 Strabismus
Refractive errors
Amblyopia
Strabismus
= Squint
- Misalignment of the eyes (fovea of one eye
fixates at the target & and fovea of the
other eye is off...
Anatomy of extra ocular
muscles
-Six extra-ocular muscles in each
eye(responsible for eye movements)
- Four rectus (straig...
Cont…
Rectus muscles:-
- Origin:-common annular tendon of Zinn,
around the optic foramen.
- Insertion:-sclera,various dist...
Cont…
Innervation : - IIICN = - Medial Rectus
- Inferior rectus
- Superior rectus
- Inferior oblique
-IV CN = Superior
obl...
Actions of the rectus muscles
 LR = abduction
 MR = adduction
 SR = elevation, intorsion and adduction
 IR = depressio...
Oblique Muscles
Inferior oblique:-
- origin:-inner end of the inferior orbital rim
- insertion:- outer part of the sclera...
Cont…
 Superior Oblique
Origin:- upper and inner margin of optic
foramen
Insertion:-posterior to equator-supero-temporal
...
Strabismus
- Strabismus = a Latin word for
squint
- Squint= eyes are looking in different
direction
- Many possible causes...
Binocular Reflexes
 Involve Sensory and Motor parts
 Sensory:- takes two images produced by
the two eyes and joins them ...
Cont…
 Disorders of vision affect Sensory part of the
reflex
-no stimulus from the diseased eye to
remain pointing in the...
Cont…
 Disorders of the eye movements affect the
motor part of the reflex
- Extra ocular muscles
-Congenital abnormalitie...
Strabismus Cont…
 Phoria:- a latent deviation where there is
an underlying tendency for the
eyes to drift apart
- held in...
Bruckner test=Red reflex test
=Illumination test
 Part of routine pediatric ophthalmology
examination
 Uses direct ophth...
Problems which can be
identified by Brückner-test:
1. Squint
2. Anisometropia
3. Opacities within the optical media (
corn...
Bruckner test cont…
 Brighter reflex :-Strabismus
 Dimmer reflex :- Ametropia
-Media opacity
N.B.: Strabismic angles as
small as 1° are detectable!
Strabismus cont…
 Esotropia:- inward deviation
 Exotropia:- outward deviation
 Hypertropia:- upward deviation
 Hypotro...
Esotropia
 Inward turning of the eye
 The most common form of childhood
strabismus
 Usually associated with hyperopia
...
Management of Esotropia
 Convex (+) glasses
Accommodative esotropia
 Surgery
- Congenital Esotropia
- Acquired nonaccomm...
Exotropia
 Outward deviation of the eye
 Types:-
- Congenital
- Acquired - nonparalytic
- paralytic e.g III
nerve palsy
Management of Exotropia
 Nonsurgical
Corrective glasses espe. Myopia
Overminusing!
 Surgical
Vertical Strabismus
 Hypertropia, hypotropia
 Types:-
-Comitant:-
usually accompanies horizontal
strabismus
-Incomitant ...
Management of Vertical
strabismus
Surgery!
Management of Strabismus
 In children:-
1. Find the cause
2. Correct refractive errors with spectacles
3. Treat Amblyopia...
Refractive Errors
Refractive states of the eye
 Measured looking in the
distance(usually 6mts) so that the
ciliary muscle is relaxed (that ...
Emmetropia
 A normal condition
 Parallel rays of light from infinity come
to a focus on the retina(fovea)
=> no error of...
Ametropia
 Abnormal condition/absence of emmetropia
 Parallel rays of light from infinity do not
come to a focus on the ...
Anisometropia
 Unequal refractive power of the eyes
e.g :-
1. one eye emmetropic, the other one
myopic
2. OD;- 0, OS:- -3...
Pinhole test
 Any patient with defective visual acuity
should be tested again with a pinhole
 If visual acuity improves ...
Ametropia cont…
 Axial ametropia:-
- the eye ball is either unusually long
(Myopia)or short(Hyperopia)
 Refractive ametr...
Myopia=Short-sightedness
 Short-sightedness
 A condition where the light rays from a
distance object are focused in fron...
