Strabismus

Strabismus and Amplyopia
Liang Ya
The First Affiliated Hospital of
Nanjing Medical University
[email protected]
Outline
• Anatomy of extraocular muscles
• Ocular movements
• Neurogenic control of binocular movements
• Binocular vision
• Strabismus(incomitant/restrictive/comitant/surgery)
• Nystagmus
Anatomy of extraocular muscles
R
R
Superior Oblique Muscle
• This muscle arises from the body of the sphenoid bone, superomedial to the
common tendinous ring.
• It passes anteriorly, superior and medial to the superior and medial rectus
muscles.
• It ends as a round tendon that runs through a pulley-like loop called the
trochlea.
• After passing though the trochlea, the tendon of the superior oblique turns
posterolaterally and inserts into the sclera at the posterosuperior aspect of
the lateral side of the eyeball.
Inferior Oblique Muscle
• The muscle arises from the maxilla in the floor of the orbit.
• It passes laterally and posteriorly, inferior to the inferior rectus muscle.
• It inserts into the sclera at the posteroinferior aspect of the lateral side of
the eyeball.
Nerve Supply
Muscle Action(s) on the Eyeball NerveSupply
Medial Rectus Adducts CN III
Lateral Rectus Abducts CN VI
Superior Rectus Elevates, adducts, and medially CN III

rotates
Inferior Rectus Depresses, adducts, and laterally CN III
rotates
Superior Oblique Depresses, abducts, and medially CN IV
rotates
Inferior Oblique Elevates, abducts, and laterally CN III
rotates
Blood Supply
• The muscular branches of the ophthalmic
artery
Ocular movements
• The vertical axis adduction and abduction
• The horizontal axis elevation and depression
• The anteroposterior axis torsion
Terminology of ocular movements
• Duction
Adduction abduction,
supraduction infraduction,
Intorsion extorsion
• Version
• Vergence
Positions of Gaze
• Primary position 1
• Secondary position 4
• Tertiary position 4
Actions of extraocular muscles
Agonist, synergist and antagonist
• Agonist
a muscle moving the eye in the direction of its
action.
• Synergist
any muscle which aids the action of other muscle
and it could either be in the same eye or in the
other eye.
• Antagonist
any muscle opposing the action of other muscle.
Yoke muscles
Neurogenic control of binocular
movements
• Hering’s law
During conjugate ocular movements, simultaneous and equal
innervation flows to the yoke muscles.
• Sherrington’s law
Increased innervation and contraction of an extraocular muscle
are accompanied by a reciprocal decreased innervation and
contraction of its antagonist
Central control of eye movements
Binocular vision
• The vision achieved by the coordinated use of both
eyes in such a way that the images formed in
individual eyes seperatedly are appreciated as a single
mental picture.
• Grade I: Simultaneous macular perception
• Grade II: Fusion
• Grade III: Stereopsis
Anomalies of binocular vision
• Suppression
• Amblyopia
• Anomalous retinal correspondence
• Eccentric fixation
Amblyopia (lazy eye)
• Unilateral or bilateral decrease in visual acuity
without any organic ocular lesion.
1 Strabismic amblyopia
2 Refractive amblyopia
3 Anisometropic amblyopia
4 Isoametropic amblyopia
5 Deprivation
Amblyopia management
• Removal of amblyogenic factor
• Occlusion
• Penalization
• Stimulation of amblyopia eye
• Levodopa treatment
Strabismus (squint)
Certain eyes are so positioned that the
image falls upon the fovea of one eye
but not on the fovea of the other.
The misalignment of the visual axes of

the two eyes is called strabismus.
Classification of Strabismus
1. age of onset 2. type of deviation
a. congenital a. horizontal
b. acquired b. vertical
c. rotated
d. combined
3. fusional status 4. variation of deviation with gaze

