staribmus

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Strabismus For Medical
Students & GP
Samir Jamal
MD, FRCSC
KAUH

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Strabismus
 Misalignment of one or both eyes so as
the eye (eyes) is not looking straight at
the object of regard.

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Significance In Children
 Children need normally aligned eyes to
develop vision.
 Strabismus in childhood is the second
most common presentation of
retinoblastoma.
 Strabismus is a common presentation
for refractive errors.

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Significance in Adults
 Frequent sign of neurological disease
 Frequent presentation of systemic
disease ( Thyroid disease & Myasthenia)
 Cosmetology

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Types of Eye Movements
 Horizontal direction
 Vertical direction
 Torsional direction
All superior muscles are intortors.
All inferior muscles are extortors.

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Anatomy & Physiology
Muscle Nerve Function Testing
MR 3 rd Nasal Look to nose
LR 6th Temporal Look away
SR 3rd Elevate, intorts,
adducts
Up & Out
IR 3 rd Depress, extrorts,
adduct
Down & Out

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Anatomy & Physiology
Muscle Nerve Function Testing
Superior
Oblique
4th Intorts, depress,
abducts
Look Down
& In
Inferior
Oblique
3rd Extrorts, elevates,
abducts
Look Up & In

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Types of Strabismus
 Esodeviation  eye turned in
 Exodeviation  eye turned out
 Hyperdeviation  eye turned up
 Hpodeviation  eye turned down

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Classification of Strabismus
 Constant or intermittent
 Latent or manifest (phoria or tropia)
 Unilateral or alternating
 Comitant or incomitant (restrictive or
paralytic)
 Paralytic or non-paralytic
 Nuclear or supranuclear

10. Non-Accommodative Esotropia
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11. Non-Accommodative Esotropia
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12. Alternating Esotropia
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13. Exotropia
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15. Alternating Esotropia
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Causes of Strabismus
 Congenital: imbalance between innervations
and contraction
 Refractive errors
 Loss of vision
 Paralysis or Neuromuscular
 Restrictive: thyroid eye disease
 Tumors

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Strabismus secondary to loss of
vision from Cataract in Lt. eye

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Presenting symptoms of
Strabismus
 Deviation of the eye (cosmesis)
 Double vision
 Torticollis (abnormal head posture)
 Unexplained visual loss in a normal
looking eye (Microtropia)

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Abnormal Head Posture

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Role of GP
1. Confirm Diagnosis
2. Decide on urgency
3. Teach patients
4. Referral to Ophthalmologist

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Management of Strabismus
History:
4 most important questions:
1. Age of onset
2. Constant or intermittent
3. Unilateral or alternating
4. Diplopia or torticollis

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Management of Strabismus
Examination:
Three objectives:
1. Confirm the diagnosis
2. Diagnose type of strabismus
3. Differentiate paralysis from no paralysis

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Examination of Strab Patient
To achieve the first and second
objectives we do:
1. Simple observation for the nasal
white of the eye
2. Corneal light reflex
3. Cover test

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Examination of Strab Patient
To achieve the 3 rd objective we look for:
1. Presence of torticollis
2. Answer the following question:
Is the strabismus the same in all directions
of gaze or not i.e. comitant or incomitant?
 Same = no paralysis.
 Different = paralysis or restriction.

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Examination
3. Test the extraocular movements in all
directions of gaze.
 Paralysis / restriction  Limitation
 No Paralysis  No limitation

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Doll's Head Manoeuvre
 Used for testing the eye movement
when the patient is uncooperative.
 The eyes move in opposite direction to
the head movement.

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Common Forms of Esotropia
 Congenital (No-Accommodative)
 Surgery.
 Accommodative  R/ Glasses.
 P. Accommodative Glasses then
surgery.
 Sixth Nerve Palsy  observation
for 6 M  surgery.

30. Accommodative Esotropia
Before Glasses After Glasses
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31. Non-Accommodative Squint
Non-Accommodative Esotropia Before and After
Surgery
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32. Partially Accommodative
Squint
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Common Forms of Exotropia
 Congenital exotropia Surgery
 Sensory deprivation exotropia
 Third nerve paralysis

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Common Causes of Hypertropia or
Hypotropia
1. Fourth nerve palsy
2. Third nerve palsy
3. Thyroid disease
4. Myasthenia gravis
5. Orbital floor fracture