Treatment of myopia
 Concave(-) spherical glasses
 Contact lenses(concave)
 Laser surgery
Hyperopia/Hypermetropia
=long-sightedness
 An error of refraction in which parallel
rays of light from infinity come to a...
Symptoms of Hyperopia
 Blurring of near vision
 Not much compliant regarding
distance vision, as distance vision does
no...
Treatment
 Convex (+)spherical glasses
 Convex contact lenses
 Laser surgery
Astigmatism
 The eye has a different focus in
different planes
 An error of refraction in which the
parallel rays of lig...
Causes of astigmatism
a. Unequal curvature of the cornea or
lens in different meridians, so that
the refractive surfaces a...
Symptoms of astigmatism
 Diminished visual acuity
 Headache due to exertion of
accommodation to rectify the defect
parti...
Treatment
 Cylindrical lenses
-spectacles
-contact lenses
 Laser surgery
Presbyopia
 Usually becomes age beyond 40 years
 Part of the natural ageing process in
the lens
 With age lens becomes ...
Symptoms of Presbyopia
 Blurring of vision while reading
books/carry out near- vision tasks.
 Vision improves if the obj...
Treatment of presbyopia
 Convex spherical lenses, which is
added on glasses if any for distant
vision.
Amblyopia
=>Poor vision caused by abnormal
visual experience early in life. (i.e. in
the immature visual system)
Visual development…
 Continues until 7/8 years
 Latent period in first 6/52 of life
 Followed by critical or sensitive ...
Cont…
 Amblyopia=a greek term
amblyos=dull/blunt,
Opia=vision
 Occurs in 2-4% of the general
population
 The most commo...
Definition of amblyopia
 A unilateral/bilateral reduction of best
corrected visual acuity that can’t be
attributed to the...
Pathophysiology
i. Abnormal binocular interaction
ii. Retinal image blur
iii. Both
Three “D”s
i. Deviated i.e strabismus
i...
Management
 One of the most time consuming
tasks in pediatric ophthalmology
,but if successful it is one of the
most rewa...
Cont…
 Basic Strategies:-
1. Provide a clear retinal image
2. Correct ocular dominance
Cont…
1. Occlusion:-
-”gold standard”
- priciple:- cover the sound eye to force
the poor seeing eye to see better
2. Penal...
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
#8 re,strabismus & amblyopia (2)
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#8 re,strabismus & amblyopia (2)

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#8 re,strabismus & amblyopia (2)

  1. 1.  Strabismus Refractive errors Amblyopia
  2. 2. Strabismus = Squint - Misalignment of the eyes (fovea of one eye fixates at the target & and fovea of the other eye is off the target) - affects~5% of the population
  3. 3. Anatomy of extra ocular muscles -Six extra-ocular muscles in each eye(responsible for eye movements) - Four rectus (straight) :- Superior rectus - Inferior rectus - Medial rectus - Lateral rectus - Two oblique:- - Superior Oblique - Inferior Oblique
  4. 4. Cont… Rectus muscles:- - Origin:-common annular tendon of Zinn, around the optic foramen. - Insertion:-sclera,various distances from the limbus - Blood Supply:- muscular branches of the ophthalmic artery
  5. 5. Cont… Innervation : - IIICN = - Medial Rectus - Inferior rectus - Superior rectus - Inferior oblique -IV CN = Superior oblique -VI CN = Lateral Rectus
  6. 6. Actions of the rectus muscles  LR = abduction  MR = adduction  SR = elevation, intorsion and adduction  IR = depression, extorsion and adduction
  7. 7. Oblique Muscles Inferior oblique:- - origin:-inner end of the inferior orbital rim - insertion:- outer part of the sclera behind the equator, around the macula - Action :- Extortion, elevation and abduction
  8. 8. Cont…  Superior Oblique Origin:- upper and inner margin of optic foramen Insertion:-posterior to equator-supero-temporal quadrant ( after passing through TROCHLEA) Action :- intorsion, depression and abduction
  9. 9. Strabismus - Strabismus = a Latin word for squint - Squint= eyes are looking in different direction - Many possible causes for a squint to develop=>a cause should be looked for - For a squint to develop, Binocular reflexes should fail.
