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Fundamental of Clinical Ophthalmology .. Strabism
Fundamental of Clinical Ophthalmology .. Strabism
Strabismus
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INTRODUCTION
In normal binocular single vision (BSV) the two visualaxes intersect at the point of
fixation, with the imagesfrom the two eyes being aligned by the fusion reflex and
combined by binocular responsive cells in the visualcortex to give BSV.
Definitions
Orthophoriaimplies perfect ocular alignment in the absenceof any
stimulus for fusion; this is uncommon.
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Axes of the eye
Visual axis
passes from the fovea, through the nodal point of the eye
to the point of fixation (object of regard).
The fovea is usually slightly temporal to the geometrical
center of the posterior pole so that visual axis cuts cornea
slightly nasally.
ANATOMICAL AXIS ( pupillary axis) Is a line passing from
the posterior pole through the center of the cornea.
Because the fovea is usually slightly temporal to the
anatomical center of the posterior pole of
the eye , the visual axis does not usually correspond to the
anatomical axis of the eye.
Optic axis:line passing through the center of the cornea
(P), center of the lens(N), and meets the retina on the nasal
side of the fovea.
Fixation axis: line joining the fixation point(O), and the
center of rotation(C).
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The angle is 'positive' when the fovea is temporalto the center of the
posterior pole resulting ina nasal displacement of the corneal reflexand
'negative' when the converse applies .
ANGLE KAPPA
A large angle kappa may give the appearance ofa squint when none is
present ( pseudosquint ) and is seen most commonly asa pseudo-
exotropia following displacement ofthe macula in ROP where the angle
maysignificantly exceed + 5 degrees.
Orbital bones
Angle of the medial and lateral walls of the orbit is 45°, so the orbital
axis forms approximately 23°with both medial and lateral walls.
The orbits are parallel to each The medial walls of 2 other.
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Basic knowledge of ocular motility
Extraocular muscles
• Not playing role in vision procedure directly,
but critically important for eyeball motility and
binocular vision function.
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Anatomy of extraocular muscles
There are six extraocular muscles for the human
eye.
Namely:
– Medial rectus m.
– Lateral rectus m.
– Superior rectus m.
– Inferior rectus m.
– Superior oblique m.
– Inferior oblique m.
Extraocular Muscles
4 rectus muscles - origin is in the common
tendous ring (annulus of Zinn)
– Oval ring of connective tissue
– Continuous with periorbita
– Anterior to optic foramen
Medial and lateral rectus attached to both the
upper and lower tendon limbs.
The muscles traveling from the this tendon
ring to the insertions create muscle cone.
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Medial Rectus:
• Originates on both the upper and lower limbof the common tendous
ring and the opticnerve sheath.
• Length 40 mm , thicker than other EOM
• Inserts along a vertical line 5.5 mm from thecornea.
• Fascial expansion from muscle sheath formsthe medial check ligament
and attach tomedial wall of orbit.
Lateral rectus
• Originates on both the upper and lower limb of the common tendous
ring. And a process of the greater wing of thesphenoid bone.
• parallels the lateral orbital wall until it passes through a connective
tissue pulleyjust posterior to the equator of the globe; at this point it
follows the curve of theglobe to its insertion.
• Inserts parallel to medial rectus 6.9 mm from the cornea.(Tendon 9.2
mm wide, 8.8 long).
• Fascial expansion from muscle sheath forms the lateralcheck ligament
and attach to lateral wall of orbit atWhitnalls tubercle.
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Superior Rectus
• Originate on superior limb of the tendonousring, and optic nerve
sheath.
• Muscle passes forward underneath thelevator, but the two sheaths are
connectedresulting in coordinated movements.
• Insertion 7.4 mm from limbus, and obliquely.
• The angle from the origin to the insertion is23° beyond the sagital axis.
• Frontal nerve runs above the SRand levator.
• The nasociliary nerve and ophthalmic arteryrun below.
• The tendon for insertion of the superioroblique muscle runs below the
anterior partof the superior rectus.
• Innervation is via superior division of CN III,from the inferior surface;
additional branchesmake their way to the levator.
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When the globe is abducted to 23°, the visual and orbital
axiscoincide. In this position superior rectus acts as a pureelevator.
If the globe were adducted to 67° the angle between thevisual and
orbital axis would be 90° In this position SRwould act as intortor.
Inferior rectus
• Originates on lower limb of commontendonous ring.
• Inserts 6.7 mm from limbus, insertion is an arc
• It is parallel to superior rectus, making a 23°angle beyond the sagittal
axis.
• Innervated by inferior division of CN III whichruns above it (within the
muscle cone).
• Below is the floor of the orbit and inf. oblique
• Fascial attachments below attached to inferior lid coordinate
depression and lid opening.
• Fascia below Inf. Rectus and Inf. Oblique contribute to the suspensory
ligament oflockwood.
• Primary Action downward gaze depression
• Secondary action: Adduction, as is the casefor SR.
• Also extorsion due to oblique arc of insertion.
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Spiral of Tillaux
• The rectus muscle pass through tenon’scapsule and insert into the
sclera.
• The muscles insert at different distances fromthe cornea.
• The insertion pattern is a spiral with themedial rectus closest to the
cornea (5.5 mm)and the superior rectus the furthest away
from the cornea (7.4 mm).
Superior Oblique
• Anatomical origin is on the lesserwing of the
sphenoid bone. Thephysiological origin is the
trochlea, a cartilagenous “U” on the
superiormedial wall of the orbit.
• Longest thinnest EOM, the muscleends before
the trochlea, tendon is2.5 cm, smooth
movementthroughtrochlea.
• Innervation by CN IV,
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Action of SO:
• Primary action is intorsion _ rotation of 12o’clock position
toward midline.
• Because the insertion of the oblique muscle isin the lateral,
posterior quadrant thesecondary actions are
– Rotating the back half of the globe from lateral tomedial (the
anterior pole will move away)abduction.
– Also depression (posterior superior quadrant ofthe globe being
pulled upward).
○ When the globe is adducted 51°, the visual axis coincideswith the line
of pull of the muscle. In this position it can act only as a depressor.
○ When the eye is abducted 39°, the visual axis and thesuperior oblique
make an angle of 90° with each other. In this position the superior
oblique can cause onlyintorsion.
Inferior Oblique
• Originates on the maxillary bone inferior to the nasolacrimal fossa. The
ONLY EOM originating in the anterior orbit.
• Inserts on the posterior lateral aspect of globe mostly inferior, below
the ant.-post. Horizontal plane.
• Innervation from inferior division of CN III inserts on the upper surface
(within muscle cone.)
•Action of Inf. Oblique:
- Primary is extorsion
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- Secondary action is due to posterior, lateral,inferior insertion being
pulled around,underneath globe and toward the anterior
inferior insertion medially.
- Rotation about the Z axis will be nasal totemporal (abduction).
- Rotation about the X axis will be elevation.
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MUSCLE PULLEYS
The four rectus muscles pass throughcondensations of connective tissue
and smoothmuscle just posterior to the equator. These condensations
act as pulleys and minimizeupward and downward movements of the of
thebellies of the medial and lateral rectus muscles during up-gaze and
down-gaze, andhorizontal movements of the superior rectus and
inferior rectus bellies in Left and right gaze .
Pulleys are the effective origins Of the rectus muscles and play an
important role in thecoordination of eye movements by reducingthe
effect of horizontal movements on vertical muscle actions and vice
versa.
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Displacement of the pulleys can be one cause ofabnormalities of eye
movements such as V and A patterns.
OCULAR MOVEMENTS
DUCTIONS:
Ductions are monocular movements around the axes ofFick . They
consist of adduction , abduction ,elevation , depression , intorsion and
extorsion .They are tested by occluding the fellow eye and askingthe
patient to follow a target in each direction ofgaze .Torsional ductions are
mainly observed in associationwith other abnormal eye movements.
VERSIONS:
Versions are binocular, simultaneous, conjugatemovements ( in the
same direction ) .
Dextroversion and laevoversion ( gaze right, gaze left ), elevation ( up-
gaze ) anddepression( down-gaze ).
These four movements bring the globe into thesecondary positions of
gaze by rotationaround either a vertical Z or a horizontal X axis
of Fick .
Dextroelevation and dextrodepression ( gaze upand right , gaze down
and right ) andlaevoelevation and laevodepression ( gaze up
and left and gaze down and left ).
These four oblique movements bring the eyesinto the tertiary positions
of gaze by rotationaround oblique axes lying in Listing plane,equivalent
to simultaneous movement aboutboth horizontal and vertical axes .
Torsional movements to maintain uprightimages occur on tilting of the-
head . These are known as the righting reflexes. On head tilt tothe right
the superior limbi of the two eyes rotate to the left, causing intorsion of
theright globe and extorsion of the left.
VERGENCES
Vergences are binocular , simultaneous ,disjugate or disjunctive
movements ( in opposite directions).
Convergence is simultaneous adduction ( inward turning ),divergence is
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outwards movement from a convergent position.
Convergence may be voluntary or reflex. Reflex convergence has four
components:
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accommodation is associated with 3-5 prism diopters of accommodative
convergence .
Calculated/Heterophoric method:
• AC/A = IPD (cm) + N (m) (D’-D)
IPD = interpupillary distance in centimeters
N = near fixation distance in meters
D’ = near phoria (eso is plus and exo is minus)
D = distance phoria (eso is plus and exo is minus)
NOTE:
-Be sure to use the correct signs for Eso and Exo.
-Be sure to use correct unit.
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– Example: IPD = 60 mm, the patient is 2Δ exophoric
at distance and 10Δ exophoric at near (40 cm)
AC/A = 6 + 0.4(-10 - (-2))
= 6 + 0.4(-10 + 2)
= 6 + 0.4(-8) = 6 + (-3.2)
= 2.8
CONVERGENCE EXCESS:
n>d esotropia
high AC/A ratio
EX: 3EP(D)-16EP’(N)
Treatment
Near add (overcorrection of plus poweror under correction of minus
powermost effective
Base-out prism (alternative method )
Base-in training(not so effective)
DIVERGENCE INSUFFICIENCY
n <d esotropia
low AC/A ratio
EX: 8EP-3EP’
Treatment
Base-out prism.
CONVERGENCE INSUFFICIENCY
n>d exotropia
Low AC/A ratio
EX:3XP(D)-15XP’(N)
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Treatment:
Base-out training (most effective)
“ Pencil push-up” training.
DIVERGENCE EXCESS
n<d exotropia
high AC/A ratio
EX:15XP(D)-5XP’(N)
Treatment:
overcorrection of minus power orundercorrection of plus power
in mild case base-in prism for full time wear.
Gradient method:
– Phoria is measured a second time using a -1.00/+1.00 lens.
– The change in phoria with the additional minus or
plus is the AC/A ratio.
AC/A=(a-a')/F
a= phoria at near.
Response vs Stimulus
• Alpern et.al (1959) found that the accommodativeresponse will be
about 10% less than the stimulus. Thuswhen we measure
accommodative response directlywe find for a +2.50 D (40 cm) stimulus
there will be alag of accommodation of about +0.25 to +0.75D
– Clinically we measure the stimulus AC/A.
• Clinical Examples:
Case1:
• AC a 7 year old girl presents with complains of
headaches and eye strain with near work
• Unaided VA’s
OD 20/20
OS 20/20
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• Cover test at distance ortho and 5EP' at near
• IPD=53mm
AC/A- calculation
AC/A = 5.3 + 0.4(5 - 0)
= 5.3 + 0.4(5)
= 5.3 + 2
= 7.3/1
-High AC/A
-Convergence excess
•Gradient:
Trial frame + 1.00 DS
Remeasure CT at near find?
AC/A=(5-(-2))/1
=7/1
• Treatment
– Rx +1.00 DS OU for near only
– RTC 1 month.
CASE 2:
• TA a 8 year old boy presents with complaints of
headaches and eye strain with near work
• Unaided VA’s at distance
OD 20/50
OS 20/50
At near 20/20 OD,OS,OU
• Cover Test: 2XP @distance/10XP’ @near
• IPD=54mm
• Examination findings:
• Refraction:
– OD: -1.50 DS 20/20
– OS: -1.50 DS 20/20
• Management
– Rx -1.50 DS OU
– RCT 1 month
– What do we expect?
• Treatment;
– Vision Therapy.
• Treat the compensating vergence.
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Eye position for examination
• Primary position:
– With condition in which head being put vertically and straightforward
and two eyes looking straightforward.
• Secondary position:
– The two eyes being in adduction or abduction or elevation or
depression position.
• Tertiary position:
– Two eyes gazing in oblique directions (up or downward).
POSITIONS OF GAZE:
SIX CARDINAL: positions of gaze are those in which one muscle in each
eye has moved the eye into that position as follows :
- Dextroversion ( right lateral rectus and left medial rectus ).
- Laevoversion ( left lateral rectus and right medial rectus ).
- Dextroelevation ( right superior rectus and left inferior oblique ).
- Laevoelevation ( left superior rectus and right inferior oblique ).
- Dextrodepression ( right inferior rectus and left superior oblique).
- Laevodepression ( left inferior rectus and right superior oblique).
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Terminology of extra-ocular muscle regarding their
physiological functions
• Antagonist m:
– the muscle that counteracts the agonist (or the prime mover);
– lengthening when the agonist muscle contracts.
– e.g., medial rectus and lateral rectus muscles.
• Yoke m:
– The contra-laterally paired extra-ocular muscles of two fellow eyes
thatwork synergistically to direct the gaze in a given direction.
– Example: in directing the gaze to the right, the right lateral rectus and
left medial rectus operate together as yoke muscles.
• Synergist m:
– The muscles moving one single eye ball in the same direction as the
prime moving muscle.
– e.g., inferior oblique m. is the synergist of
superior rectus m. when the
eye turns upward.
Hering law:
• The yoke muscles are innervated equally by nervous
system in eye movement.
