Dr Jusuf Wijaya , SpM

FK - UKI
Cawang
Curriculum Vitae
1994 : Dokter Umum , Vrije Universiteit Brussel
(Belgia)
1999 : Dokter Spesialis Mata , Vrije Universiteit
Brussel (Belgia)
2001 : Fellow Ilmu Bedah , Foundation Eye
Care Himalaya (Belanda Nepal)
2002 : Fellow di bidang Glaukoma , Rotterdam
Eye Hospital (Belanda)
2004 : Adaptasi (penyesuaian) , Universitas
Sam Ratulangi (Manado)
I. Fysiology of the Ocular Muscles
II. Definition of Strabismus
III. Classification of Strabismus
There are six extraocular muscles which act to
turn or rotate an eye about its vertical,
horizontal, and antero-posterior axes:
1. Medial Rectus (MR)
2. Lateral Rectus (LR)
3. Superior Rectus (SR)
4. Inferior Rectus (IR)
5. Superior Oblique (SO)
6. Inferior Oblique (IO)
The Six Extraocular
Muscles
 Nervus III :
- Musculus rectus superior
(1)
- Musculus rectus inferior (2
- Musculus rectus medialis
(3)
- Musculus obliquus inferior
Nervus IV :
- Musculus obliquus
superior(5)
Nervus VI :
- Musculus rectus lateralis (
Nervus II :
- N Opticus (7)
A given extraocular muscle moves an eye in a
specific manner, as follows:
1. Medial Rectus (MR)
- moves the eye inward, toward the nose (adduction)
2. Lateral Rectus (LR)
- moves the eye outward, away from the nose
(abduction)
3. Superior Rectus (SR)
- primarily moves the eye upward (elevation)
- secondarily rotates the top of the eye toward the
nose (intorsion)
- tertiarily moves the eye inward (adduction)
4. Inferior Rectus (IR)
- primarily moves the eye downward (depression)
- secondarily rotates the top of the eye away from
the nose (extorsion)
- tertiarily moves the eye inward (adduction)
5. Superior Oblique (SO)
- primarily rotates the top of the eye toward the nose
(intorsion)
- secondarily moves the eye downward (depression)
- tertiarily moves the eye outward (abduction)
6. Inferior Oblique (IO)
- primarily rotates the top of the eye away from the
nose (extorsion)
- secondarily moves the eye upward (elevation)
- tertiarily moves the eye outward (abduction)
Each extraocular muscle is innervated by a specific
Cranial Nerve (C.N.):
- Medial Rectus (MR) : cranial nerve III (Oculomotor)
- Lateral Rectus (LR) : cranial nerve VI (Abducens)
- Superior Rectus (SR) : cranial nerve III
(Oculomotor)
- Inferior Rectus (IR) : cranial nerve III (Oculomotor)
- Superior Oblique (SO) : cranial nerve IV (Trochlear)
- Inferior Oblique (IO) : cranial nerve III
(Oculomotor)
Ductions
When considering each eye separately, any
movement is called a duction.

Versions
When considering the eyes working together, a
version or conjugate movement involves
simultaneous movement of both eyes in the
same direction.
There are six principle versional movements
where both eyes look or move together in the
same direction, simultaneously:
1. Dextroversion (looking right)
- right lateral rectus
- left medial rectus
2. Levoversion (looking left)
- left lateral rectus
- right medial rectus
3. Dextroelevation (looking right and up)
- right superior rectus
- left inferior oblique
4. Dextrodepression (looking right and down)
- right inferior rectus
- left superior oblique
5. Levoelevation (looking left and up)
- right inferior oblique
- left superior rectus
6. Levodepression (looking left and down)
- right superior oblique
- left inferior rectus
Vergences
A vergence or disconjugate movement
involves simultaneous movement of both eyes
in opposite directions.
There are two principle vergence movements:
- Convergence - both eyes moving nasally or
inward
- Divergence -both eyes moving temporally or
outward
I. Fysiology of the Ocular Muscles
II. Definition of Strabismus
III. Classification of Strabismus
 Strabismus
Strabismus is a visual disorder where the eyes are
misaligned and point in different directions. This
misalignment can occur part of the time
(intermittent) or all of the time (constant).

Strabismus occurs in approximately 2% of children

under 3 years of age and about 3% of children and
young adults, affecting boys and girls equally.
Strabismus
Normal alignment of both eyes during childhood
allows the brain to fuse the two pictures into a
single 3-dimensional image. This allows a high
degree of depth perception.
Strabismus (heterotropia)
Normally, when viewing an object, the lines of
sight of both eyes intersect at the object; that is,
both eyes point directly at the object being
viewed. An image of the object is focused upon
the macula of each eye, and the brain merges
the two retinal images into one.
Sometimes, however, due to some type of
extraocular muscle imbalance, one eye is not
aligned with the other eye, resulting in a
strabismus, also called a heterotropia or
simply tropia.
In children, when the two eyes fail to focus on the
same image, the brain may learn to recognize the
stronger image and ignore the weaker image of
the amblyopic eye, to avoid double vision. If this
is allowed to continue, the eye that the brain
ignores will never see well. This loss of vision is
called amblyopia.
Amblyopia results if vision from one eye is
consistently suppressed and the other eye
becomes dominant.
Among children with strabismus, one-third to one-
half develop amblyopia.
If strabismus develops for the first time in
adulthood, the affected individual usually
experiences double vision ; diplopia .
Because the brains of adults are already
developed for vision, the problems associated
with amblyopia, in which the brain ignores input
from one eye, do not occur with adult
strabismus.
I. Fysiology of the Ocular Muscles
II. Definition of Strabismus
III. Classification of Strabismus
 III.Classification of
Strabismus
1. Classification according to the direction of
misallignment
2. Other classification :
Strabismus Paralyticans
Strabismus Concomitans
Strabismus is classified according to the
direction of misalignment.
When one eye is looking straight ahead;
- the other eye may turn inward (esotropia or
convergent strabismus)
- outward toward the ear (exotropia or
divergent strabismus)
- downward (hypotropia)
- upward (hypertropia).
This child has a right esotropia. The child is looking at you with
their left eye. The right eye is turned in towards the nose
In the right picture, the child is fixating with their right eye. In
this position, it is the left eye which is esotropic.
A child can be made to alternate between the eyes simply by
covering the left eye when it is fixating (left picture) thus
forcing the right eye to fix (right picture).
The ability of the child to keep either eye in the straight ahead
position for a while indicates that there is no weakness of vision
in either eye.
Pseudoesotropia is a common condition in infancy
and early childhood in which the child appears to
have crossed eyes due to a wide bridge of the nose
and/or epicanthal folds. This causes the medial
sclera to be hidden when the child looks just off
centre and therefore the eyes appear to be crossed.
This patient may look like he has crossed eyes but in
fact the eyes are straight.
Exotropia (picture on the left)
Hypertropia (picture on the right)
Acquired strabismus in adults can be caused by:
- injuries to the orbit of the eye
- braininjury (including closed head injuries and
strokes).
People with diabetes often have loss of circulation
causing an acquired paralytic strabismus.
Loss of vision in one eye from any cause will
usually cause the eye to gradually turn outward
(exotropia).
Strabismus can be caused by :
- problems with the eye muscles
- problems with the nerves that control the eye
muscles
- problems with the brain, where the signals for
vision are processed.
Strabismus can accompany some illnesses such as:
- high blood pressure
- multiple sclerosis
- myasthenia gravis
- thyroid disorders.