  10. 10. Binocular Reflexes  Involve Sensory and Motor parts  Sensory:- takes two images produced by the two eyes and joins them together in the brain.  Motor:-the two eyes always move together, so that they are always pointing in the same direction  The binocular reflexes are much weaker in children, and there fore squints usually start in early childhood
  11. 11. Cont…  Disorders of vision affect Sensory part of the reflex -no stimulus from the diseased eye to remain pointing in the same direction as the healthy eye, so the diseased eye develops a squint e.g -corneal scar -cataract -retina/optic nerve lesion
  12. 12. Cont…  Disorders of the eye movements affect the motor part of the reflex - Extra ocular muscles -Congenital abnormalities -Fractures of the orbital walls -Dysthyriod eye diseases -Diseases of the EOM(e.g.myopathy) - Cranial Nerves -Paralysis
  13. 13. Strabismus Cont…  Phoria:- a latent deviation where there is an underlying tendency for the eyes to drift apart - held in alignment by motor fusion  Intermittent tropia:- -a latent deviation becomes manifest when fusion brakes at times  Tropia:-strabismus is manifest
  14. 14. Bruckner test=Red reflex test =Illumination test  Part of routine pediatric ophthalmology examination  Uses direct ophthalmoscope  In a dim room the observer views through the ophthalmoscope from a distance of ~ 1 meter.  Assesses the RED REFLEXES in both eyes SIMULTANEOUSLY- should appear BRIGHT and EQUAL in both eyes
  15. 15. Problems which can be identified by Brückner-test: 1. Squint 2. Anisometropia 3. Opacities within the optical media ( cornea,lens,vitreous) 4. Changes of the fundus (Coloboma, RBL)
  16. 16. Bruckner test cont…  Brighter reflex :-Strabismus  Dimmer reflex :- Ametropia -Media opacity
  17. 17. N.B.: Strabismic angles as small as 1° are detectable!
  18. 18. Strabismus cont…  Esotropia:- inward deviation  Exotropia:- outward deviation  Hypertropia:- upward deviation  Hypotropia:- downward deviation
  19. 19. Esotropia  Inward turning of the eye  The most common form of childhood strabismus  Usually associated with hyperopia  Types:-congenital -Acquired:-Accommodative -Nonaccommodative -Incomitant e.g VI nerve palsy
  20. 20. Management of Esotropia  Convex (+) glasses Accommodative esotropia  Surgery - Congenital Esotropia - Acquired nonaccommodative esotropia - Paralytic esotrpia  Parasympathomimetics
  21. 21. Exotropia  Outward deviation of the eye  Types:- - Congenital - Acquired - nonparalytic - paralytic e.g III nerve palsy
  22. 22. Management of Exotropia  Nonsurgical Corrective glasses espe. Myopia Overminusing!  Surgical
  23. 23. Vertical Strabismus  Hypertropia, hypotropia  Types:- -Comitant:- usually accompanies horizontal strabismus -Incomitant - muscle restriction - paralytic e.g IV nerve palsy
  24. 24. Management of Vertical strabismus Surgery!
  25. 25. Management of Strabismus  In children:- 1. Find the cause 2. Correct refractive errors with spectacles 3. Treat Amblyopia 4. Straighten the eyes with surgery  In adults:- - If the squint started in childhood= cosmetic surgery - If the squint is recent - look for a cause -wait 6 mons.before considering surgery
  26. 26. Refractive Errors
  27. 27. Refractive states of the eye  Measured looking in the distance(usually 6mts) so that the ciliary muscle is relaxed (that is not accommodated)
  28. 28. Emmetropia  A normal condition  Parallel rays of light from infinity come to a focus on the retina(fovea) => no error of refraction/visual acuity is normal
  29. 29. Ametropia  Abnormal condition/absence of emmetropia  Parallel rays of light from infinity do not come to a focus on the retina (fovea) =>error of refraction * Myopia or short/Near-sightedness * Hyperopia or long/Far- sightedness * Astigmatism ** Presbyopia
  30. 30. Anisometropia  Unequal refractive power of the eyes e.g :- 1. one eye emmetropic, the other one myopic 2. OD;- 0, OS:- -3.0 D 3. OD:- +1.5 D, OS:- +3.5 D
  31. 31. Pinhole test  Any patient with defective visual acuity should be tested again with a pinhole  If visual acuity improves with pin hole=> refractive error  If no improvement=>the loss of vision is from eye disease
  32. 32. Ametropia cont…  Axial ametropia:- - the eye ball is either unusually long (Myopia)or short(Hyperopia)  Refractive ametropia:- -The length of the eye is normal - Excessive power in myopia, inadequate in hyperopia e.g of extreme refractive hyperopia=Aphakia
  33. 33. Myopia=Short-sightedness  Short-sightedness  A condition where the light rays from a distance object are focused in front of the retina.  There fore the image at the retina is blurred and the vision is poor for distance objects, but good for near objects.  The greater the degree of myopia, the closer the patient has to hold things to see them clearly without any spectacles
  34. 34. Treatment of myopia  Concave(-) spherical glasses  Contact lenses(concave)  Laser surgery
  35. 35. Hyperopia/Hypermetropia =long-sightedness  An error of refraction in which parallel rays of light from infinity come to a focus behind the retina, so they are blurred at the retina.  Visual acuity is decreased except for young people who can use their accommodation to focus on the retina.  With age the power of accommodation decreases.