Muscle sequelae
Are the effect of interactions described by these laws.they are of
prime importance in diagnosing ocular motility disorders and in
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particular in distinguishing a recent acquired palsy from long
standing one
For example
In left superior oblique palsy( left 4th nerve palsy)
Primary underaction left SO
Secondary contracture of unopposed direct antagonist (left I O)
Secondary contracture of contralateral synergist yoke muscle(right
IR)
Secondary inhibitional palsy( right SR)
BINOCULAR VISION
Vision is based on the retinal imageformed in each eye, and monocular
visionalone provides us with much significantdata.
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visual fields, and it is in this overlap area that we have stereopsis
(depth perception).
Stereopsis. Stereopsis is the highly accurate senseof depth
perception that is unique to binocularvision, and is considered the
most significantadvantage gained by binocular vision.
Minor Advantages:
Spare eye:
◦ If one eye is lost to injury or disease, we will still beable to see
well with the other.
Binocular summation:
◦ Certain aspects of vision are improved because of theadditional
input provided by the second eye. Theimprovement may be small,
but it definitely improvesthe quality of vision.
◦ Suprathreshold binocular summation
1. Visual acuity
2. Contrast sensitivity
3. Brightness perception
4. Detection of dim light
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has no depth perception. Actually, thereare many important
monocular cues thatallow a person to judge depth in the absence
of binocular vision.
In fact, beyond a few meters from the eye ofan observer,
monocular cues are moreimportant (and stereopsis contributes
little)to depth perception.
Conditions necessary for normal BSV :
1- normal routing of visual pathways with overlapping visual field.
2- binocularly driven neurons in the visualcortex .
3- normal retinal ( retino - cortical (correspondence ( NRC )
resulting incyclopean viewing .
4- accurate neuromuscular development andcoordination , sothat
the visual axesdirected at , and maintain fixation on , theobject of
regard .
5- approximately equal image clarity and
size for both eyes.
BSV is based on NRC , which requires firstan understanding of
uniocular visualdirection and projection .
Visual Direction
When a person with normal binocular vision looks at anobject, both
visual axes converge such that they intersect atthe object of regard.
When this object is at optical infinity (6 meters or greater),and the
patient is emmetropic or myopic, one or two typesof vergence are
responsible for the position of each eye.
If the person is orthophoric (i.e. has no phoria), then onlyTonic
vergence is responsible for turning each eye to pointat the target.
Where a heterophoria is present, tonic vergence andfusional vergence
are responsible for turning each eye topoint at the target.
PROJECTION
is the subjective interpretation of theposition of an object in space on
thebasis of stimulated retinal elements.If a red object stimulates the
right fovea( F ) , and black object which lies in thenasal field stimulates a
temporal retinalelement (T) , the red object will beinterpreted by the
brain as havingoriginated from the straight aheadposition and the black
object .
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RETINO – MOTOR VALUES
The image of an object in the peripheral visualfield falls on an
extrafoveal element. To establishfixation on this object a saccadic
version ofaccurate amplitude is required . Each extrafovealretinal
element therefore has a retino – motorvalue proportional to its distance
from the fovea, which guides the amplitude of saccadicmovements
required to ( look at it ) .
Retino – motor value, zero at the fovea,increases progressively towards
the retinal periphery.
Retinal Correspondence
When a person with normal binocular
vision looks atan object, the image of that
object falls on bothfoveas. In this case both
foveas receive informationfrom the same
object. The foveas are then said to
berelated (conjugate or corresponding).
This is NormalRetinal Correspondence
(NRC).
Abnormal retinal correspondence occurs
when theimages from the object above fall on
the fovea of oneeye, and on an extra-foveal
point of the other eye. Inthis case, the fovea of
one eye is conjugate with theextra-foveal point
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of the other eye.
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disparity ).
-Objects are seen singly and the disparity information is used to
produce a perception of binocular depth ( stereopsis ) .
-Objects in front of and behind Panum space appear double .
-This is the basis of physiological diplopia .
Panum space is shallow at fixation( 6 sec. of arc )and deeper towards the
periphery( 30 – 40seconds of arc at 15 deg. From the fovea ),Therefore
objects on the horopter are seensingly and in one plane . -Objects in
Panumfusional area are seen singly andstereoscopically .-Objects
outside Panumfusional area appear double .
-Physiological diplopia is usually accompaniedby physiological
suppression and manysubjects remain unaware of thisphenomenon .
Simult
aneou
s
Perce
ption;
This
occurs
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in both binocular singlevisible (BSV) and binocular vision (BV)where the
images of the object of regardfrom both eyes are
simultaneouslyperceived in the brain.
Fusion:
Is characterized by the ability to fuse theimages from the two eyes and
to perceivebinocular depth .
- SENSORY FUSION :involves theintegration by the visual areas of
thecerebral cortex of two similar images, one from each eye, into one
image. It may be central , which integrate the image falling on the fovea,
or peripheral, whichintegrates parts of the image falling outsidethe
fovea.
It is possible to maintain fusion with acentral visual deficit in one eye,
butperipheral fusion is essential to BSVand may be affected in patients
withfield loss as in advanced glaucoma .
Stereopsis:
Fusion of these slightly different retinal
images is theprecursor to Stereopsis.
Stereopsis enables the perception of depth (3-
D vision) and helps in the accurate judgment
of relative distance between two objects, and
relative speed (or change of speed) of
oneobject with relation to another.
There are many cues to the perception of
depth, butstereoscopic depth is the most
important.
Stereoscopic cues are caused almost
exclusively by retinaldisparities.
Retinal disparities are small positional displacementsbetween
otherwise well-matched images.
In the visual system, because of thehorizontal separation of the eyes,
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onlyhorizontal disparities convey depthinformation.
The horizontal shift in the objects’positions is what happens in
normalvision, and is the result of the difference in horizontal positions of
both eyes.
Fusion and stereopsis only occur in binocular single vision.
The ability for the brain to fuse both retinal images isdependent on
where the images of an object of regard fall onboth retinas.
We have already discussed the fact that, in normal
retinalcorrespondence, when both eyes look at an object, bothvisual
axes intersect at the object of regard so the eachimage falls exactly on
the fovea of each eye.
Subsequently the brain is able to fuse these two images into one visual
perception.
- The question is: Can the brain fusethe images of both eyes if one
imagefalls on the fovea, for example, theleft eye, and the other image
falls onan extrafoveal point of the right eye?
→The answer to the question above isYES, but only if the image on the
righteye falls within a circumscribed areaknown as Panum’s Fusional
Area. Ifthe image falls outside of this area,then fusion is not possible.
The firstconsequence of this is diplopia which may or may not progress
to corticalsuppression.
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Sensory adaptation to strabismus
NOTE:
- It should now be apparent that binocular vision is not inborn.
-A series of conditioned reflexes develop in the first three years of life to
produce binocular input to the cortical cells -leading to the development
of binocularly driven cells in the cortex.
-These reflexes become firmly established by about 5to6 years (the
plastic period) and hence become unconditioned reflexes.
However
• If strabismus develops before three years:
adaptation to normal development occurs to prevent symptoms,
leads to abnormal unconditioned reflexes developing by age
6years.
•Usually no symptoms if strabismus acquired from 6years to adult:
-binocular vision is well established (symptoms very likely to occur).
•if strabismus is acquired at 3-6years:
symptoms will occur .
but the system is unstable and readily breaks down .
adaptations will develop (plastic period) .
and again symptoms are unlikely to occur .
DIPLOPIA:
Object of interest seen by fovea of one eye and peripheral retina of the
other eye.
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Visual confusion:
Fovea of both eye (or corresponding retinal point ) are seen 2 object s of
interested interpreted as coming from the same point in space.
CONFUSION:
Is the simultaneous appreciation of two superimposed
but dissimilar images caused by stimulation of
corresponding retinal points ( usually the foveae ) by
images of different objects .
PATHOLOGICAL DIPLOPIA:
Is the simultaneous appreciation of two images of the same
object in different positions and results from images of the
same object falling on non- corresponding retinal points .
-In esotropia the diplopia is homonymous ( uncrossed ).
-In exotropia the diplopia is heteronymous ( crossed ).
Monocular diplopia:
More than one image of the object of regard is formed in the retina of
one eye or both eyes, like in :
- Irregular astigmatism (corneal scars, haze, corneal distortion).
- Subluxated clear lenses .
- Poorly fitting contact lenses .
- Early cataract .
- Macular disorder (edema, CNVM etc.) .
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- Suppression and ARC are interrelated adaptations to strabismus
occurring before 6 years.
- Is a binocular sensory adaptation that occurs when the patient is
using both eyes in the presence of a strabismus to avoid confusion
and diplopia.
- Is a cortical adaptive phenomena which prevents images in the
strabismic eye from reaching a conscious level.
- Also represents an obstacle in trying to restore normal
sensorimotor function.
- In small strabismus < 25Δ: both suppression and ARC usually occur
In larger strabismus > 25Δ: suppression dominates .
- Suppression is an extension of normal visual processing .
SUPPRESSION:
- involves active inhibition , in the visual cortex , of an image from
one eye when both eyes are open .
- Stimuli for suppression include diplopia , confusion and a blurred
image from one eye resulting from astigmatism / anisometropia .
Clinically , suppression may be :
CENTRAL OR PERIPHERAL:
in central suppression the image from the fovea of the deviating eye
is inhibited to avoid confusion. Diplopia on the other hand , is
eradicated by the process of peripheral suppression , in which the
image from the peripheral retina of the deviating eye is inhibited .
-MONOCULAR OR ALTERNATING:
- suppression is monocular when the image from the dominant eye
always predominate over the image from the deviating eye ( or more
ametropic ) eye , so that the image from the latter is constantly
suppressed . This type of suppression leads to amblyopia .
- When suppression alternates ( switches from one eye to the other )
amblyopia does not develop .
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FACULTATIVE OR OBLIGATORY:
- facultative suppression occurs only when the eyes are misaligned .
Obligatory suppression is present at all times , irrespective of whether
the eyes are deviated or straight .
- Examples are seen in intermittent exotropia and Duane syndrome .
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Delay in treatment.
Small constant strabismus angle.
Esotropia>exotropia.
Unilateral > alternating.
Classification
1. Harmonious ARC(HARC) :
angle of anomaly is equal to the objective angle of deviation )
subjective angle = o).
This indicates that the ARC fully corresponds to the strabismus.
Provides a compensation for the angle of squint.
Eliminate the awareness of diplopia and confusion.
3-Paradoxical(PARC):
when the angle of anomaly is greater than the objective angle of
deviation.
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binocular responses can be demonstrated , the unharmonious form may
be a lesser adaptation or an artifact of testing .
Advantages:
- Avoids the necessity for dense amblyopia (HARC).
- Permits anomalous fusion range and some degree of stereopsis.
- Prevents consecutive divergence.
- Allows a form of binocular convergence to take place.
Disadvantages
- Prevents the development of normal retinal correspondence, true
fusion and normal stereopsis.
- Represents an abnormal reflex development.
Treatment
- Occlusion Preventive as well as curative measure.
- Prolonged alternating occlusion is not recommended.
- Prevent further development of ARC as well as normal
correspondence.
- Exercises with major amblyoscope.
Eccentric fixation
A uniocular condition in which some part of retina other than
fovea is used for fixation, but in which the fovea retains its normal
straight ahead projection.
It may be associated with a defect of central vision caused by a
structural lesion of fovea.
Eccentric fixation can be present during both monocular and
binocular viewing conditions, but it is best diagnosed under
monocular viewing conditions.
This is important to keep in mind to avoid confusion with
anomalous correspondence.
Anomalous correspondence is relevant only during binocular
fusion.
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Monofixation Syndrome
The term monofixation syndrome is used to describe a particular
presentation of a sensory state in strabismus.
The essential feature of this syndrome is the presence ofperipheral
fusion with the absence of bi -macular fusion due to a macular scotoma.
A patient with monofixation syndrome may have no manifest deviation
but usually has a small heterotropia,most commonly esotropia.
Stereoacuity is present but reduced. And amblyopia is a common
finding.
Monofixation may be a primary condition. It is a favorable outcome of
infantile strabismus surgery.
This syndrome can also result from anisometropia or macular lesions.
It can be the cause of unilaterally reduced vision when no obvious
strabismus is present.
Amblyopia
Amblyopia is a unilateral or, less commonly, bilateral reduction of best
corrected VA that cannot be attributed directly to the effect of any
structural abnormality of the eye or the posterior visual pathways.
Amblyopia is caused by abnormal visual experience early in life resulting
from one of the following:
• strabismus.
• anisometropia or high bilateral refractive errors (isometropia).
• stimulus deprivation.
With a prevalence of 2%- 4%in the North American population.
This fact is particularly distressing because, in principle, most amblyopic
vision loss is preventable or reversible with timely detection and
appropriate intervention.
Screening plays an important role in detecting amblyopia and other
vision problems at an early age and can be performed in the primary
care practitioner's office, Amblyopia is primarily a defect of central
vision, the peripheral visual field is usually normal.
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In general, the critical period for stimulus deprivation amblyopia occurs
earlier than that for ocular misalignment or anisometropia.
Furthermore, the time necessary for amblyopia to occur during the
critical period is shorter for stimulus deprivation than for strabismus or
anisometropia.
Amblyopia has traditionally been subdivided in terms of the major
disorders that may be responsible for its occurrence.
1-Strabismic Amblyopia:
The most common form of amblyopia develops in the consistently
deviating eye of a child with strabismus.
Constant, non-alternating heterotropias (typically esodeviations) are
most likely to cause significant amblyopia. Strabismic amblyopia is
thought to result from competitive or inhibitory interaction between
neurons carrying the non-fusible inputs from the two eyes, which leads
to domination of cortical vision centers by the fixating eye and
chronically reduced responsiveness to input by the non-fixating eye.
Amblyopia itself does not as a rule prevent diplopia.
Older patients with long-standing deviations might develop double
vision after strabismus surgery despite the presence of substantially
reduced visual acuity from amblyopia.
When visual acuity is checked with the use of a neutral-density filter, the
acuity of an eye with amblyopia tends to decline less sharply than that of
a normal eye. This phenomenon is called the neutral-density filter effect.
