diopter.
* Surgical success rates are dependent upon many variables, some of which are unique
to a given clinical situation.
* Patients who undergo surgery attain their final alignment within 1 – 6 weeks after
surgery.
Type of surgery
Reference/Kanski textbook