STRABISMUS/SQUINT

Dr. Nyoman Sunerti, Sp.M Strabismus Division, Opthalmology Departement Udayana Medical Faculty

Strabismus/Squint

Is a misalignment of the eyes Misalignment may be in any direction - inward - outward - upward - downward Strabismus: ocular misalignment

Abnormality of binocular vision Anomalies of neuromuscular control of ocular motility

Extraocular Muscle

There are six extra ocular muscle plays a role in eye position - Medial Rectus --------------- N III - Superior Rectus --------------- N III - Inferior Rectus --------------- N III - Inferior Obliq --------------- N III - Superior Obliq -------------- N IV - Lateral Rectus -------------- N VI

Strabismus, Terms
1. Fusional Status
Phoria, intermitten tropia, tropia 2. Fixasi Alternating, monocular 3. Type Deviasi Horisontal: esodeviasi/exodeviasi Vertical: hyperdeviasi/hipodeviasi Torsional: incyclodeviasi/excyclodeviasi Combine: horisontal, vertical, torsional 4. Age onset: congenital, acquired

Functions of the ocular muscle

Law of ocular motility

Yoke Muscles Are pairs of muscles, one in each eye, that produce conjugate ocular movement Hering Law Of equal innervation states that during any conjugate eye movement, equal and simultanius inervation flow to the yoke muscle

Main fields of action ektraocular muscle

Yoke muscles in cardinal positions of gaze

Examination of strabismus

History is important in the diagnosis of strabismus

Family history Strabismus and ambliopia frequently found to occur in families Age at onset The earlier the onsert of strabismus, the worse the prognosis Type of onset The onset my be gradual, sudden, or intermitent Type of Deviation Fixation One eye may constantly deviate or aternating fixation

Determination of angle of strabismus

A. B.

Prisma and Cover tests Objective test

Cover test consist four parts 1. The cover test 2. The un cover test 3. The alternate cover test 4. The Prism cover test

Cover test

The examiner observes one eye A cover is placed in front of the other eye If the observed eye moves to take up fixation

COVER TEST
A. Normal B. Right eye Normal C. Left Eye Normal D. Right Eye Esotropia

E. Right Eye Eksotropia

F. Right Eye Hypertropia G.Right Eye Hypotropia

Objective test

Hirschberg Method A pen torch is shone into the eyes and the patient fixate the light. The corneal reflection of the light will be centered in the pupil of the fixating eye, but will be decentered in a squinting eye.

Hirschberg test
Rough measure of deviation Note location of corneal light reflex

Reflex at border of pupil = 15

Reflex at limbus = 45

HIRSCHBERG TEST

Sensory Changes in Strabismus

Up to age 7 or 8 the brain usually develop respons to ab normal binocular vision that may occur if the onset of strabismus is later. This canges include

diplopia supresion Anomalous retinal correspondence Eccentric fixation

Ambliopia

Is a unilateral or bilateral reduction of best corrected visual acuity, that caused be attributed to the effect abnormality of the eye Caused by abnormal visual experience early in life, resulting from
Strabismus Anisometropia (High bilateral refractive errors) Visual deprivation Treatment : Occlusion therapy, the sound eye is covered with patch to stimulate the ambliopic eye

Treatment of Strabismus

Non surgical - Eye glasses - Occlution Surgical

Principles of squint sugerys

Recesion Slackens of muscle by moving its insertion to ward its origin

Resection Shorten a muscle to enchance its effective pull

Esotropia

The most common type of strabismus more than 50% of deviation in pediatric population The causes can result from abnormality of inervational, anatomical, mechanical, refractive and accommodative

Mayor type of Esodeviation

1.

2. 3.

Accomodative (Refraktive and Non Refraktive) Non Accomodative (Basic, acute) Incomitant esotropia (Sixth cranial nerve paralysis, medial rectus restriction)

Exotropia

The most common type of exodeviation is intermittent exotropia Which is latent at time and manifest at other Onset is usually occurs early

Classification

Basic type : Exodeviation approximately the same at distance and near fixation Divergence excess type Exodeviation that is greater at distance fixation than at near Convergence insufficiency type Is Present when the exodeviation is greater at near than at distance