Eccentric fixation:
Eccentric fixation refers to the consistent use of a non-foveal region of
the retina for monocular viewing by an amblyopic eye, Minor degrees of
eccentric fixation, detectable only with special tests such as visuscopy,
are seen in many patients with strabismic amblyopia and relatively mild
acuity loss. A visuscope projects a target with an open center
surrounded by two concentric circlesonto the retina, and the patient is
42
asked to fixate on the target. If the target is not directed at the fovea,the
degree of eccentric fixation can be measured using the concentric circles
as a guide,Many ophthalmoscopes are equipped with a visuscope.
Clinically evident eccentric fixation, detectable by observing the non -
central position of the corneal reflection from the amblyopic eye while it
fixates a light with the dominant eye covered, generally implies visual
acuity of 20/200 or worse.
Use of the non-foveal retina for fixation cannot, in general, be regarded
as the primary cause of reduced acuity in affected eyes.
2-Anisometropic Amblyopia:
Second in frequency to strabismic amblyopia, anisometropic amblyopia
develops when unequal refractive errors in the twoeyes causes the
image on 1 retina to be chronically defocused.
This condition is thought to result partly from the direct effect of image
blur on visual acuity development in the involved eye and partly from
interocular competition or inhibition similar (but not necessarily
identical) to that responsible for strabismic amblyopia.
Relatively mild degrees of hyperopic or astigmatic anisometropia(1.00-
2.00 D) can induce mild amblyopia.
Mild myopic anisometropia (less than -3.00 D) usually does not cause
amblyopia, but unilateral high myopia (-6.00 D or greater) often results
in severe amblyopic vision loss, Unless strabismus ispresent, the eyes of
a child with anisometropic amblyopia look normal to the family and
primary care physician, typically causing a delay in detection and
treatment.
3-Ametropic Amblyopia:
Ametropic amblyopia, a bilateral reduction in acuity that is usually
relatively mild, results from large, approximately equal, uncorrected
refractive errors inboth eyes of a young child.
It's mechanism involves the effect of blurred retinal images alone.
Hyperopia exceeding about 5.00 D and myopia in excess of 6.00 D carry
a risk of inducing bilateral amblyopia.
43
Uncorrected bilateral astigmatism in early childhood may result in loss
ofresolving ability limited to the chronically blurred meridians
(meridional amblyopia).
The degree of cylindrical ametropia necessary to produce
meridional amblyopia is not known, but most ophthalmologists
recommend correction of greater than 2.00 D of cylinder.
44
Diagnosis
Amblyopia is diagnosed when a patient is found to have a
condition known to increase the risk of amblyopia and when
reduced visual acuity cannot be explained entirely on the basis of
physical abnormalities of the eye.
Characteristics of vision alone cannot be used to reliably
differentiate amblyopia from other forms of vision loss.
The crowding phenomenon‘ for example, is typical of amblyopia
but is not pathognomonic or uniformly demonstrable.
Afferent pupillary defects rarely occur in amblyopia, and then,
only in severe cases.
Amblyopia sometimes coexists with vision loss directly caused by
an uncorrectable structural abnormality of the eye such as optic
nerve hypoplasia or coloboma.
When the clinician encounters doubtful or borderline cases of this
type ("organic amblyopia") in a young child, it is appropriate to
undertake a trial of occlusion therapy.
Improvement in vision confirms that amblyopia was indeed
present.
Multiple assessments using a variety of tests orperformed on
different occasions are sometimesrequired to make a final
judgment concerningthe presence and severity of amblyopia.
Trying to determine the degree of amblyopic vision loss in a young
patient should keep certain special considerations in mind.
The fixation pattern, which indicates the strength ofpreference for
1 eye or the other under binocularviewing conditions, is a test for
estimating the relativelevel of vision in the 2 eyes for preverbal
children with strabismus.
This test is quite sensitive for detecting amblyopia, but results can
be falsely positive, showinga strong preference when vision is
equal or nearlyequal in the 2 eyes, particularly with small-
anglestrabismus.
A variety of optotypes can be used to directly measure acuity in
children 3-6years old. When possible, it is best to use linear
symbols to measure visual acuity. Often, however, only isolated
45
symbols can be used, which may lead to underestimated
amblyopic vision loss due to the crowding phenomenon.
Crowding bars help alleviate this problem. In addition, the young
child's brief attention span frequently results in measurements
that fall short of the true limits of acuity; these results can mimic
bilateral amblyopia or obscure or falsely suggest a significant
interocular difference.
Treatment
Treatment of amblyopia involves the following steps:
Cataract Removal:
Cataracts capable of producing amblyopia require surgery without
unnecessary delay. In young children, amblyopia may develop as quickly
as 1 week per age of life. Removal of visually significant congenital lens
opacities during the first 4-6 weeks of life is necessary for optimal
recovery of vision. In symmetric bilateral cases, the interval between
operations on the first and second eyes should be no more than 1-2
weeks.
Acutely developing severe traumatic cataracts in children younger than 6
years should be removed within a few weeks of injury, if possible.
Refractive Correction:
In general, optical prescription for amblyopic eyes should be based on
the refractive error as determined with cycloplegia. Because an
amblyopic eye's ability to control accommodation tends to be impaired,
this eye cannot be relied on to compensate for uncorrected hyperopia as
would a normal child's eye. Sometimes, however, symmetric decreases
in plus lens power may be required to foster acceptance of spectacle
wear by a child.
46
-Refractive correction for aphakia following cataract surgery in childhood
must be provided promptly to avoid compounding the visual deprivation
effect of the lens opacity with that of a severe optical deficit.
-Both anisometropic and ametropic amblyopia may improve or resolve
with refractive correction alone over several months. Given this, many
ophthalmologists wait to initiate patching or penalization. in order to see
whether the vision improves with spectacle correction alone. The role of
refractive surgery in those patients who fail conventional treatment with
spectacles and/ or contact lenses is under investigation.
47
The effectiveness of more acceptable part-time patching regimens in
older children is being actively investigated. Furthermore, studies in
older children with amblyopia have shown that treatment can still be
beneficial beyond the first decade of life. This is especially true in
children who have not previously undergone treatment.
48
tape or a Bangerter foil (a neutral-density filter) to the spectacle lens can
be tried. Proper utilization (no peeking!) of spectacle-borne devices
must be closely monitored.
Another benefit of pharmacologic penalization and other non-occluding
methods in patients with straight eyes is that the eyes can work
together, a great practical advantage in children with latent nystagmus.
Complications of Therapy
Any form of amblyopia therapy introduces the possibility of
overtreatment leading to amblyopia in the originally better eye.
Full-time occlusion carries the greatest risk of this complication and
requires close monitoring, especially in the younger child.
The first follow-up visit after initiation of treatment should occur within
1 week for an infant and after an interval corresponding to 1 week per
year of age for the older child (e.g., 4 weeks for a 4year-old). Subsequent
visits can be scheduled at longer intervals based on early response.
Part-time occlusion and optical degradation methods allow for less
frequent observation, but regular follow-up is still critical.
The parents of a strabismic child should be instructed to watch for a
switch in fixation preference and to report its occurrence promptly.
Iatrogenic amblyopia can usually be treated successfully with judicious
patching of the better-seeing eye or by alternating occlusion.
Sometimes, simply stopping treatment altogether for a few weeks leads
to equalization of vision.
The desired endpoint of therapy for unilateral amblyopia is free
alternation of fixation (although 1 eye may still be used somewhat more
frequently than the other), linear Snellen acuity that differs by no more
than 1 line between the 2 eyes, or both.
The time required for completion of treatment depends on the
following:
• degree of amblyopia
• choice of therapeutic approach
• compliance with the prescribed regimen
• age of the patient
49
More severe amblyopia, less complete obstruction of the dominant
eye's vision, and older age are all associated with a need for more
prolonged treatment.
Full-time occlusion during infancy may reverse substantial strabismic
amblyopia in 1 week or less.
In contrast, an older child who wears a patch only after school and on
weekends may require a year or more of treatment to overcome a
moderate deficit.
Unresponsiveness
In some cases, even conscientious application of an appropriate
therapeutic program fails to improve vision at all or beyond a certain
level. Complete or partial unresponsiveness to treatment occasionally
affects younger children but most often occurs in patients older than 5
years. The decision of whether to initiate or continue treatment in a
prognostically unfavorable situation should take into account the wishes
of the patient and family.
Primary therapy should generally be terminated if there is a lack of
demonstrable progress over 3-6 months with good compliance.
Before it is concluded that intractable amblyopia is present,
refraction should be rechecked, the pupils carefully reevaluated,
and the macula and optic nerve critically inspected for subtle evidence
of hypoplasia or other malformation that might have been previously
overlooked. Neuroimaging might be considered in cases that inexplicably
fail to respond to treatment. Amblyopia associated with unilateral high
myopia and extensive myelination of retinal nerve fibers is a specific
syndrome in which treatment failure is particularly common.
Recurrence
When amblyopia treatment is discontinued after fully or partially
successful completion, approximately 25% of patients show some
degree of recurrence, which can usually be reversed with renewed
therapeutic effort.
50
Institution of a maintenance regimen such as patchingfor 1-3 hours per
day, optical penalization with spectacles, or pharmacologic penalization
with atropine 1 or 2 days per week can prevent backsliding.
If the need for maintenance treatment is established, treatment must be
continued until stability of visual acuity is demonstrated with no
treatment other than regular spectacles.
This may require periodic monitoring until age 8-10 years. As long as
vision remains stable, intervals of up to 6 months between follow-up
visits are acceptable. The improvement in visual acuity that is obtained
in most children treated between 7 and 12 years of age is sustained
following cessation of treatment.
51
superior oblique is paralysed, the left eye will become
extorted. In order to compensate for this, the head will tilt
to the right, shoulder, effectively 'intorting' the left eye
52
In distance fixation (assuming emmetropia) the phoria will
represent the error between the position of the eyes produced by
tonic convergence, and parallelism (fusional divergence).
In near fixation the phoria represents the error between the
position of the eyes produced by tonic, accommodative and
proximal convergence and the vergence required for the fixation
distance.
In heterophoria the eyes are kept aligned by motor fusion and
hence sensory fusion should develop normally .
In cases of large heterophoria sensory problems may occur e.g.
suppression or reduced stereopsis.
Small heterophorias are usually asymptomatic indeed most
people have some degree of heterophoria that can be considered
as physiological, or normal.
The likelihood of symptoms increases with the size of the
deviation and may include: asthenopia, headaches and diplopia.
Increased severity and/or frequency of symptoms imply poor
compensation.
53
Classification of Heterophoria:
54
- This is usually taken either at : 6m (optical infinity) or near (30 - 40
cm)
- The measurements taken are known as distance phoria and near
phoria respectively, and they may differ in degree and direction
from one another.
Esophoria
a) Divergence Weakness Esophoria
Distance esophoria > Near esophoria
b) Convergence Excess Esophoria
- Near esophoria > Distance Esophoria
- high AC/A ratio is a common cause
c) Basic Esophoria
Does not significantly alter between distance and near fixation.
Exophoria
a) Convergence Weakness Exophoria
Near Exophoria > Distance Exophoria
b) Divergence Excess Exophoria
Distance Exophoria > Near Exophoria
c) Basic Exophoria
Does not significantly alter between distance and near fixation.
MIXED PHORIA
Incidence of Heterophoria:
Most investigators have found some heterophoria in 70 - 80% of the
population.
- Abraham (1931) found esophoria in 38%, exophoria in 30% and
hyperphoria > 0.5Δ in 16%
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Partially accommodative strabismus30%
Non-accommodative strabismus 20%
Fully accommodative strabismus17%
Hypertropia and decompensated hyperphoria 6%
Exotropia and decompensated exophoria 27%
Treatment:
Vergence abnormalities:
CONVERGENCE INSUFICIENCY:
Convergence
Disjugate simultaneous and synchronous inward rotation of both
eye which results from co- contraction of the two medial rectus
muscles.
Allows bifoveal single vision maintained at near fixation distance.
Does not deteriorate with age.
Can be improved by exercises
One-third of convergence relates to tonic, fusional and proximal
convergence.
Two-thirds is accommodative .
NPC value is greater than 10 cm .
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CONVERGENCE INSUFICIENCY:
Nausea
motion sickness
Dizziness
panoramic headaches
gritty sensation in the eyes
general fatigue
57
Aetiology of CI :
Primary or idiopathic:
In many cases, exact etiology is not known.
May be associate with:
o Wide IPD
o Delayed or inadequate functional development
o General debility
o Psychological instability
o Over work or worry
Refractive:
Clinical features:
58
Treatment:
Optical:
Proper refractive correction for any presence of ametropia.
Myopes given full correction and hyperopes under corrected to
stimulate accommodation.
Training of voluntary convergence:
Prism therapy:
o Base –in prism reading glasses or bifocals with prism in the
lower segment are useful as relieving prism.
o Relieving prisms and bifocals should be prescribed
cautiously in young age.
ACCOMMODATIVE INSUFFICIENCY :
59
2- complete paralysis
in which no convergence or accommodation can be initiated may be
of functional origin or caused by midbrain disease or follow head
trauma ( recovery possible ) .
2- treatment:
Involves reassurance and advising the patient to look away and cease
the activity that triggers the response . If persistent , atropine and a
full reading correction are prescribed but it is difficult later to
abandon treatment without recurrence . Patients usually seem to live
a fairly normal life despite the signs and symptoms .
Divergence insufficiency:
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STRABISMUS
CLASSIFICATION OF STRABISMUS:
1-True:
1. Fusional status
Phoria
Intermettent tropia
Tropia
2.DIRECTION OF DEVIATION
HYPERTROPIA
HYPOTROPIA
EXOTROPIA
ESOTROPIA
3. COMITANCY
concomitant / non-paralytic
incomitant / paralytic
4. TYPE OF FIXATION
Alternating
Monocular
5. Age of onset
congenital
acquired
2- Apparent (pseudo squint)
1- epicanthic folds
2- abnormal inter-pupillary distance
3- angle kappa
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TRUE STRABISMUS:
Heterophoria:
Heterophoria is a latent tendency for misalignment of the two eyes that
becomes a manifest only if binocular vision is interrupted such as by
covering one eye.