a. phoria with fusional control position
b. tropia without fusional control a. comitant
b. incomitant
Pseudostrabismus
• Epicanthal folds
• Hypertelorism
• Orbital or palpebral asymmetry
• Abnormal angle kappa
Incomitant Strabismus
• Definition
• Etiology
• Clinical feasures
• Investigations
• Treatment
Impaired action of one or more extraocular
muscles associated with diplopia and variation
in the angle of deviation in different directions of
gaze.
Neurogenic cause
Myogenic cause
Mechanical cause
• Clinical features
• Diplopia
• Vertigo
• Angle of deviation
• Primary and secondary deviation
• Limitation of ocular movement
• Compensatory head and chin positon
• Ocular torticollis
• False projection or false orientation
• Ophthalmoplegia
• Postparalytic secondary changes in extraocular muscles
• Investigations
• Diplopia charting
• Hess screen test
• Forced duction test
• Treatment
• Conservative measures
• Chemodenervation
• Surgery
Restrictive strabismus
• Definition
• Etiology
• Investigations
• Treatment
• Etiology
• Duane’s syndrome
• Brown’s syndrome
• Strabismus fixus
• Treatment
• When binocularity is compromised
• Or for cosmetic reason
Comitant Strabismus
• Definition
• Etiology
• Investigations
• Treatment
Comitant Strabismus
• The eyes maintain their abnormal relationship
in all direction of cardinal gaze.
Comitant Strabismus
• Etiology
• Genetic
• Uncorrected refractive error
• Abnormal convergence
• Imbalance between accommodation and convergence
• Anisometropia
• Unilateral visual impairment
• Congenital and developmental defects of extraocular muscles
• Defects in the central mechanism
Comitant Strabismus--Types
esophoria
exophoria
heterophoria
hyperphoria
cyclophoria
esdeviation
exodeviation
heterotropia
hypertropia
A- and V- patterns
Comitant Strabismus
• Heterophoria is a condition in which there is a
tendency for nonalignment of the visual axes
which is corrected or compensated by the
fusional reflex.
• Heterotropia is a manifest strabismus in which

deviation of the eye remains constant in all
directions of gaze.
A- and V- patterns
Comitant Strabismus
• Symtom-free
• Bought by their parents for cosmetic purpose
• Strabismus angle remains constant
• No diplopia owing to suppression of the image
in the deviating eye
Comitant Strabismus
• Diagnosis
• History
• Visual acuity
• Refractive error
• Cover/uncover test
• Measurement of deviation angle
• Test for binocular sensory function
Measurement of deviation angle
• Corneal reflex test(Hirschberg’s Test)
• Prism reflex test of krimsky
• Measurement on synoptophore
Test for binocular sensory function
• Worth’s four dots test
• Bagolini striated glasses test
• Hering-Bielschowsky after-image test
• Determination of type of fixation
• Synoptophore examination
Comitant Strabismus
• Treatment principles
• To improve the cosmetic appearance

• To improve the viaual acuity in each eye
• To maintain the binocular vison
• Correction of refractive error
• Occlusion
• Orthoptic exercises
Strabismus surgery
• To align the two eyes cosmetically
• To restore the binocularity also
• Resection Strengthen a weak muscle
• Recession Weaken an overacting muscle
• Complicaitons
Complications of the surgery
• Undercorrection
• Overcorrection
• Diplopia
• Enophthalmos
• Conjunctival cyst
• Granuloma
Nystagmus
• Definition
• Etiology
• Types
• Differential diagnosis
• Treatment
Nystagmus
• Rapid, regular and rhythmic involuntary
movements of bilateral eyes with very poor
vision
Etiology:
Physiological
Congenital
Infantile
Acquired
Treatment of nystagmus
• Correction of refractive error
• Prism therapy
• Surgery
Summary
1 Anatomy of extraocular muscles 2 Eye movements
3 Amblyopia 4 Strabismus

Strabismus

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Strabismus and Amplyopia

Medial Rectus Adducts CN III

Lateral Rectus Abducts CN VI

Superior Rectus Elevates, adducts, and medially CN III

The misalignment of the visual axes of

3. fusional status 4. variation of deviation with gaze

• Heterotropia is a manifest strabismus in which

• To improve the cosmetic appearance

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