Lecture given at Ateneo School of Medicine and Public Health, Philippines, November 2015

1. Strabismus &
Amblyopia
Alvina Pauline D. Santiago, MD
November 14, 2015
ASMPH

2. http://www.slideshare.net/
AlvinaPaulineSantiag/2015-asmph-strabismus-
and-amblyopia

3. Orbital Apex
Annulus of Zinn
Nerve Supply
http://lms.ecco-org.eu

4. http://www.cambridgequestions.co.uk

5. Spiral of Tillaux
www.cybersight.org

6. Horizontal rectus muscles

7. Vertical rectus muscles

8. Oblique muscles
Superior oblique
Inferior oblique

9. Inferior Oblique
❖ Origin: Shallow
depression on orbital
plate of maxilla
❖ Insertion:
inferotemporal
quadrant of sclera near
the macula
Rangeen Shandran R. http://
www.slideshare.net/RangeenChandran

10. Superior Oblique
❖ Origin: Lesser wing of
sphenoid
❖ Functional origin:
Trochlea
❖ Insertion: curved
❖ anterior: 12-14 mm
behind limbus
❖ posterior 17-19 mm
behind limbus
OM Patel, http://
www.slideshare.net/ompatel9889

11. Blood Supply
❖ ciliary arteries also arise from
these muscular arteries
❖ 7 branches
❖ 2 per rectus muscle except LR
which receives only 1
OM Patel, http://www.slideshare.net/ompatel9889

12. EOM Concepts & Movements
❖ agonist muscles
❖ antagonist muscles
❖ yoke muscles
❖ synergistic muscles
❖ contralateral antagonist
❖ Ductions & Versions
❖ dextroversion
❖ levoversion
❖ dextroelevation
❖ levoelevation
❖ Dextrodepression
❖ Levodepression
❖ Vergence Eye Movements
❖ Convergence
❖ Divergence

13. Ocular Motility: EOM Movement

14. Laws of Ocular Motility: Hering’s Law

15. Laws of Ocular Motility: Sherrington’s Law

16. Strabismus

17. Strabismus Evaluation
❖ Complete 5 point examination
❖ Gross
❖ Pupils
❖ EOM
❖ Intraocular Pressure
❖ Fundus evaluation
❖ Perform refraction
❖ Stereoacuity testing
❖ Strabismus Evaluation:
❖ Gold Standard: Alternate Prism Cover Test

18. Strabismus Evaluation: Hirschberg’s

19. Strabismus Evaluation: Bruckner Test

20. Strabismus Evaluation
❖ Cover
Uncover
Test
https://www.youtube.com/watch?v=f5HbIZi4u70

21. Strabismus Evaluation
❖ Alternate Cover Test
https://www.youtube.com/watch?v=U59OEkjoIGg

22. Strabismus Evaluation
From Rosenbaum & Santiago, Clinical
Strabismus Managemenment 1999

24. Strabismus Evaluation: Torsion
From Rosenbaum & Santiago, Clinical
Strabismus Managemenment 1999

25. From Rosenbaum & Santiago, Clinical
Strabismus Managemenment 1999

26. Amblyopia Evaluation
❖ Fixation
Preference
vonNoorden, Ocular Motility

27. Fixation Preference

28. Fixation Preference & Visual Acuity

29. Vision Assessment

30. Pre verbal Vision Test
❖ Allen cards
❖ Cultural bias
❖ “dated”
❖ Based on experience
❖ Lea symbols
❖ more universal
❖ Same in every culture
❖ Equal blurr

31. Visual Acuity Testing

32. Amblyopia
PEDIG Studies
http://www.slideshare.net/
AlvinaPaulineSantiag/2015-amblyopia-pedig-v2
http://pedig.jaeb.org/Studies.aspx
http://www.abcd-vision.org/amblyopia/ats-
pedig.html

33. ❖ Amblyopia PEDIG Studies

34. ❖ Amblyopia PEDIG Studies

35. ❖ Amblyopia PEDIG Studies

36. ❖ Amblyopia PEDIG Studies

37. ❖ Amblyopia PEDIG Studies

38. ❖ Amblyopia PEDIG Studies

39. Lessons learned from PEDIG
❖ Atropine = patching
❖ 6 hours = full time
❖ 2 = 6
❖ 6 > 2
❖ Glasses alone works.
❖ If not, then glasses+patching.
❖ Teenagers benefit from patching.

40. Lessons learned from PEDIG
❖ Daily = weekly
❖ Near = far
❖ 2 hours works.
❖ Bangerter filter = patching
❖ Levodopa-carbidopa promising