A minor degree of Heterophoria is normal for most individuals.
CONCOMITANT(NON-PARALYTIC):
•The movement of both eyes are full (there is no paresis) but only one
eye is directed towards the fixated target.
•The angle of deviation is constant and unrelated to the direction of
gaze.
•It is the common squint that is seen in childhood.
•Under age of 6, it is rarely caused by serious neurological disease. It’s
usually primary in this age group.
•Strabismus arising later in life may have a specific and serious
neurological basis.
Incomitant (paralytic):
•The degree of misalignment varies with direction of the gaze.
•One or more of the extraocular muscles or nerves may not be
functioning properly, or normal movement may be restricted
mechanically.
•This type of strabismus may indicate either a nerve palsy or extraocular
muscle disease.
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•Trauma, most common cause of palsy of 4th,6th
•Neoplasia, glioma
•Raised intracranial pressure may cause a 3rd or 6th nerve palsy
•Inflammation, sarcoidosis
Clinical evaluation
History
AGE OF ONSETcan give an indication as to the etiology of a squint.
The earlier the onset , the more likely the need for surgical correction .
The later the onset , the greater the likelihood of an accommodative
component ( mostly arising between 18 – 36 months.)
The longer the duration of squint in early childhood the greater the risk
of amblyopia , unless fixation is freely alternating.
Inspection of the previous photographs may be useful for the
documentation of strabismus or AHP
2- SYMPTOMS may indicate decompensation of preexistent
heterophoria or more significantly a recently acquired , usually paretic
,condition. In the former the patient usually complains of discomfort ,
blurring and possibly diplopia of indeterminate onset and duration
compared to the acquired condition with sudden onset of diplopia. The
type of diplopia ( horizontal , cyclovertical ) should be established , the
direction of gaze in which it predominates and whether any BSV is
retained .
In adults it is very important to determine exactly what problems the
squint is causing as a basis for decisions about treatment . It is not
63
unusual for patients to present with spurious symptoms which mask
embarrassment over a cosmetically noticeable squint.
3-VARIABILITY is significant because intermittent strabismus
indicates some degree of binocularity . An alternating deviation suggests
symmetrical VA in BE.
4- GENERAL HEALTH or developmental problems are significant ( e.g.
children with cerebral palsy have an increased incidence of strabismus ) .
In older patients poor health and stress may cause decompensation and
in acquired paresis patients may report associations or causal factors (
trauma , neurological disease , diabetes etc. ).
5- BIRTH HISTORY including period of gestation , birth weight and any
problems in utero , with delivery or in the neonatal period .
6- FAMILY HISTORY is important because strabismus is frequently
familial , although there is no definitive inheritance pattern .
It is also important to know what therapy was necessary in other family
members.
7- PREVIOUS OCULAR HISTORY including prescription and
compliance with spectacles or occlusion , previous surgery or prism is
important to future treatment options and prognosis .
• Light sense
• Form sense ( central & peripheral ) it inclusive for visual acuity &
contrast sensitivity
• Color sense
64
The minimum separable (resolution )
Why 6 M or 20 Ft distance ?
Visual angle
65
Baby's Vision Development:
• Small pupil
• For their first two months, babies’ eyes often do not work
together very well
• At around three months old, your baby may have enough eye and
arm coordination to bat at a nearby moving object
66
• Good color vision .
Eye popping.
67
Binocular fixation pattern
Evaluation
CSM 6/9 – 6/6
CSNM 6/36 – 6/60
Unsteady Central Fixation < 6/60
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Fixation of small targets .
Optokinetic Nystagmus
69
Vestibular-ocular reflex test
- The examiner rotates with the child held at arm's length and
facing the examiner which induced horizontal nystagmus .
- If the nystagmus is prolonged , it suggested that the baby is
blind or has severe cerebellar disease.
70
Lea paddle
71
Objective technique to assess functional state of visual system
beyond the retinal ganglion cells.
Types :
1. Flash VEPs
2. Pattern reversal VEPs
3. Sweep VEPs
Snellen chart
logMAR chart
72
Sheridan gardiner chart
73
The examiner shows normally center symbol but at the same time
he can ask for other symbols too
The patient is given a key card .
74
It's used for screening and V A for pediatric patient.
The charts are changed fast so that patients eye movement can
be seen .
The chart has conversions in feet , meter , decimal and logMAR.
Snellen chart
LogMAR Chart
75
76
Stereopsis:
-Implies the ability to obtain an impression of depth by super imposition
of two picture of the same object which have been taken from different
angle.
-Depth perception means the perception of distance of objects from
each other it' s a visual appreciation of three dimensions during
binocular vision.
PROCEDURE:
1. Explain the test to the patient: I am now going to test your 3D vision.
Ask the patients to wear the red/green goggles.
2. Ask the patient to hold the booklet at about 40cm.
3. Keep the room lights on.
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4. For general screening test, the first four plates are useful as the
disparity is large & provides a qualitative assessment of stereopsis.
(a) Plate I: two butterflies; one is easily seen monocularly, the other is
only seen in stereopsis.
(b) Plate II: four discs; Two are seen without stereopsis. Ask the
patient: how many circles? Which is the biggest?
(c) Plate III : four “hidden” shapes( circle/square/triangle/diamond) are
arrange around a centrally easily visible cross.
(d) Plate IV : Three disc. One seen with right eye, one seen by left &
one seen binocularly.
2) Lang test
- This test( Lang,i983) was designed to simplify stereopsis screening in
children.
- Itis based on two principles; random dots & cylindrical gratings.
- The test is a single card that can be held easily by yourself or the Pt.
- It has three levels of stereopsis, all of which are at a
low level.
• The test presented at 40cm the pt. has to locate the arc of the
moon(2oseconds),a star(2oo seconds),a car(4oo seconds) & an
elephant(600 seconds).
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3) Frisbytest
• In this test consist of three plastic cards each containing for squares of
small random shape one of this squares in each plate contains a hidden
circle which is seen disparity.
• The disparity is created by displacement of random
shapes by the thickness of the plate so this test also does
not require use of glasses.
•The disparities measured range from 600 – 15 seconds
of arc . It is important not to allow the subject to tilt the
plate or move their head during testing as this gives
monocular clues .
4) TITMUS
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TESTS FORSENSORY ANOMALIES:
SUBJECTIVE MEASUREMENT TESTS
Subjective dissimilar image tests are of limited value in the
assessment of strabismus . They require simultaneous perception
( cannot be used in manifest strabismus with suppression ) and do
not reveal the full deviation .
the instrument is constructed in such a way that the right eye sees only
a white vertical arrow and a red horizontal arrow , whereas the left eye
sees only horizontal and vertical rows of numbers
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2-MADDOX ROD TEST:
Maddox rod test uses a device consisting of series of parallel
cylinders that converts apoint source of light in to line image.
The Maddox rod can be used to test for horizontal and vertical
deviation and when used in conjunction with another Maddox rod
,for cyclodevation.
81
The Maddox rod Test Results:
A- Esodeviation(uncrossed images).
B- Exodeviation(crossed images).
C- Hypodeviation(Redline from right eye over the dot from left eye).
D- Hyperdeviation(Redline from right eye under the dot from left
eye).
E- 1→without having deviation " NRC".
2→with deviation " ARC".
** If he saw one of them then its suppression.
** If he saw the line and dot alternating then its alternating suppression.
The double Maddox rod test can also be used to assess torsion and
measure cyclotropias.
1-The room lights should be dimmed and only one
light source should be visible.
2-Maddox rods are placed into the trial frames, one
before each eye.
3-Cylinders are placed into trial frame vertically,
making the two red lines horizontal.
4-Vertical prism can also be added into the trial
frames to separate the two red lines.
5-The degree of deviation and the direction (incyclo or excyclo) can be
determined by the angle of rotation that causes the line images
toappear horizontal and parallel.
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6-The amount of cyclodeviation is measured in degrees.
7-Patient is instructed to fixate on the light source with both eyes
opened.
8-Patient is asked to rotate OR the examiner rotates the cylinders with
the axis knob on the trial frame until the 2 red lines are parallel.
9-This test can be repeated for the secondary and tertiary positions of
gaze.
-The test is repeated using increasing prism powers until the deviated
eye no longer shift
-Simultaneous prism and cover test provide the best indication of size of
deviation .
Definition:
Is often considered atest of sensory fusion.
it Best use to test suppression scotoma.
This is a dissociation test that can be used with both
distance and near fixation and differentiates between BSV,
ARC and suppression.
Results can only be interpreted if the presence or absence
of a manifest squints known at time of testing.
Procedure:
The patient wears a red lens in front of the right eye ،which
filters out all colors except red and a green lens In front of
the left eye which will filter out all colors except green.,
so red and green dot are each seen by only one eye while
the white dot seen by both eye.
The patient then views target consisting of 4 dot.
the stimulus dots can be presented in awall –mounted
display or by handheld flashlight.
The test should administered in good light so peripheral
feature in the room can stimulate motor fusion .
84
4 Δ PRISM TEST:
This test distinguish bifoveal fixation (normal BSV) from foveal
suppression (also known as a central suppression scotoma – CSS)
in microtropia .
Document the presences of small facultative scotoma in patient
with monofixation syndrome and no manifest deviation.
Procedure:
85
2- The image is moved temporally in the left eye but falls within the CSS
and no movement of either eye is observed.
3- The prism is then moved to the right eye which adducts to maintain
fixation; the left eye similarly moves to the left consistent with the
Hering law of equal innervation, but the second image falls within
the CSS of the left eye and so no subsequent refixation movement is
seen .
1-Objective methods:
86
- Prism bar cover test
- Synoptophore
2.Subjective methods:
87
PSEUDO SQUINT:
1- epicanthic folds:
may simulate an Esotropia .
2- abnormal inter-pupillary
distance:
if short may simulate an ET and if wide an XT .
3- Angle kappa :
Krimsky test:
88
o Convenient test for quick evaluation of the angle of strabismus,
especially in the abnormal fixation of the squint eye.
Brukner test:
89
cover-uncover test:
90
○ The test is repeated for the opposite eye.
○ Most examiners perform the cover test and the uncover
test sequentially, hence the term cover–uncover test.
91
Prism cover test:
The prism cover test measures the angle of deviation, It combines
alternate cover test with prisms .
Procedure: -
The alternate cover test is performed first .
Prism of increasing strength placed in front of one eye with base
opposite the direction of deviation.
Alternate cover test is performed continously as stronger prisms
are used.
Amplitude of refixation gradually decreases.
End point reached when no movement is seen.
To ensure maximum angle is found , prism strength is increased
until movement is observed in opposite direction.
Then reduced again to find neutral value Angle of
deviation equals the strength of the prism.
Synaptophore(amblyoscope):
92
- Controls allow vertical separation of the target as well cyclotorsional
adjustment.
- Mirror in each tube to reflect the image of target through
the eye piece into corresponding eye.
- Scales to measure the amount of deviation.
- Illumination system to increase or decrease the stimulus luminance.
SLIDES:
Simultaneous perception slides
o Foveal
o Macular
o Para macular
o Peripheral
Fusion slides
Stereopsis slides
Special purpose slides
o After image slides
o Haidinger brushes
o Slide with number or letters
93
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Uses of synaptophore
- The uses of synaptophore divided into two
- Diagnostic uses
- Therapeutic uses
Diagnostic uses
- Estimation of grade of binocular single vision
- Measurement of objective and subjective angle of deviation
- Measurement of deviation in all cardinal direction of gaze
- Measurement of inter pupillary distance
- To investigate the state of retinal correspondence
- Measurement of primary and secondary deviation
- To estimate presence and type of suppression
- Measurement of fusional vergance
- measurement of angle kappa
- Measurement of AC/A ratio
Therapeutic uses:
- It is used in treatment off
- Suppression
- ARC
- Amblyopia with Eccentric fixation
- Accommodative esotropia
- Heterophorias and intermittent heterophorias
Preliminary setting:
1. The patient’s chair and the table should be adjusted so that he is able
to look through the
centre of the eye-pieces comfortably with his head erect.
2. The chin and forehead rest should be adjusted to suit the patient.
3. The patient’s interpupillary distance (I.P.D.) must be measured and
the instrument adjusted
so that the distance between eye-pieces is equal to the interpupillary
distance.
Diagnosis uses:
Simultaneous perception
First grade of BSV
95
Tested using two dissimilar picture such as an object and a
surround e.g. cage and lion
Patient is asked to put the lion in cage by moving the arm of
synaptophore
Ideally the foveal picture must be used. But the target size should
be appropriate to the patient visual acuity.
Recording
If the patient is able to see both the pictures at a time then S.M.P.
is present and recorded as S.M.P. at zero degree or at a particular
angle.
Fusion
Tested using similar but incomplete picture eg: tworabbit one lacking tail
and one lacking bunch offlowers. If fusion is present one rabbit complete
withtail and flower will be seen.
Sensory fusion:
One tube is locked and patient is asked to create a composite
image and the position of sensory fusion was achieved is read off
the scale.
96
Motor fusion:
Lock the Colum at their real corrected angle then to measure
negative fusion adduction knob adjusted and for positive fusion
abduction knob is adjusted. Then note the value when the image
split into two.
Recording
Sensory fusion: present …………degree………
Motor fusion:
Adduction BP:………………..RP:……………
Abduction BP:………………..RP:……………
Stereopsis
Tested using two pictures of same object which have been taken
from slightly different angle.
If the images are fused and is seen three diamensioly stereopsis
present.
Measurement of IPD:
The patient should be seated at the Synoptophore, Then inter-pupillary
distance (IPD) should be
adjusted so the lines on the eyepiece line-up with the corneal
reflections.