  36. 36. Symptoms of Hyperopia  Blurring of near vision  Not much compliant regarding distance vision, as distance vision does not need accommodation that much.  Headache due to constant strain on accommodation
  37. 37. Treatment  Convex (+)spherical glasses  Convex contact lenses  Laser surgery
  38. 38. Astigmatism  The eye has a different focus in different planes  An error of refraction in which the parallel rays of light from infinity cannot converge to a point focus due to unequal refraction in different meridians of the optical focus of the eye.
  39. 39. Causes of astigmatism a. Unequal curvature of the cornea or lens in different meridians, so that the refractive surfaces are not spherical. b. Decentering of the lens due to slight shifting in position or tilting of the lens as occurs in subluxation.
  40. 40. Symptoms of astigmatism  Diminished visual acuity  Headache due to exertion of accommodation to rectify the defect particularly in hypermetropic astigmatism
  41. 41. Treatment  Cylindrical lenses -spectacles -contact lenses  Laser surgery
  42. 42. Presbyopia  Usually becomes age beyond 40 years  Part of the natural ageing process in the lens  With age lens becomes harder=>loss of elasticity of the lens=>loss of accommodative response  The eye can still see distant objects clearly, but cannot focus on near objects.
  43. 43. Symptoms of Presbyopia  Blurring of vision while reading books/carry out near- vision tasks.  Vision improves if the object is held further away from the eye.  Those doing close work feel the symptoms earlier.
  44. 44. Treatment of presbyopia  Convex spherical lenses, which is added on glasses if any for distant vision.
  45. 45. Amblyopia =>Poor vision caused by abnormal visual experience early in life. (i.e. in the immature visual system)
  46. 46. Visual development…  Continues until 7/8 years  Latent period in first 6/52 of life  Followed by critical or sensitive period  Affected by disease/visual deprivation in sensitive period
  47. 47. Cont…  Amblyopia=a greek term amblyos=dull/blunt, Opia=vision  Occurs in 2-4% of the general population  The most common cause of decreased vision in childhood(birth-7/8 yrs.)
  48. 48. Definition of amblyopia  A unilateral/bilateral reduction of best corrected visual acuity that can’t be attributed to the effect of any structural abnormality of the eye or posterior visual pathway.  If best corrected vision in one eye is at least two lines worse in the snellen chart than the other eye or a vision of 6/12 or worse in both eyes
  49. 49. Pathophysiology i. Abnormal binocular interaction ii. Retinal image blur iii. Both Three “D”s i. Deviated i.e strabismus ii. Defocused i.e anisometropia, ametropia iii. Deprived e.g. cataract,corneal opacity,etc
  50. 50. Management  One of the most time consuming tasks in pediatric ophthalmology ,but if successful it is one of the most rewarding!
  51. 51. Cont…  Basic Strategies:- 1. Provide a clear retinal image 2. Correct ocular dominance
  52. 52. Cont… 1. Occlusion:- -”gold standard” - priciple:- cover the sound eye to force the poor seeing eye to see better 2. Penalization(optical/pharmacologic):- Blurring of the sound eye to force fixation with the amblyopic eye.
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