Strabismus

Prepared by:
Adolf Joshua Oliveros
 Definition
• A disorder in which the eyes do not line up
in the same direction when focusing
• Commonly known as CROSSED EYES,
WALL EYE
 Description
• Lack of coordination between the eyes
 The eyes look in different directions and
do not focus at the same time on a single
point
 Etymology
• Strabismus  to squint
 Causes
• Unknown
• Hereditary
In Adults:
• May develop strabismus from eye or blood
vessel damage. Loss of vision, an eye or
brain tumor, stroke, and various muscle
and nerve disorders can also cause
strabismus in an adult.
 Risk Factors
• Family with strabismus
 Symptoms
• Crossed eyes
• Double vision
• Eyes that do not align in the same
direction
• Uncoordinated eye movements (eyes do
not move together)
• Vision loss in one eye, includes a loss of
the ability to see in 3-D (loss of depth
perception)
 Types
1. Horizontal Strabismus
– Exotropic is outwards (away from the midline)
– Esotropic is inwards (towards the nose)
2. Vertical Strabismus
– Hypertropia is upward
– Hypotropia is downward
 Diagnostic Tests
1. Hirschberg test (Hirschberg corneal reflex test)
 Is a screening test that can be used to assess whether
a person has strabismus (ocular misalignment)
 Developed by German ophthalmologist Julius
Hirschberg who in 1886 used a candle to observe the light
reflex in an eye with strabismus
Steps:
A flashlight is shone in the patient's eye
When the patient is looking at the light, a reflection can be
seen on the front surface of the pupil.
Interpretation:
(+)  Positive Hirschberg sign: the light falls on the
centre of the right pupil, but is medial to the centre of the
left pupil
(-)  Negative Hirschberg sign: the light reflects from
congruent points in both lenses.
2. Alternating Cover Test
 Objective determination of the presence and
amount of ocular deviation
Steps:
Having the child (typically) focusing on a near object.
A cover is placed over an eye for a short moment
then removed while observing both eyes for movement.
The "lazy eye" will wander inwards or outwards, as it
begins to favor its perceptive visual preference.
The process is repeated on both eyes and then with
the child focusing on a distant objects.
 Medical Management
1. Botulinum toxin (Botox)
• Classification: Muscle relaxants
• Indication: Treatment of disorders of ocular
muscle including strabismus
• Adverse Effects: Localized pain, tenderness &/or
bruising, local weakness
• Intervention:
a. Inform patient that it may cause excessive
weakness or atrophy in target muscle
2. Atropine (Isopto eyedrops)
• Classification: Mydriatic Drugs
• Action: Atropine is an anticholinergic agent which
competitively blocks the muscarinic receptors in
peripheral tissues such as the heart, intestines,
bronchial muscles, iris and secretory glands.
• Adverse Reaction: dry mouth, dysphagia,
constipation, flushing and dryness of skin,
tachycardia, palpitations, arrhythmias, mydriasis,
photophobia, cycloplegia, raised intraocular
pressure
• Intervention:
• a. May be taken with or without food. (Take w/ food
or water.)
 Surgical Management
• Surgeon loosens or tightens the muscles
attached to the eye by changing their length or
position. Changing the pull of the muscles can
bring the eyes back into line with each other.
• A child may need more than one surgery to
realign the eyes and improve vision and may
have to start or continue wearing glasses after
the surgery.
• Strabismus in very young children sometimes
disappears on its own as development
continues.
 Nursing Management
A. Situational Low Self Esteem R/T Disturbed Body Image
• Planning: To be able to express positive self-appraisal
• Interventions:
a. Convey confidence in client’s ability to cope with
current situation
b. Encourage use of visualization, guided imagery and
relaxation
c. Assist client to problem solve situation, developing
plan of action and setting goals to achieve desired
outcome
B. Risk for loneliness R/T Social Isolation
• Planning: To be able to engage in social
activities
• Interventions:
a. Convey confidence in client’s ability to
cope with current situation
b. Involve in classes such as
assertiveness, language and social skills.
C. Impaired social interaction R/T Self-concept
disturbance
• Planning: To be able to give self positive
reinforcements for changes that are achieved
• Interventions:
a. Have client list behaviors that cause discomfort
b. Help client prioritize those behaviors needing
change
c. Provide positive reinforcement for improvement
in social behaviors and interactions
 Prognosis
• When strabismus is congenital or develops in infancy, it
can cause amblyopia, in which the brain ignores input from
the deviated eye. Strabismus can lead to a permanent
weakening of vision in the strabismic eye called amblyopia
sometimes referred to as lazy eye. The appearance of
strabismus may also be a cosmetic problem. One study
reported that 85% of adult strabismus patients "reported
that they had problems with work, school and sports
because of their strabismus." The same study also
reported that 70% said strabismus "had a negative effect
on their self-image.
• With early diagnosis and treatment, the problem can
usually be corrected. Delayed treatment may lead to
permanent vision loss in one eye.
 Research
• Strabismus in Adults
• (Nov.3,2007-David Marshall)
• Dr. David Guyton at the Wilmer Eye Institue of Johns Hopkins sent
this to me along with some other articles, but this one is a very
powerful reminder of how crippling strabismus can be to those of us
who suffer from it. It is a study conducted by George R Beauchamp,
MD, Joost Felius, PhD, David R Stager, Sr, MD,and Cynthia L
Beauchamp, MD from the Department of Ophthalmology, University
of Texas Southwestern Medical Center (Dr G. Beauchamp, Dr
Felius, Dr Stager, Dr C. Beauchamp), and the Retina Foundation of
the Southwest (Dr Felius), Dallas, Texas.
• About 60% of all patients indicated willingness to trade part of their
life expectancy in return for being rid of strabismus and its
associated effects.
Thank you!