97
Then according to the directions of eye movement the tube before the
non-fixing eye is adjust until no movement is seen. Then the
measurement is recorded from scale. If the eyes moves out to take
fixation left arm moved in and vice versa. This can be repeated for
vertical deviations.
98
Measurement of cyclodeviation with Maddox slide
99
Recording
Fixing RE
Objective angle: 0 degree
Subjective angle: 0 degree
Angle of anomaly: zero
- Retinal correspondence: normal.
Measuring AC/A ratio
Gradient method is often used:
Measure the deviation with accommodation and without
accommodation divided by change in accommodation gives AC/A ratio
AC/A =ΔL - ΔO /D where ΔL – deviation with add lens, ΔO –
originaldeviation D – dioptric power of lens
100
- In complex ocular motility cases, all 9 cardinal positions of gaze
can be subjectively measured along with unilateral ductions with
repeatable, standardized conditions.
- The subjective measurement can be performed
fixing either eye in the primary position, when the
central lock is released on lateral versions and using
the elevation and depression controls up to +/- 30°
vertically.
Haidinger’s Brushes
Haidinger brushes correspond to macula.
Therapeutic uses:
Anti suppression exercises
• chasing
• flashing
• Macular massage
• Crossing technique
Flashing:
This can be done with an automatic flashing device
or by manual control of the switches. The
tubes are set at the objective angle of deviation.
First one light and then the other is extinguished at
interval of a few seconds. This induces alteration. The speed of
altera
tion
shoul
101
d be slow at first but gradually increased.
CHASING TECHNIQUE
- It is a subjective exercise using the smallest SMP slide that the
patient can superimpose
- The two arms of the synaptophore are loosened and the patient is
asked to hold the tube in front of the suppressed eye
- Examiner moves the other tube in front the fixating eye in a
random position
- patient is asked to chase it and superimpose the two pictures by
moving the other tube
- As the pt.’s performance improves , smaller pictures are used
MACULAR MASSAGE
This exercise stimulates retina of deviated eye
It is done by moving the visual target across the suppression
scotoma
CROSSING TECHNIQUE
Target is moved in front of suppressed eye from
periphery of field towards suppression scotoma
Target will disappear in suppression area & reappear on the other
side of scotoma
The movement is continued until this area has decreased to such
an extent that patient can perceive both target and can
superimpose the two object
Fusion exercises
Fusion exercises were given on major amblyoscope with the fusion
slides. Fusion range could be
increased by gradually converging both the tubes of major amblyoscope
till the fusion breaks.
Exercises were given daily or on alternate days for 10 to 15 minutes
depending on the tolerance and
convenience of the patients.
Advantages
Accurate measurement is possible
Tube can be move separately
Large selection of suitable slides are available
102
The patient’s eye can be seen by the orthoptist and the corneal
reflections can be observed.
There can be rapid interchange from objective to subjective
conditions.
Disadvantages
Poor fixation
Not useful in non-cooperative child
Only corneal reflex is noted
Bulky instrument, difficult to transfer from one place to other.
Though the slides are kept in optical infinity distance but still it
stimulates proximal accommodation of the patient.
Needs expert orthoptist to handle the instrument accurately.
MOTILITY TESTS:
Ocular movements:
1- versions:towards the eight eccentric positions of gaze are tested by
asking the patient to follow a target , usually a pen or a pen-torch (which
offers the advantage of corneal light reflections to aid assessment ).
A quick cover test is performed in each position of gaze to confirm
whether a phoria has become a tropia or the angle has increased and
the patient is questioned regarding diplopia .
They may also be elicited voluntarily , in response to a noise or by the
doll’s head maneuver in uncooperative patients .
103
Force duction test:
• Also known as traction test.
• Described by wolf ,Gifford and jaensch (19001929).
• It is performed to differentiate between the incomitant squint due to
paralysis of EOM and that due to mechanical restriction of the ocular
movement.
104
Procedures:
105
Near point of accommodation
-The near point of accommodation ( NPA ) is the nearest point on which
the eyes can maintain clear focus . It can also be measured with the RAF
rule . The patient fixates a line of the print , which is then slowly moved
towards the patient until it becomes blurred . The distance at which this
is first reported is read off the rule and denotes the NPA .
-The NPA recedes with age ; when sufficiently far away to render reading
difficult without optical correction , presbyopia is present .
-At the age of 20 years the NPA is 8 cm and by the age of 50 years it has
receded to 46 cm .
Hofstadter's Formula:
Fusional amplitudes:
-Fusional amplitudes measure the efficacy of vergence movements.they
may be tested with prism bars or the synoptophore .
-Increasingly strong prisms are placed in front of one eye , which will
then abduct or adduct ( depending on whether the prism is base-in or
base-out ), in order to maintain bifoveal fixation .
-When a prism greater than the fusional amplitude is reached , diplopia
is reported or one eye drifts the other way. This is the limit of vergence
ability .
-The prism fusion range must be assessed in any binocular patient
before strabismus surgery .
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Postoperative diplopia test
This simple test is mandatory prior to strabismus surgery in all non-
binocular patients over 7-8 years of age to assess the risk of diplopia
after surgery .
Corrective prisms are placed in front of one eye ( usually the deviating
eye ) and the patient asked to fixate a straight ahead target with both
eyes open .The prisms are slowly increased until the angle is significantly
overcorrected .
The patient reports if diplopia occurs . If suppression persists throughout
, there is little risk of diplopia following surgery ; in a consecutive
exotropia of 35∆ diplopia may be reported from 30∆ and persist as the
prism correction mimics an esotropia .
Diplopia may be intermittent or constant but in either case this would be
an indication to perform a diagnostic botulinum toxin test .
Diplopia is not restricted to patients with good VA in the deviating eye ;
intractable diplopia is a difficult condition to treat and is best avoided .
INVESTIGATION OF DIPLOPIA
The Hess test and the Lees screen are two similar tests that plot the
dissociated ocular position as a function of the extraocular muscles .
They enable differentiation of paretic strabismus caused by neurological
pathology from restrictive myopathy ( such as in thyroid eye disease or a
blow-out fracture of the orbit ) , and recent onset paresis from long-
standing
107
from primary position ) and a peripheral field ( 30° ); each square
represents 5° of ocular rotation .
- The patient is seated 50cm from the screen and wears red-green
goggles , red lens in front of the right eye , and holds a green
pointer.
LEES SCREEN
- The apparatus consists of two opalescent glass screens at right-
angles to each other, bisected by a two-sided plane mirror which
dissociates the two eyes .
- Each screen has a tangent pattern marked onto the back surface
which is revealed only when the screen is illuminated .
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- The examiner indicates the dot required for the patient to plot .
- When all of the dots have been plotted the patient is repositioned
to face the other screen and the procedure is repeated . The
results are charted as before .
- interpretation :
- The two charts are compared .
- The smaller chart indicates the eye with the paretic muscle .
- The larger chart indicates the eye with the overacting yoke muscle
.
- The smaller chart will show its greatest restriction in the main
direction of action of the paretic muscle ( right lateral rectus ).
- The larger chart will show its greatest expansion in the main
direction of action of the yoke muscle ( left medial rectus ).
109
- Changes with time are very useful as a prognostic guide . For
example , in right superior rectus palsy , the Hess chart will show
underaction of the affected muscle with an over action of its yoke
muscle ( left inferior oblique ) .
- This could lead to the incorrect impression that the left superior
oblique was the primary muscle at fault .
110
- With further passage of time , the two charts become more and
more concomitant until it may be impossible to determine which
was the primary paretic muscle .
CYCLOPLEGIA
The commonest refractive error causing strabismus is
hypermetropia . Accurate measurements of hypermetropia
necessitate effective paralysis of the ciliary muscle , in order to
neutralize the effect of accommodation , which masks the true
degree of this refractive error .
1- cyclopentolate : affords adequate cycloplegia in most children
. The concentration employed is 0.5 % under the age of 6
months and 1% thereafter .
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One drop , repeated after 5 minutes , usually results in maximal
cycloplegia within 30 minutes , with recovery of
accommodation within 2-3 hours and of mydriasis within 24
hours .
The adequacy of cycloplegia can be determined by comparing
retinoscopy readings with the patient fixating for distance and
then for near . If cycloplegia is adequate , there will be little or
no difference . If cycloplegia is incomplete there will be a
difference between the two readings and it may be necessary to
wait another 15 min or to instil another drop .
Topical anaesthesia with an agent such as topical
proximethocaine , prior to instillation of cyclopentolate , is
useful in preventing ocular irritation and reflex tearing , thus
affording better retention of the cyclopentolate in the
conjunctival sac and effective cycloplegia .
2- Atropine may be necessary in some children with either high
hypermetropia or heavily pigmented irides , in which
cyclopentolate may be inadequate . Atropine may be used as
drops or ointment . Drops are easier for an untrained person to
instil , but there is less risk of overdose with ointment . The
concentration is 0.5% under the age of 12 months and 1%
thereafter . Maximal cycloplegia occurs at 3 hours ; recovery of
accommodation starts after about 3 days and is usually complete
by 10 days . Atropine is instilled ( by the parents ) b.d. for 3
days before retinoscopy , but not on the day of examination.
The parents should be warned to discontinue medication if there
are signs of systemic toxicity such as flushing , fever or
restlessness, and seek immediate medical attention .
112
Change of refraction:
Because refraction changes with age , it is important to check at
least every year and more frequently in smaller children and if
acuity is reduced . At birth most babies are hypermetropic .
After the age of 2 years there may be an increase in
hypermetropia and a decrease in astigmatism .
Hypermetropia may continue to increase until the age of about 6
years , and then between the ages of 6 and 8 years levels off ,
subsequently decreasing until the early teenage years .
When to prescribe
1- hypermetropia : in general up to 4D of hypermetropia should
not be corrected in a child without a squint unless they are
having problems with near vision . With degrees of
hypermetropia greater than this a two-thirds correction is usually
given . However , in the presence of esotropia the full
cycloplegic correction should be prescribed , even under the age
of two years .
2- astigmatism : a cylinder of 1.50D or more should be
prescribed , especially in cases of anisometropia after the age of
18 months .
2- myopia : the necessity for correction depends on the age of
the child . Under the age of two years -5.00 or more of myopia
should be corrected ;between the ages of 2 and 4 the amount is -
3.00 D . Older children should have correction of even milder
degrees of myopia to allow clear distance vision .
4- anisometropia : after the age of 3 the full difference in
refraction between the eyes should be prescribed if it is more
than 1 D. if there is no squint then any associated hypermetropic
correction may be equally reduced for each eye .
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ESOTROPIA
Concomitant esotropia:
Accommodative:
o A.Refractive
Fully accommodative
Partially accommodative
o B. Non-refractive
With convergence excess
With accommodation weakness
o c.Mixed
2.Non-accommodative
Essential infantile
Microtropia
Basic
Convergence excess
Convergence spasm
Divergence insufficiency
Divergence paralysis
Sensory
Consecutive
Acute onset
Cyclic
Tropia:
Primary
Secondary
Consecutive
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Constant
With Accommodative Element.
without Accommodative Element.
Intermittent
Accommodative
Distance - near eso-distance eso
Time - cyclic/alternate day squint
Non-specific
PHPRIA:
1-Conv. Excess
2-Div. Weakness
3-Non-specific
Accommodative:
A. Refractive Accommodative Esotropia:-
Clinical features
•Esotropia which becomes apparent when accommodation is exerted
(usually intermittent at first) .
•Age of onset 1-4 years .
•Hypermetropia of any amount .
•Similar amount of esodeviation at distance and near (normal AC/A
ratio).
115
•No residual esotropia for near or distance when wearing full
hypermetropic spectacles correction.
•Normal binocular function when squint not .
•Amblyopia rare (may occur due to anisometropia or if the squint
becomes constant .
•Family tendency .
Management
-Prescribe fully hypermetropic lenses .
-Glasses worn full time .
-Occlusion – if amblyopia present .
-Orthoptic exercises – to strengthen BSV .
1- convergence excess :
-High AC/A ratio due to increased accommodative convergence
(accommodation is normal , convergence is increased ) .
-Normal near point of accommodation .
-Straight eyes with BSV for distance .
-Esotropia for near, usually with suppression .
-Straight eyes through bifocals .
116
-High AC/A ratio due to decreased accommodation ( accommodation is
weak, necessitating increased effort , which produces overconvergence).
-Remote near point of accommodation .
-Straight eyes with BSV for distance .
-Esotropia for near , usually with suppression .
Medical treatment:
117
Surgery:
Non-Accommodative Esotropia
Definition:
118
119
A. ESSENTIAL ESOTROPIA:
Etiology :
-Primary cause idiopathic .
-Secondary causes are :
• Differential diagnosis:
bilateral congenital sixthnerve palsy .
secondary (sensory) esotropia due to organiceye disease
nystagmus blockage syndrome .
120
Duane syndrome .
Mӧbius syndromes and strabismus fixus.
Initial treatment:
Subsequent treatment:
• Undercorrection may require further recession of the
medial recti, resection of one or both lateral recti or
surgery to the other eye, depending on the initial
procedure.
• Inferior oblique overaction may develop subsequently, most
commonly at age 2 years The parents should
therefore be warned that further surgery may be necessary
despite an initially good result. Initially unilateral, it
frequently becomes bilateral within 6 months. Inferior
oblique weakening procedures include disinsertion, recession
and myectomy.
• DVD is characterized by up-drift with
excyclorotation (extorsion) of the eye when under cover, or
spontaneously during periods of visual inattention. When
the cover is removed the affected eye will move down
121
without a corresponding down-drift of the other eye. It is
usually bilateral. Surgical treatment may be indicated for
cosmesis; options include superior rectus recession with or
without posterior fixation sutures and inferior oblique
anterior transposition.
• Amblyopia subsequently develops in about 50% of cases as
unilateral fixation preference commonly develops
postoperatively.
• An accommodative element should be suspected if the eyes
are initially straight or almost straight after surgery and then
start to reconverge. Regular refraction is therefore
important.
Etiology
-Innervational imbalance in muscle
Excessive Tonic convergence.
