This document provides information about strabismus (misalignment of the eyes) for medical students and general practitioners. It discusses the significance of strabismus in children and adults, describes the different types and causes of strabismus, and outlines how to examine and manage patients with strabismus. The key points are that strabismus can affect vision development in children, may indicate neurological or systemic disease in adults, and causes include refractive errors, paralysis, restrictions, and loss of vision. Examination involves observing eye alignment and movements while management depends on the type of strabismus, ranging from glasses to surgery.

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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