Strabismus (Squint)

Strabismus: A condition in which

the visual axes of the eyes are not
parallel, and the eyes appear to be
looking in different directions

Orthophoria is a condition of binocular

fixation in which the lines of vision meet at
the object toward which they are directed,
and considered as a normal condition of
balance of the ocular muscles of the two eyes.

Orthophoria?? Strabismus??
 Binocular Single vision (BSV)
• 3 prerequisites for BSV:
1- functional Eyes >> 2 images on both retinae
should be identical (refraction, visual acuity, ..)
2- functional EOMs >> good balance to maintain 2
identical images falling on normal
corresponding retinal points.
3- functional CNS >> normal fusion center
perception of depth and
3-dimensional structure 
•Simultaneous perception
•Fusion
•stereopsis
•stereopsis
 Patterns of squint:
Eso- , exo- , hyper- , hypo-

Hypertropia Hypotropia
Diplopia
 Extrafoveal point

2 options
• If the brain saw both fovea at the same time 
confusion
• If the brain saw the fovea in on eye and the
Extrafoveal point in the other eye  diplopia
 Strabismus
A) Latent (heterophoria)  occur in sometimes when the brain loss
the control on eye alignment (case of illness , decreased immunity )
B) Manifest :
- false (apparent/pseudostrabismus)
- True : * Incomitant (paralysis, restrictive) 
change depend on the vision gaze

*concomitant (heterotropia) 
same degree in all directions
Comitant (or concomitant) strabismus is a deviation that is the same magnitude
regardless of gaze position. Noncomitant (or incomitant) strabismus has a magnitude
that varies as the person shifts his or her gaze up, down, or to the sides.
 Heterophoria
• Causes: -uncorrected errors of refraction
(hyprmetropia, myopia)
-congenital weakness of one or more of EOMs
• Symptoms :
- if compensated >> no symptoms
- if uncompensated >> asthenopia (eye strain),
blurred vision, intermittent squint, intermittent
diplopia
• Dx: Uncover test, Maddox wing test
• Tx: depends on compensation
Resolves with aging
Central light reflex
Cranial Nerve Palsies Incomitant

Left hypertropia
head tilt to right
 Lesions to CN III (oculomotor) result in ptosis , mydriasis and a
"down and out" gaze

gaze due to unopposed action of the lateral rectus and superior oblique;
ptosis due to denervation of levator palpebrae superioris

Most dangerous sign is mydriasis , as this indicated the

parasympathetic fibers are affected  means there is a
tumor compressing the nerve

3rd nerve palsy

• Pupil sparing  better  we can wait a week to see if
the condition will resolve b4 we do imaging

• Pupil involvement  worse  need imaging now

3rd nerve palsy 4th nerve palsy 6th nerve palsy

-ptosis If Right SO is affected If Rt LR is affected, C/P

C/P will be: will be:
-limitation of eye -Right hypertropia -right esotropia
movement in direction
of action of involved -limited depression in -limitation of
muscles adduction (much movement when pt
discomfort in going moves his eye to Rt
-the eye is laterally downstairs)
depressed -angle of squint is large
-abnormal head when Rt eye is fixing .
-dilation of pupil, posture: chin 2ry angle > 1ry angle
paralysis of depression, face turn to
accommodation Lt, head tilt to Lt -diplopia most marked
when pt looks to rt

-face turn to the right

Heterotropia (concomitant squint)
*Refractive cause (uncorrected errors of
refraction): - Hypermetropia -Myopia

*Non-refractive cause :
-congenital ( esotropia > exotropia)
-sensory (2ry to monocular impaired vision
>>> unilateral squint)
#sequelae:
-suppression – amblyopia – eccentric fixation
 Infantile Esotropia
• Onset within 6 months of birth
• Constant, large-angle esotropia
• Normal refractive error for age (mild
hyperopia)
• Treatment: surgical correction “bi-medial
rectus recession”
– Best at the age of 1 year , maximum until 2 years
 Accommodative (refractive) esotropia

• Examination reveals:
- hyperopia accommodation
convergence Esotropia
- Treatment: correct refractive error (convex
lenses)
 Sensory Esotropia
• Secondary to poor vision in the involved eye
• Possible causes: congenital cataract,
retinoblastoma
• Very bad prognosis
• Treatment: treat underlying cause
• Surgery to treat his strabismus
 Intermittent exotropia
• Exophoria becomes manifested under
conditions of illness, stress and daydreaming
• ‫بس يسرح بتطلع عينه لبرا‬
• Good prognosis : Most of the times the eye is
strait  suppression is low
• Progressive : With time the control gets worse
• Treatment: surgery if control deteriorated
 DUANE SYNDROME

 an eye movement disorder present at birth (congenital) characterized by horizontal eye

movement limitation. More in women
 The sixth cranial nerve that controls the lateral rectus muscle does not develop properly.
 Irregular innervation of a branch from the third cranial nerve, which controls the medial
rectus muscle may also associated.
 S&S : absent ability to move their eye temporally. (ie, abduction), Retraction of the 
eyeball into the socket , with associated narrowing of the palpebral fissure upon
adduction , some have a limited ability to move the same eye nasally .
 Many patients with Duane syndrome develop a habit of turning their face to maintain
binocular vision and thus compensate for improper turning of the eyes. 
 80% of all cases of Duane syndrome, only one eye is affected, most often the left eye.
 In 70% of cases, Duane syndrome is an isolated condition. However, other conditions and
syndromes have been associated with Duane syndrome. These include malformation of the
skeleton, ears, eyes, kidneys, and nervous system
 DUANE SYNDROME
 Duane syndrome is often clinically divided into 3
types :
 In Duane syndrome type 1, the ability to move the
Retraction of the eyeball into the socket ,
with associated narrowing of the palpebral
fissure upon adduction

affected eye temporally (abduction) is limited /

most common
 Standard management of Duane syndrome may
involve observation /no need for intervention ,
treatment of amblyopia and refractive errors or
possibly surgical correction .
 Surgery indications :

1. Strabismus at primary position of gaze 

2. Abnormal head position absent ability to move their eye temporally

3. Cosmetic
4. Reduction of severe retraction
 BROWN SYNDROME
 restriction of the superior oblique trochlea-tendon complex such that the affected eye
does not elevate in adduction due to shortening or tightening of the anterior superior
oblique tendon.
 Pts may exhibit compensatory head tilt away from the affected eye and, occasionally,
amblyopia.
 Usually unilateral but can be bilateral.
 Congenital > than acquired Brown syndrome
 A tight or inelastic superior oblique tendon muscle complex would restrict ocular
elevation in adduction.
 acquired Brown syndrome with signs of inflammation can be treated with anti-
inflammatory medication. Oral ibuprofen is a good first-line choice , Consider surgery
for long-standing cases.
 Congenital Brown syndrome is unlikely to improve spontaneously; therefore, surgery
is important to consider as an option : lengthen the tendon and release the restriction.
 The most important indications for surgery are the presence of chin elevation and
severe limitation of elevation in adduction, which significantly interferes with the
quality of life.
BROWN SYNDROME

Right brown syndrome

Two options
• tight or inelastic superior oblique tendon muscle  if
there was restriction when we tried to elevate it

• Inferior oblique palsy  if under anesthesia we were

able to elevate the eye