Muscle Imbalance .
Improper Muscle Tone .
CLINICAL FEATURES :
- Onset = after 6 months - 5 years
- Amount of Deviation = almost equal for distance and near Normal
AC/A ratio
- NPA within normal limit
- Refractive Error: Hyperopia or Emmetropia
-
122
TREATMENT:
- No glasses or miotics are helpful .
- First treat amblyopia .
- Muscle Surgery (BL MR recession but depends on surgeon) .
B. Convergence ExcessEsotropia
- Comitant Esotropia
- More deviation at near than distance
- Divergence is normal ( Deviation at distance is neutralized)
- Not associated with any refractive error or High AC/A ratio
Etiology
- Increased Innervational Tone of Converging Muscle
Clinical Features
- onset - 1 to 5 years of age .
- AC/A ratio is normal.
- NPA is normal .
- Amount of Deviation is more at near than distance .
- Refractive Error may be Hyperopic or else emmetropic.
TREATMENT
- Muscle Surgery ( BL MR Recession but depends on surgeon)
123
- Refractive Error is not associated
TREATMENT
- Muscle Surgery is not reliable
- Spectacles with BO prisms are helpful
- Spectacle to be worn when distance vision is needed
CLINICAL FEATURES:
- Onset is acute , can occur at any age group.
- Diplopia is alwayspresent( Patient may close one or both eye to
avoid diplopia )
- Amount of Deviation is slightly more in near than distance
Associated with precipitating factors (Refractive Error or Systemic
Illness)
TREATMENT
- Refractive Error management.
- Systemic Illness management.
- Muscle Surgery:BL MR Recession or BL LR Resection.
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- STRATEGY:Removal of Precipitating factors may dissolve deviation
in some cases. Unless, Surgery is done.
2. ACUTE STRABISMUS WITHOUT PRECEEDING
DISRUPTION OF FUSION:
Characteristics:
- Acute onset Diplopia .
- Relatively large angle of Esotropia.
- No sign of paralysis of muscle .
- No interruption in fusion is associated.
- Precipitating Factors: Prolonged illness .
CLINICAL FEATURES
- Onset is acute for all age group .
- Refractive error has minimal effect .
- Accommodative Element is minimal .
- Amount of deviation ranges from 20 – 60pd.
ETIOLOGY
- Idiopathic
TREATMENT
- Refractive Error management.
- Determination of angle by prism adaptation test.
- Muscle Surgery: BL MR Recession or BL LR Resection.
Characterized by:
- It is always associated with neurological problems like:
o Hydrocephalus
o Brain Tumor
o Craniocervical junction anomaly
CLINICAL FEATURES
- Etiology neurologic origin .
- Onset is acute .
- Refractive error Influence is minimal .
- No certain associations, sign or symptoms .
125
TREATMENT:
STRATEGY:Being a life threatening entity
( Refer to Neurologist):
Treatment may dissolve Esotropia, If Not Go for Surgery.
C. CYCLIC ESOTROPIA
Characterized by:
o A strabismic and no- strabismic phase of 24 hours each.
o This 48 hours of cycle is most common.
o However 72 and 96 hours cycle is also reported.
o Cycle may last from 4 months to several years.
o Unless treated , esotropia becomes constant.
CLINIAL FEATURES
Onset - early infancy : Usually during early childhood.
Amount of deviation for both Near and Distance ranges from 40-70
Suppression in one eye .
History of Amblyopia after being constant deviation .
Fusional Amplitude is defective or absent.
Fusion and stereopsis are normal(Non strabismic phase)
No manifest deviation, esophoria may be present.
ETIOLOGY
- Idiopathic
TREATMENT
- Muscle Surgery
126
RECURRENT ESOTROPIA (Malignant Esotropia)
CLINICAL FEATURES
o Recurrent occurrence AC/A Normal Refractive Error
influence is minimal .
ETIOLOGY
o Idiopathic.
TREATMENT
o Initially Muscle Surgery .
o BI Prisms mounted on spectacle.
127
EXOTROPIA
EXOTROPIA:
visual axis is deviated laterally and fovea rotated nasally.
Exodeviation
latentmanifest
Pseudoexotropia:
Appearance of exodeviation:
-wide interpupillary distance
-large positive angle kappa- hyperopia, ROP
Types:
A. COMITANT
- Primary
- Infantile exotropia
- Intermittent exotropia
- Secondary
- Sensory exotropia
- Consecutive exotropia
B.Incomitant
- Paralytic
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- Restrictive
- Musculofascial innervational
anomalies.
Comitant Exotropia
Constant Exotropia:
- Infantile Exotropia
- Sensory Exotropia
- Consecutive Exotropia
- End stage of decompensated intermittent exotropia
Intermittent Exotropia
Craniofacial anomalies
Ocular albinism
Cerebral palsy
Features:
Large angle constant exo deviation is mostly more
than 35PD
Fusion will be poor
Amblyopia> intermittent exotropia
Sensory exotropia:
Poor vision in one eye leads to XT.
Sensory esotropia or exotropia may occur.
Secondary to some sensory deficit.
Causes -Marked anisometropia E.g.; unilateral high myopia.
Retinoblastoma(22% present with strabismus).
Unilateral cataract .
129
CONSECUTIVE EXOTROPIA:
Formerly esotropic patient.
Either spontaneously or after surgical
overcorrection.
Treatment:
o Correction of refractive error if
present.
o surgery(cosmetic).
Intermittent Exotropia:
Outward drifting of either eye.
Interspersed with periods of goodalignment
Exodeviation less common than esodeviation in West.
Female> Male.
Exodeviation found areas with more sunlight.
Frequently seen in neonatal period –
year of life )35-40%) .
Often positive family history.
Common with facial asymmetry and neurological defects.
Classic presentation:
Begins as exophoria– shortly after birth
–Binocular fixation and NRC
–Progresses to intermittent exotropia( XT)
o Adults have diplopia
o Children develop hemiretinal suppression
o Periods of phoria and tropia
Frequent pseudo-oblique dysfunction associated with tight laterals
Called “leash phenomenon”.
130
Natural History
Progression occurs in 35% - 75% of pts.
Improvement occurs in 16% - 65%
Factors:
- Age:
o Decreasing tonic convergence
- Suppression sets in :
o The key to unlocking fusion
o Worsening seen at distance first
Decreased accommodation.
Orbital divergence from maturation of facial features.
Most common form of divergent strabismus.
Onset before 5 years of age.
Manifest during:
o Visual inattention
o Fatigue
o Illness
o Daydreaming
o Drowsiness upon awakening
Symptoms
Asymptomatic
Transient diplopia
Asthenopic symptoms
Reflex closure of one eye in bright sunlight
131
Deviation Sensory
CLASSIFICATION:
- Burian has classified IDS into 4 types based on measurements
of the distance and near deviation.
1. Basic type: distance deviation and near deviation are within 10 PD
of each other.
2. Divergence excess type: distance measurement 10 PD or greater
than the near deviation.
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Basic exotropia:
Burian and Kushner:
- Distance = Near - Normal AC/A
• Kushner:
- Normal AC/A
- Fusional convergence insufficiency.
-AC/A LOW.
-Accommodative convergence insufficiency.
Divergence Excess:
•Burian:
Distance 15 PD more than at Near.
• Kushner:
- True Divergence Excess
- Normal AC/A RATIO
-HIGH AC/A RATIO
- Simulated:
Tenacious proximal fusion.
133
Examination:
• Comprehensive ophthalmologic examination .
• Check fusion and stereopsis beforeoccluding eyes for visual acuity
examination. So ARC and suppression do not set in.
• Check stereo acuity for distance and for near.
• Versions .
• Cover test.
• Important to obtain cycloplegic retinoscopy
• “Pseudoamblyopia”
- Exodeviation often manifests with fixation preference
- Misinterpreted as evidence of amblyopia
- Excellent fusion and stereopsis when eyes are aligned
- Patching may worsen situation and induce iatrogenic loss of fusion and
stereopsis.
Measurement of deviation:
134
EXOTROPIA RESPONSE PATTERNS FOR TESTS:
FUSIONAL CONTROL:
135
3- Stereo-acuity: (mainly for distance) Indicator of both control of the
deviation and deterioration of fusion.
The distance stereoacuity can be assessed using Random dot E test.
Treatment:
-Two types:
•Non-surgical
•Surgical
136
Various Non-Surgical Therapies for Intermittent Exotropia:
137
Overcorrecting minus lens therapy:
Prism therapy:
138
Indications of Surgical Treatment:
•Gradual loss of fusional control .
•Increased frequency of manifest phase .
•Increase size of the basic deviation .
•Development of suppression .
•Decrease of Stereoacuity .
Surgery:
•Bilateral lateral rectus recession .
•Unilateral lateral rectus recession with
ipsilateral medial rectus resection .
•Unilateral lateral rectus recession .
139
LR recession and MR resection:
Post-operative complications:
Over Correction:
- Persistent esotropia 3-4 weeks after surgery.
Treatment:
•Correction of refractive error
•Part-time alternate patching
•Base-out prisms
•Botulinum toxin injection
•Reoperation
Under Correction:
•Observation .
•Orthoptic exercise.
•Prism therapy.
•Reoperation.
140
Alphabetical pattern deviation:
Patterns of Strabismus:
A Pattern.
V Pattern.
…A PATTERN:
- Relative convergence on up gaze and relative divergence on down
gaze.
- Minimum of 10-pd diopters difference between up gaze and down
gaze.
…V PATTERN:
- Relative divergence on up gaze and relative convergence on down
gaze.
- Minimum of 15-pd diopters difference between upgaze and down
gaze.
- This allows for a slight physiological V pattern.
A PATTERN V PATTERN
141
why necessary:
- It is Common.
- Countless surgical overcorrections andundercorrections have
been made due tofailure to recognize patterns.
Must-know point:
… Anatomy of EOMs
- Only when there is integrity of a sensorimotor apparatus is there a
BSV.
- Any anomaly-no normal BSV.
- Origin of EOMs.
… Anatomical peculiarities of IO
- Only EOM that does not originate from the orbital apex
- Short tendon of less than 2 mm
- The tendon-insertion lies within 2 mm of macula
- Run shortest course
- Only muscle to come in contact with other two muscles:IR and LR.
AETIOLOGY:
- A great deal has been advanced as regards the role of
o Horizontal, vertical and oblique muscle dysfunctions
o Facial characteristics
o Abnormal muscle insertions
- …But no assent concerning pathophysiology has been obtained.
- … Several schools of thought have evolved and some of them
which are into acceptance arepresentedhere.
Horizontal school:
This theory was believed to be responsible for V-pattern strabismus, but
no convincing evidence supports it.
In V-pattern esotropia, the medial rectus muscle was believed to
overact, thereby increasing esotropia in downgaze, and, in V-pattern
exotropia, the lateral rectus muscle overaction was responsible for
increased exotropia in upgaze.
142
-V pattern esotropia: OA of MR on downgaze
OA of LR on upgaze
-V pattern exotropia: OA of LR on upgaze
OA of MR on downgaze
- A pattern exotropia: UA of MR on downgaze
- A pattern esotropia: UA of LR on upgaze
- It has been found that there occurs an elevation or depression upon
adduction. And this is a common feature in A and V pattern.
- Villascea shared a view that although some vertical elements could be
present, the pattern strabismus could be treated with the horizontal
surgery only.
2-Vertical school
Oblique school
- A syndrome: OA of SOs
- V Syndrome: OA of IOs
A syndrome:
Overaction of SOs Overaction may be primary or secondary to
underaction (paresis) of IOs. SO is abductor and its abducting factor will
be most noticeable in depression There occurs relative divergence of
eyes producing A pattern.
143
V syndrome:
Overaction of IOs Overaction may be primary or secondary to
underaction (paresis) of SOs. IO is abductor and its abducting factor will
be most noticeable in elevation There occurs relative divergence of eyes
producing V pattern.
Anatomical factors:
- Facial and orbital configuration.
- Urrets-Zavalia reported association of A esotropia (with UA IOs)
and V exotropia (with OA IOs) in patients with mongoloid features.
- Mongoloid features:
o Hyperplasia of malar bones
o Upward slanting of palpebral fissures
o Straight lower lid margin
- Urrets-Zavalia reported association of V esotropia (with OA IOs)
and A exotropia (with UA IOs) in patients with antimongoloid
features .
- Antimongoloid features:
o Hypoplasia of malar bones
o Downward slanting of palpebral fissures
o S-shaped contour of lid margin
144
Muscle Insertion anomalies:
Sensory Deprivation:
Prevalence:
- … Co-existence of A or V pattern with horizontal strabismus is
seen in 12.5% to 50% of cases.
- …According to 1964 American Academy of Ophthalmology: V
eSo> A eSo> V eXo> A eXo.
- … However, a somewhat different distribution was reported by
von Noorden and Oslon: V eXo> A eXo> V eSo> A eSo.
145
Clinical Features:
Symptoms:
- Age at presentation:
o 58% of patients had age of onset at 12 months or younger.
- If the pattern is small in magnitude it may not be recognized until
the early school when head posture becomes apparent or reading
difficulties are noted.
- Asthenopia and Diplopia.
- A exotropia and V esotropia.
- Anomalous Head Posture:
o 11% of patients with alphabet patterns.
o A esotropia and V exotropia have fusion in
the downward gaze. So usually have chin
elevation.
o V esotropia and A exotropia have fusion in
the upward gaze. So usually have chin
depression.
- Amblyopia.
o Ciancia found abnormal retinal
correspondence in 89% of cases of A or V
pattern.
Crouzon syndrome
146
PSEUDOPATTERNS:
- Patients with accommodative esotropia may have Pseudo- V
pattern
- This is particularly apparent if the patient is examined without
hypermetropic correction as with
o Uncorrected hyperopia there is a tendency to
accommodate in the primary gaze and downgaze, thus
simulating a V pattern.
Clinical investigation:
Aims
- To detect and measure A/V patterns .
- To assess ocular movements to determine the reason if possible.
