• Crossed eyes.

• Strabismus.
• Squint.
• Misaligned eyes.

DR. IRFAN SHAFIQ

FRCS, FCPS
Assistant Prof.Ophthalmology
 What is Strabismus?

• Normally visual axis of

the two eyes are
parallel to each other in
the ‘primary position of
gaze’ and this alignment
is maintained in all
positions of gaze.
• A misalignment of the
visual axes of the two
eyes is called squint or
strabismus.
Anatomy of the extraocular muscles

• They are 6 in number

• They control eye movements
• There are four recti and two
oblique muscles in each eye
• Arranged in 3 pairs
– Pair of horizontal recti (medial &
lateral)
– Pair of vertical recti (superior &
inferior)
– Pair of oblique (superior and
inferior)
 Extraocular muscles origin and insertion
• All four recti and superior
oblique have their origin at the
apex of the orbit, while
inferior oblique has its origin
at the nasal end of the
anterior orbital floor.

• The recti insert anterior to the

equator, at 7.5 mm (superior),
7.0 mm (lateral), 6.5 mm
(inferior), and 5.5 mm
(medial) behind the limbus.
• The obliques insert behind the
equator; the insertion of the superior
oblique tendon lies along the lateral
border of superior rectus, having been
reflected through the pulley of the
trochlea at the anterior nasal orbital
roof, and the insertion of inferior
oblique lies external to the macula.
• The superior oblique tendon passes
beneath the superior rectus, and the
inferior oblique passes beneath the
inferior rectus.
Nerve supply
The extraocular muscles are
supplied by third, fourth and sixth
cranial nerves.

The third cranial nerve

(Oculomotor) supplies the superior,
medial and inferior
recti and inferior oblique muscles.
The fourth cranial nerve (Trochlear)
supplies the superior oblique and
The sixth nerve (Abducent)
supplies the lateral rectus muscle
Blood supply
from muscular branches of
ophthalmic artery
ACTIONS OF EXTTAOCULAR MUSCLES

• The extraocular muscles

rotate the eyes around
three axes to produced
vertical (elevation &
depression), horizontal
(adduction & abduction)
and rotational (intorsion
& extorsion) movements
 ACTIONS OF EXTRAOCULAR MUSCLES
• The horizontal recti
produce purely horizontal
movements
• The vertical recti and the
obliques have vertical,
rotational, and horizontal
actions. Their principal effect
depends upon the horizontal
position of the eye in the
orbit, and therefore varies
with gaze position.
 PRIMARY AND SECONDARY ACTIONS OF
MUSCLES
• The primary action of the
horizontal rectus muscles is
horizontal. They have trivial
secondary or tertiary actions.

• The primary action of the

vertical rectus muscles is
vertical, and they have
secondary torsional and
horizontal actions.

• The primary action of the

oblique muscles is cyclorotation
(torsion) and they have
secondary vertical and
horizontal actions.
• Horizontal ductions
The horizontal recti are mainly
responsible for adduction and
abduction.
• Vertical ductions
The vertical recti act as pure
elevators and depressors in
abduction.
• Torsion
The superior rectus and superior
oblique act as intortors, and the
inferior rectus and inferior
oblique act as extortors.
 Types of Ocular movements
• Monocular (uniocular)
movements: ductions
– Adduction
– Abduction
– Supraduction (elevation)
– Infraduction (depression)
– Incycloduction
– Excycloduction

• Binocular movements
• Binocular movements
– Version
– Vergence
• Convergence
• Divergence
• Position of gaze
– Six cardinal position of
gaze
• Dextro version
• Levo version
• Dextro elevation
• Levo elevation
• Dextro depression
• Levo depression
– Nine diagnostic position
of gaze
• Nine diagnostic position of
gaze
– Primary
– Secondary
– Tertiary
• Dextro elevation
• Levo elevation
• Dextro depression
• Levo depression
• Binocular single vision (BSV)
– When a normal individual fixes his visual
attention on an object of regard, the image
is formed on the fovea of both the eyes
separately; but the individual perceives a
single image.
– Advantages of BSV
• Stereoscopic image
• Large field of vision
• Blind spot of each eye overlapped
• Better than uniocular vision
– Grades of BSV
• Grade I: simultaneous perception
• Grade II: fusion
• Garde III: stereopsis
– Anomalies of BSV
• Diplopia
• Suppression
• Amblyopia
•Amblyopia(lazy eye)
Refers to a partial loss of vision in one or both eyes, in the absence
of any organic disease of ocular media, retina and visual pathway.
–Pathogenesis
• The most sensitive period for development of amblyopia is first six months of life and it usually does not develop
after the age of 9 years.
–Types
• Strabismic amblyopia
• Stimulation deprivation amblyopia
• Anisometropic amblyopia
• Isoametropic ambylopia
–Treatmant
• Refractiv correction
• Occlusion of normal eye
• penalization
 Classification of strabismus
I. Apparent squint or
pseudostrabismus.
II. Latent squint
(Heterophoria)
III. Manifest squint
(Heterotropia)
Concomitant squint
Incomitant squint.
 Pseudostrabismus
• In pseudostrabismus (apparent squint),
the visual axes are in fact parallel, but
the eyes seem to have a squint:

1. Pseudoesotropia or apparent
convergent squint may be associated
with a prominent epicanthal fold
(which covers the normally visible
nasal aspect of the globe and gives a
false impression of esotropia).

2. Pseudoexotropia or apparent
divergent squint may be associated
with hypertelorism, a condition of
wide separation of the two eyes.
Heterophoria
In this condition, a tendency for deviation of the eye is present when
fusion is broken. However eyes regain normal alignment with fusion.

Latent convergent and divergent squint are, respectively,esophoria and

exophoria.

Heterotropia
Manifest deviation i.e. failure of the visual axes to meet at the fixation point.

Manifest convergent squint is described as esotropia, and manifest divergent

squint as Exotropia. Vertical squint is hypertropia and hypotropia

Concomitant
Constant angle of deviation irrespective of the direction of gaze (non-
paralytic).
Non concomitant
Variable angle of squint, according to gaze direction, paralytic squint is
Incomitant.
• Heterotropia (Menifest Squint)
– Etiological types
• Concomitant (Non paralytic) squint
• Non concomitant (Paralytic) squint

– Clinical types
• Esotropia
• Exotropia
• Hypertropia
• Hypotropia
• Incyclotropia
• Excyclotropia
 Non paralytic=concomitant squint

• Concomitant squint (non

paralytic)
– The deviation remains the same in
all direction of gaze
– Common Types
• Esotropia
• Extropia
– Etiology
• Refractive error
• Abnormal ratio of accommodative
convergence to accommodation (AC/A)
• Defective fusion mechanism
• Sensory problem (central corneal
opacity, congenital cataract,
retinoblastoma)
• Hereditary
– Examination
• Visual acuity assessment
• Assessment of Extraocular movement
• Cover uncover
• Hirschberg corneal reflection test
• Prism and cover test
• Krimsky corneal reflex test
• Synoptophores

– Cycloplegic refraction

– Fundus examination

– Determination of AC/A
 Non paralytic=concomitant squint

Esotropia= inward deviation

1-Congenital.
2-Accommodative (refractive, non-refractive,
mixed).
• Congenital / infantile
esotropia
• occurs during the first six
months of life
– Clinical features
• Angle of devation is larger
than 30 prism diopters
• Alternate fixation
• Cross fixation
• Refractive error; usually
normal for the age of child
– Treatment
• Surgical correction
• Accommodative esotropia
• Most common type of childhood squint
• Moderate amount of esotropia
– Types
• Refractive accommodative esotropia
• Non-refractive accommodative esotropia
• Mixed
• Refractive accommodative
esotropia
• Caused by accommodative
convergence associate
with hypermetropia
• Presents between 6
months and 7 years
• AC/A ratio is normal
• Treatmnet
– Glasses
– Amblyopia therapy
– Surgery
• Non-Refractive accommodative
esotropia
» Straight eyes for distance
» AC/A ratio is high
» BSV is reduced for near and
normal for distance
» Treatment
• Executive bifocal
glasses
• Amblyopia therapy
• Surgery
• Exotropia= outward
deviation
1-intermittant
2-constant
3-congenital
Intermittent exotropia
Most common type.
The average age of onset is about 2.5 years (range, 6 months-6 years.
The cause is unknown. It may be weakly hereditary.

The deviation may be unilateral or alternating

Eyestrain, blurring, headache, transient horizontal diplopia

Constant exotropia
• When intermittent exotropia is not treatment in time it may becomes constant
• Treatment
– Glasses
– Prism
– Orthoptic exercise
– surgery
Congenital exotropia
1. Rare
2. Present at birth
3. Angle of deviation is large
and constant
4. Alternative fixation
5. Normal refractive error
6. Neurological anomalies are
frequently present
7. Treatment (surgical)