- To assess significance of A/V patterns for prognosis and
management.
Observation AHP
Ocular movement
o COVER TEST :primary positionAnd up gaze and down gaze
Measure of deviation
Ocular movement:
147
Prism cover test:
Measure patient's alignment in 25:up gaze and 25: down gaze
with the patient fixating an accommodative target at distance,
with fusion prevented.
Measure patient's alignment in 25º upgaze and 35ºdowngaze with
the patient fixating an accommodative target at 33 cm.
148
INCOMITANT STRABISMUS;
Definition: a strabismus where the angle or degree of the deviation
varies in different directions of gaze OR with each eye fixing (i.e. the
secondary deviation is greater than the primary).
Classification
According to the underlying cause:
i. Neurogenic
ii. Mechanical
iii. myogenic
Also may be congenital or acquired.
Congenital:
Usually isolated defects in otherwise healthy individual.
Sometimes familial.
Specific cause unknown, presumed due to a developmental
anomaly in the anatomy or functioning of the extra-ocular muscles
or their innervating nerves.
Some are associated with serious developmental neurological
defects e.g. hydrocephalus & cerebral palsy .
Gradually become more comitant as patient gets older Not likely to
respond to orthoptic treatment .
Acquired:
Caused by injury or disease of the ocular motor system e.g.
trauma, inflammation.
Vascular.
Space-occupying lesions.
Metabolic disorders.
NB It is vital that we distinguish between longstanding/ static
acquired disorders and recent onset/active ones.
149
Paralytic strabismus:
150
Terms:
151
Sequelae of Ocular Muscle Palsy:
152
For right eye read from the top:
Muscle Direct Contralateral Contralateral
Antagonist synergist antagonist
RMR RLR LLR LMR
RLR RMR LMR LLR
RSR RIR LIO LSO
RIR RSR LSO LIO
RIO RSO LSR LIR
RSO RIO LIR LSR
PARALYTIC SQUINT:
Diagnosis:
Signs of a left third nerve palsy :
- Weakness of the levator causing profound ptosis , due to which there is
often no diplopia .
-Unopposed action of the lateral rectus causing the eye to be abducted
in the primary position .
-The intact superior oblique muscle causes intorsion of the eye at rest ,
which increases on attempted down gaze .
-Normal abduction because the lateral rectus is intact .
-Weakness of the medial rectus limiting adduction .
-Weakness of the superior rectus limiting elevation .
-Weakness of inferior rectus limiting depression .
-Parasympathetic palsy causing a dilated pupil associated with defective
accommodation .
-Partial involvement will produce milder degrees of ophthalmoplegia .
153
Treatment
1- non-surgical treatment:options include the use of Fresnel prisms if
the angle of deviation is small , uniocular occlusion to avoid diplopia ( if
ptosis is partial or recovering ) and botulinum toxin injection into the
uninvolved lateral rectus muscle to prevent its contracture before the
deviation improves or stabilizes.
2- surgical treatment: as with other ocular motor nerve palsies , should
be contemplated only after all spontaneous improvement has ceased .
This is usually not earlier than 6 months from the date of onset .
INTRODUCTION:
ANATOMY:
From each nucleus, the nerve fibers run laterally and emerge. from
the dorsal aspect of the midbrain .
Pass medially and decussate (X).
Thus it crosses completely before passing
forward.
Once the 4th CN exits from the brain from the
dorsal side it turns ventral and passes the
Posterior Cerebral Artery and Superior Cerebellar
artery.
154
Then it pierces the arachnoid and enters the subdural
space on the posterior corner of the roof of the
cavernous sinus.
II) ACQUIRED :
1.TRAUMA : trauma is an important cause of 4th nerve palsy accounting
for 30% of acquired 4th nerve palsies, 4 th nerve is the most commonly
involved nerve in a traumatic palsy. Trauma usually causes bilateral 4th
nerve palsies due to an impact in the area of the Anterior medullary
vellum, where the two nerves decusate.
155
-Nuclear:
Most often due to stroke, less often neoplasm, and almost never
isolated; other causes include demyelinative disease and trauma.
-Fascicular:
Rare, same associations as nuclear; may get contralateral Horner’s
syndrome; trauma (especially near anterior medullary velum) may cause
bilateral CN IV palsies.
-Subarachnoid Space:
Usually due to closed head trauma; rarely tumor, infection or aneurysm.
-Intracavernous Space:
Due to cavernous sinus disease from inflammation
(sarcoidosis), infection (fungal), or neoplasm
(lymphoproliferative, meningioma, pituitary m
acroadenoma); usually associated with CN III, V, and
VI findings and sympathetic abnormalities.
-Orbital :
Trauma, inflammatory or tumor.
SY MPTOMS :
DIPLOPIA : Acute onset of a vertical diplopia, which is more on
downward gaze ,it is noted by patients while coming down stairs and
while doing near work.
SIGNS :
1)HYPERTROPIA: the involved eye is higher as a result of weakness of
the superior oblique muscle, which becomes more prominent when the
head is tilted towards the ipsilateral shoulder.
2)RESTRICTED OCULAR MOVEMENTS: there is limitation of depression
on adduction.
3)ABNORMAL HEAD POSTURE: to avoid diplopia ,head takes
a posture towards the action of the superior oblique muscle,
face is slightly turned to the opposite side, chin is depressed,
and head is tilted towards the opposite side.
156
bilateral involvement should always be suspected until proved
otherwise :
-Right hypertropia in left gaze , left hypertropia in right gaze .
-Greater than 10° of cyclodeviation on double Maddox rod test .
-V pattern esotropia .
-Bilaterally positive Bielschowsky test .
STEP 1 : (to assess which eye is hypertropic in the primary gaze.) In case
of left hypertropia, the following four muscles could be involved:
1) Depressors of the left eye i.e. superior oblique and inferior rectus.
2) Elevators of the right eye i.e. the superior rectus or inferior oblique.
- In a 4th nerve palsy the involved eye is always higher.
- In Right SO palsy , on right head tilt RSR will work thus the eye will
move upwards.
157
4TH CONFORMATORY STEP 4:(is the hypertropia worse in upgaze or
downgaze)
If the left hypertropia increases on down gaze it confirms that the left
superior oblique is involved. Helps to rule out mimickers like myasthenia
and thyroid disease.
MANAGEMENT:
158
Surgical treatment:
It is important to have a period of stable measurements of at least six
months before embarking on surgery. The surgical option depends on
the angle of deviation in primary position, area of maximum deviation
and presence of torsion.
Knapp classification:
This is a useful way of classifying IV nerve palsy as it helps planning
surgical treatment options.
- Class I: greatest hypertropia in ipsilateral inferior oblique
(contralateral up) field
- Class II: greatest hypertropia in ipsilateral superior oblique
(contralateral down) field .
- Class III: greatest hypertropia in entire contralateral field .
- Class IV: greatest hypertropia in entire contralateral field and
across the lower field .
- Class V: greatest hypertropia across lower field .
- Class VI: bilateral IV palsy .
- Class VII: traumatic paresis combined with Brown’s syndrome.
159
SIXTH NERVE PALSY :
Introduction:
Anatomy:
160
What is the sixth nerve palsy?
- Limited ability of the affected eye to turn out (abduct) due to 6th
nerve lesion.
Why?
- Due to lesion anywhere along its course between the pons to the
lateral rectus muscle, which causes impaired eye
abduction(incomplete (paresis)or complete(palsy))→incomitant
esotropia and ipsilateral abduction deficiency.
Classified under neurogenic-cause of incomitant strabismus It can
be congenital (rare) or acquired (common) .
Can be unilateral or bilateral 6th nerve palsy.
161
INCIDANCE:
The sixth cranial nerve is the most commonly affected of the
ocular motor nerves based on some studies.
- But ranking second following fourth nerve palsy according to
other reports.
Etiology:
162
163
1- ADULT:
AQUIRED:
Trauma Sarcoidosis/vasculitis
Lumbar puncture
Myasthenia Gravis
164
2- Etiology in children:
Acquired:
•Traumatic
•Tumor
•Idiopathic
•Infection
Congenital:
- Very rare
- If occurs as an isolated finding in the first week, usually resolves
spontaneously. May represent one of following: Duane syndrome,
infantile esotropia, nystagmus blockage syndrome.
Differential diagnosis:
165
CLINICAL SIGNS AND SYMPTOMS:
A- MOST COMMON
1- Esotropia:
a. N›D.
b. Increase with the gaze at affected
side.
2- LIMITATIONT TO ABDUCTION:
a. In the affected eye.
b. Normal adduction.
3- HORIZONTAL BINOCULAR DIPLOPIA:
a. Worse at affected side and distance.
4- HEAD-TURN:
a. Toward the affected side.
b. To avoid diplopia.
B- LESS COMMON:
1- Loss of vision.
2- Pain
3- Hearing loss.
4- Headache.
5- Symptoms of vasculitis, particularly giant cell arteritis.
166
Control diplopia
Patient adopt face turn towards the affected eye (Right Maintaining BSV
side)
167
168
169
170
171
OCCLUSION:
Binasal occlusion
172
Binasal occluder (determine the degree of nasal).
Monocular occlusion
Method of full patch covering affected eye.
Purpose: Remove diplopia in lateral gaze .
Material: Occluder with different grades (Bangerter foils).
Fresnel prism:
Botulinum toxin:
173
Extraocular muscles surgery:
Indicated if longstanding esotropia.
Considered when the deviation has been stable for 6month.
May include a combined medial rectus recession and lateral rectus
resection on the affected side.
174
PATHOGENESIS:
Myogenic Theory:
This theory, suggested by earlier studies, indicates there is fibrosis or
inelasticity of the lateral rectus muscles and that the medial rectus
muscle inserts abnormally far posteriorly.
Neurogenic Theory:
A disturbance in embryologic development between weeks 4-8
results in an absent abducens nerve with anomalous innervations of
the lateral rectus muscle by a branch of the oculomotor nerve.
- Simultaneous activation of the medial and lateral rectus muscles, as
demonstrated by EMG studies, may be the cause of global
retraction.
175
CLASSIFICATION (HUBERS):
Type I the most common, is characterized by:
• Limited or absent ABDUCTION.
• Normal or mildly limited adduction.
• In the primary position, straight or slight esotropia.
176
Duane’s Syndrome Type I:
OS limited abduction, retraction in adduction:
177
EPIDEMIOLOGY:
SYNDROMIC FORMS:
- 70% of cases are isolated 30% of cases are associated with other
congenital anomalies.
ISOLATED CASES
- 90%occur sporadically and are commonly unilateral.
- Remaining 10% are inherited and these are commonly bilateral.
CLINICAL FEATURES
- Characterized by some or all of the following :
1) Complete, or less often partial, absence of outward movement
(abduction) of the affected eye.
178
2) Partial, or rarely complete, deficiency of inward movement
(adduction) of the affected eye.
179
Strabismus: 76% of individuals have frank strabismus in primary
gaze .
Poor Binocular Vision .
Reviews of DRS patients have shown hypermetropia of greater
than +1.50 in 71% of the patients.
Amblyopia occurs in about 10% of individuals and will respond to
standard therapy if detected early .
Anisometropia .
Differential diagnosis:
Congenital sixth nerve palsy
Infantile esotropia
Mobius syndrome
MANAGEMENT:
A) NON SURGICAL
Spectacles or contact lenses for refractive error.
Prism glasses to improve the compensatory head position.
Treat amblyopia with standard therapy.
Botulinum Toxin: botulinum toxin decreases the amount of
deviation and leash phenomenon (upshoot or downshoot of globe
with adduction).
B) SURGICAL
The aims of surgery are:
To correct a manifest strabismus.
To centralize the field of binocular single vision.
To overcome or reduce the need for a large compensatory head
posture.
Avoid lateral rectus resection.
180
For types 1 and 3 with Leash Phenomenon and/or severe globe
retraction: recession of both medial and lateral rectus muscles
with possible Y- splitting of the lateral rectus muscle.
For type 2 with head turn and fixation with uninvolved eye:
recession of ipsilateral lateral rectus muscle.
For type 2 with head turn and fixation with involved eye:
recession of contralateral lateral rectus muscle.
For type 2 with Leash Phenomenon: recession of lateral rectus
muscle with possible Y-splitting.
Complications of Surgery:
BROWN SYNDROME:
181
ETIOPATHOGENESIS:
Brown syndrome can be divided into congenital and acquired.
182
B- Non superior oblique Brown syndrome:
183
Superior oblique click syndrome :
Inflammation produces a nodule on the superior obliquetendon, just
posterior to the trochlea. The nodule wouldhave difficulty entering the
trochlea, thus restricting tendonmovement.
Peritrochlear scarring:
EPIDEMIOLOGY:
The incidence of this condition is 1 in 450 cases ofstrabismus.
Approximately one in 20,000 live births.The actual incidence may
be higher as many cases are asymptomatic.
There is equal predilection for both sexes in congenital
Brown syndrome.
Wright noted that 5% cases are bilateral and idiopathicBrown
syndrome has a higher preponderance in females(63%) and
traumatic acquired Brown in males (82%).
CLINICAL FEATURES:
184
• Limited left elevation on upgaze is common
• Normal left elevation in abduction
• Absence of left superior oblique overaction
• Positive forced duction test on elevating the globe in adduction.
VARIABLE SIGNS:
• Down-shoot in adduction.
• Hypotropia in primary position.
• AHP with chin elevation and ipsilateral head tilt
Differential diagnosis:
1)Isolated inferior oblique palsy: This is characterized by overaction
of the superior oblique muscle and positive Parks’ three step test.
Forced duction test is free in inferior oblique palsy.
2. Double elevator palsy: Limitation of elevation is present in both
adduction and abduction. In addition the patients have ptosis or
pseudoptosis.
3. Congenital fibrosis syndrome: The differences include
restricted elevation in abduction and esotropia onattempted upgaze.
4.Blow out fracture of the inferior orbital wall: The elevation
deficiency is more marked in abduction.
Imaging reveals a fracture and there may be associatedenophthalmos.
5. Thyroid ophthalmopathy: The elevation deficiency isworse in
abduction than adduction.
6. Adherence syndrome: During inferior oblique surgeryadhesions may
form due to fat prolapse and limit elevationin abduction.
185
MANAGEMENT:
The vision needs to be checked to rule out amblyopia.
Abnormal head posture if present is indicative of thepresence of
fusion.
Forced duction testing needs to be performed to confirm
the diagnosis.
Spontaneous improvement is known to occur. Hence itmay be
prudent to observe cases where there is no threat to
binocularity.
Elevation in adduction exercises can improve the conditionin
congenital cases or in cases where there is intermittentBrown
syndrome.
Injection of corticosteroids has been reported to improvethe
Brown syndrome in patients with inflammatorydisease.
Systemic treatment of the underlying disease may improvecases
of acquired Brown syndrome.
SURGICAL MANAGEMENT:
Indications:
When there is a loss of binocularity, with the chance
ofdevelopment of amblyopia and the child does not developan
abnormal head posture, surgery is indicated.
Mild Brown syndrome needs to be observed. If there ispresence of
primary position hypotropia andunacceptable downshoot on
adduction, surgery can beconsidered.
Acquired cases due to the presence of a scleral explant or
aglaucoma filtering valve need to be operated.
TECHNIQUES:
186
MONOCULAR ELEVATION DEFICIT(MED):
Monocular elevator palsy , sometimes also referred to as double
elevator palsy , is a rare sporadic condition . It is thought to be caused by
either a tight or contracted inferior rectus muscle or a hypoplastic or
ineffective superior rectus muscle .
Etiology:
MED can be congenital or acquired in onset:
Congenitalcases of MED occur sporadically but cases occurring in twins
have been reported .The causes include supranuclear defects, primary
SR paresis and primary IR restriction (congenital fibrosis of inferior
rectus).
Acquired MED is usually caused by cerebrovascular diseases like
hypertension, thromboembolism, arteritis. Other causes include
sarcoidosis, syphilis, and midbrain tumors like pineocytomas, acoustic
neuromas and metastatic tumors.
Clinical Features
Deviation: There is hypotropia of the affected eye when the
normal eye is fixing and hypertropia of the normal eye when the
affected eye is fixing.
Elevation deficit: Monocular limitation of up gaze above midline
(horizontal plane) is present in all the three horizontal positions,
i.e., abduction, primary position and adduction.
187
Ptosis/Pseudoptosis: A hypotropic eye is associated with ptosis
because of the facial attachments between the levatorpalpebrae
superioris and the superior rectus muscle.
188
Classification:
Type 1:
It includes patients with primary IR restriction or fibrosis. They are
often orthotropic in primary gaze. FDT demonstrates restriction of
upward rotation because of a tight IR. The upward saccades are
usually normal until stopped by tight IR preventing further upgaze.
Bells phenomenon is usually poor.
Type 2:
This group includes cases of primary SR palsy and is characterized
by a forced duction test demonstrating no restriction to full
upward rotation of the eyeball. The upward saccades are slow
both below and above midline. Bell’s phenomenon is usually
absent in this type of MED.
Type 3:
It is the supranuclear type of MED, which is usually congenital and
is characterized by intact or mildly reduced vertical saccadic
velocity below midline but abnormal or absent velocity above
midline. There is no resistance to upward rotation of the eyeball
on FDT.
Differential Diagnosis
In Brown’s Syndrome:the limitation of elevation is worse
on adduction and improves on abduction. A V pattern
strabismus and superior oblique restriction on FDT is
characteristic.
Congenital absence of superior rectus and or
inferioroblique often mimic MED but are usually
associated with craniofacial abnormalities.
Congenital fibrosis of extraocular muscles affects inferior
recti initially and can be confused with MED. Bilateral
presentation and involvement of other extraocular
muscles are features that help distinguish it.
A third nerve palsy may simulate the findings of MED.
Abnormal pupillary reactions and exotropia of the
affected eye are seen. A palsy of the superior division of
the third nerve affecting the SR and levator muscle is very
difficult to distinguish from MED.
189
Management:
includes both non-surgical and surgical components.
The correction of underlying refractive error is done.
amblyopia therapy is given if needed, followed by surgery
whenever indicated.
Indications for surgery are significant vertical deviation in
primary gaze, significant abnormal head posture,
deviation-induced amblyopia, diplopia in primary gaze,
and restricted binocular fields.
The goal of surgery is to improve the position of the
affected eye in primary gaze and to increase binocular
field of vision.
190
In the primary position each eye is fixed below the
horizontal by about 10°.
The hypotropic eye may be secondarily exotropic,
esotropic or neutral.
The degree of residual
horizontal movement varies
from full to absent.
Vertical movements are
always severely restricted with
inability to elevate the eyes
above the horizontal plane.
A subset of cases show unilateral fibrosis with
enophthalmos and ptosis
Systemic associations:
o Mental retardation
o Facial palsy
o Dental anomalies
o Spina bifida
MANAGEMENT OF CFEOM :
Surgery is difficult and requires release of the restricted
muscles (weakening procedures).
Fibrosis of adjacent tissue may be present as well.
A good surgical result aligns the eyes in primary position,
but full ocular movements cannot be restored.
Outcome of such surgeries is always unpredictable.
MÖBIUS SYNDROME:
191
Neural Imaging studies have shown:
o Brain stem hypoplasia in the region of the sixth and
the seventh nerve & hypoplasia of extraocular
muscles and intraorbital motor nerves
CLINICAL FEATURES:
Systemic features :
Bilateral facial palsy which is usually asymmetrical giving
rise to a mask-like facial expression andproblems with lid
closure.
Paresis of the 12th cranial nerves which results in atrophy
of the tongue.
Mild mental handicap.
Limb & Chest wall anomalies.
Ocular features :
Horizontal gaze palsy is present in 50% of cases.
Bilateral 6th nerve palsy.
Occasionally 3rd and 4th nerve palsy and ptosis.
MANAGEMENT:
Non-surgical management-
Detection and treatment of amblyopia, corneal exposure
and refractive errors
Surgical management-
No single surgery useful
Medial rectus muscle recession is tried
Transposition of vertical recti to insertion of LateralRectus
described.
192
STRABISMUS FIXUS:
It is a rare congenital anomaly in which both eyes are fixed in either the
convergent position caused by fibrous tightening of the Medial Recti
DivergentStrabismus Fixus:
193
VISION THERAPY
•Used to correct:
- Convergence insufficiency :
•CI is one of the few ocular problems that can interfere with the physical
act of reading.
194
•It can cause blurring of vision and the sensation that letters and words
run together especially during times of prolonged reading or near work.
•Most common treatment for CI is pencil push-ups in which the patient
practices turning his/her eyes inward to converge on a near target such
as a pencil point.
195
SIGHT VERSUS VISION:
•6/6 eyesight is the ability to see a certain letter size on the eye chart
when standing 6 meter away. You can have 6/6 eyesight, but still have a
vision problem.
•This is because reading an eye chart is a static visual task, but most
daily activities require our eyes to perform more demanding, dynamic
functions.
•There are four aspects of vision that are important in daily activities
and learning.
Aspects of vision:
•Eye Tracking (Oculomotor).
•Eye focusing (Accommodation).
•Eye Teaming/Fusion (Binocularity).
•Visual Perception.
196
3-Eye Teaming/Fusion (Binocularity):
•Eye fusion is the ability of two eyes to work together to obtain a single
image.
•Many children maintain the use of both eyes working together;
however, it may come at the expense of excessive effort, fatigue and
sometimes confusion.
•Strabismus is the condition where both eyes fail to work together and
one or both of the eyes deviates instead of aiming at one location.
•The inability of both eyes to work together as a team can result in
double vision, reduced depth perception and poor physical coordination
in sports.
4-Visual Perception:
197
•Modalities include eye exercises, flashing light response exercises,
prisms, wearing tinted or colored lenses, filters, occluders, specialized
instruments, computer programs and other devices.
198
5-Visual Rehabilitation for Special Populations:
•Vision can be compromised as a result of neurological
disorders or trauma to the nervous system (such as,
traumatic brain injuries, stroke, cerebral palsy,
multiple sclerosis, etc.).
•Vision Therapy can effectively treat the visual
consequences of trauma (including double vision) .
199
Methods of treatment:
1-The Brock String :
•The Brock String is a simple tool which gives the child a great deal of
visual feedback.
•It teaches the patient how to aim his eyes together
correctly for varying distances in space and allows
him to experience the difference between
convergent and divergent eye aims.
•It also allows the child to determine if he is
suppressing, and tells him where his eyes are aimed
and how far off his eye aim may be.
•This is usually one of the first techniques the child is
taught and is often assigned as home therapy.
2-Computers :
3- Cheiroscope:
200
•Training on the cheiroscope gives the child important feedback that he
is suppressing and allows him an opportunity to gain the binocular
control necessary to correct his eye aim and eliminate suppression.
4-Aperture rule:
5-Amblyoscope :
201
•Vision therapy trains the eyes to work together but to do so both eyes
have to be "on".
•Here a therapist works with a child using
special red-green lenses and a target with red-
green letters.
•One eye can only see the red letters, and the
other the green.
•If the visual system shuts off an eye, the child
won't be able to see all of the letters.
•Antisuppression activities such as these make the child aware of when
she is suppressing and allow her to gain control and learn to leave both
eyes on simultaneously.
•This is especially important for children with crossed eyes, and lazy
eyes .
8-Mental minus:
202
9-Vectograms :
10-Tug exercises:
203
12- The rotator:
•The walking rotator integrates the child's eye movements with his or
her body movements.
•The child is asked to find letters or pictures on the turning wheel as he
walks on a raised rail.
•This activity not only helps tracking skills, but it
also improves visual motor integration skills.
•Our visual systems are continually sending
information to our bodies to help control
movement, balance, coordination.
•Children who have poor control over their visual
systems often have poor control over their body
coordination.
•These children appear awkward and clumsy, do
poorly in sports, and may find it difficult to learn to ride a bike.
•Fine motor skills are also affected. Poor handwriting is a common
problem of children with poor eye-hand coordination .
Convergence insufficiency:
204
Diagnosing of Convergence insufficiency Symptoms:
205
Cause of Convergence insufficiency:
206
- In-office Vision Therapy
•The studies conducted by the CITT Investigator Group have shown that
in-office vision therapy is the only treatment for CI more effective.
•Therapy is typically comprised of a 45 or 60-minute session conducted
once or twice a week, with 15-30 minutes of home therapy performed
during the week.
•The CITT protocol was comprised of 12 weeks of 60-minute weekly
sessions in-office, with 15 minutes of home reinforcement on weekdays.
•It is prudent to consider any prior amblyopia and suppression present
prior to starting therapy.
•It is ideal for the appropriate refractive correction to be in place.
•While this should not be the case for a patient with symptomatic CI
exophoria, the presence of an intermittent or constant strabismus would
provide additional barriers that would compromise success.
•Please note that patients with preexisting strabismus and amblyopia
were excluded from the CITT studies.
•In general, the sequence of vision therapy is as follows:
1. Anti-suppression activities and development of physiologic diplopia
awareness.
2. Monocular activities to normalize accommodative amplitude and
facility.
3. Activities utilizing monocular fixation in a binocular field.
4. Fusional vergence training – both positive and negative.
5. Integration of fusional vergence training with binocular
accommodation, as well as free space fusion activities.
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•Although deep suppression is uncommon in an exophoric patient with
symptomatic CI, shallow, central, facultative suppression may still be
present.
•Thus, anti-suppression activities are still advisable during the earlier
sessions of vision therapy. Anti-suppression activities often utilize red/
green glasses, red lenses, and polarized filters to provide the patient
with visual cues regarding suppression.
•The cheiroscope can be used to train anti-suppression.
•The Brock String is also a common and convenient
tool used during these beginning stages of vision
therapy.
•Instruments, such as the stereoscopes can also
provide an artificial environment in which the
patient can be more easily anti-suppressed.
•Once suppression is broken, the patient can be
made aware of physiological diplopia.
•The next step in vision therapy includes training of monocular
accommodative amplitude and facility. These monocular activities often
involve the use of lens flippers, as well as varying distances of targets.
•Some examples of these include monocular distance-to-near Hart chart
rock, monocular lens sorting and monocular loose lens rock.
•Once suppression has been appropriately broken and accommodative
functions strengthened, fusional vergence training can begin.
•In general, all activities begin where fusion is strongest; in the case of a
patient with symptomatic CI, these activities would be at a greater
distance.
•The targets and tools would then be brought closer as
the patient’s convergence strengthens.
•The goals of fusional vergence training are to expand
both the positive and negative fusional vergence ranges
utilizing both the slow, smooth vergence system.
•There are a number of tools used during fusional
vergence procedures.
•For example, one could use vectograms or
tranaglyphs, which are available in either variable or
non-variable forms.
•Loose prisms can also be flipped or dipped‖ to
strengthen jump vergences and vergence facility.
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Home vision therapy:
•Of course, not all patients are a good fit for active treatment measures
such as vision therapy or HBPP.
•Thus, for this subset of patients with symptomatic CI, would base-in
prism reading glasses be a viable treatment option?
•On one hand, Scheiman et al., found that base-in prism reading glasses
were no more effective than placebo lenses and thus were not an
effective treatment for children with symptomatic CI.
•The amount of prism prescribed was based on Sheard’s criterion, with
the average amount of prism prescribed being approximately 4 prism
diopters of base in prism.
•Compliance to treatment was excellent, and both groups ; those with
base-in prism reading glasses and those wearing placebo glasses;
showed statistically significant decreases in symptoms.
•On the other hand, Pang et al., used base-in prism reading glasses to
treat presbyopic patients symptomatic for CI.
•Their results indicated that glasses were successful in managing
symptoms in this patient population, particularly if those with greater
near heterophorias and receded near points of convergence.
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•Overall, it appears that base-in prism glasses for managing
symptomatic CI offers passive, rather than active treatment.
Conclusion:
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