It is one of the most viewed document from Pgblaster India website: Disorders of ocular motility with an emphasis on squint. In this document I have tried to give some important concepts of the different types of squints in simple words.At a glance, it is a much harder and complex topic of ophthalmology but I had made it as simpler as I could. Hope it will help you..
This presentation is a detailed description of how a patient should be examined in an oprthoptic clinic. it lists down all the investigations sequentially. the order of investigations mentioned is the best way to investigate a squint case.
It describes about the procedure of Hess charting. it serves as a great tool to understand the concepts involved. Suitable for optometry course. This is not a routine procedure but an important procedure which is used in diagnosis.
This presentation is a detailed description of how a patient should be examined in an oprthoptic clinic. it lists down all the investigations sequentially. the order of investigations mentioned is the best way to investigate a squint case.
It describes about the procedure of Hess charting. it serves as a great tool to understand the concepts involved. Suitable for optometry course. This is not a routine procedure but an important procedure which is used in diagnosis.
The presentation includes physiological mechanism of different functional classes of eye movements such as horizontal & vertical eye movements, saccades, persuits, vestibuloocular reflex, Bell's phenomenon and it also includes different disorders that causes abnormal supranuclear eye movements e.g. skew deviation, Perinaud syndrome, INO.
Human eye is a sense organ that responses to light and allows vision. Eyeball is placed in bony orbit in the skull and protected by eyelids. Eyeball is made up of three layers; Fibrous tunic (cornea and sclera), Vascular tunic (choroid, ciliary body and iris) and Retina. There are six extra ocular muscles to control movement of each eye. Optic nerve for its co-ordination with the brain. Blood is supplied to eye by the branches of internal carotid artery.
Similar to Diseases of ocular motility with an emphasis on squint (20)
Every pregnancy is special and every pregnant woman must receive special care.The Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) is being introduced to ensure quality Antenatal to over 3 crore pregnant women in the country.
Under the campaign, a minimum package of antenatal care services would be provided to the beneficiaries on the 9th day of every month at the Pradhan Mantri Surakshit Matritva Clinics to ensure that every pregnant woman receives at least one checkup in the 2nd and 3rd trimester of pregnancy.
This short presentation demonstrates important adverse effects of common anti-psychotic medications in clinical practice and how to effectively manage the adverse events.
The main focus of this presentation is to discuss all the drugs used nowadays in clinical practice to treat/ manage bronchial asthma. Along with the mechanism of action, use and adverse effects of anti-asthma drugs, we have given a highlight of the pathophysiology of asthma and how the drugs individually act at individual set point(s) to bring the clinical outcome.
This is a slideshow made essentially for undergraduate MBBS students to have a working knowledge about CT scan of brain in diagnosing common medical and surgical conditions. It includes detection of major anatomical structures in CT and prompt diagnosis of emergency conditions like head trauma and cerebrovascular accident. Last but not the least, I have also touched the areas where CT scan is not the first mode of diagnosis (like diagnosis of brain tumor and evaluation of headache).
This presentation comprises of congenital anomalies of kidney and urinary tract made concise and in depth for PG preparation. It contains all important topics of the regarding subject covered in detail.
Hypertensive retinopathy is a very important topic for PG examinations of all types. Especially, the fundal changes are important; Keith and Wegner Grading is also a repeated topic in PG. This slide represents all information in a compressed fashion. Have fun!
Preterm labor is labor that happens too early, before 37 weeks of pregnancy. Preterm labor can lead to premature birth. This means your baby is born before 37 weeks of pregnancy. Babies born this early can face serious health problems. India has the largest number of premature births compared to any other country.
Gestational diabetes mellitus (GDM) is a condition that develops during pregnancy when the body is not able to make enough insulin. GDM affects 2-10% of women during pregnancy.It is important to recognize and treat gestational diabetes as soon as possible to minimize the risk of complications to mother and baby.
This is a presentation which contains basics of polytrauma management,ATLS, triage, critical decision making skills, application of Glasgow coma scale and complications of different management strategies, if not applied properly.
Multiple myeloma is the most common primary malignant bone tumor in the world. It is usually seen in elderly individuals of >40 years. In this presentation, all the important aspects of Multiple myeloma have been discussed extensively and in brief..
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This is a presentation regarding the most salient features of PCPNDT act, India (formerly known as PNDT act). It is made for undergraduate medical students (MBBS). Hope it will help you in your examinations.
This is a beginner's guide to retinoblastoma. I have briefly covered all the aspects of this most common intraocular tumor of childhood. Hope it will help the undergraduate medical students. Please check out our blog, http://pgblaster.wordpress.com for more presentations and useful stuffs like this one.
More from Department of Health & Family Welfare, Government of West Bengal (20)
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
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Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Diseases of ocular motility with an emphasis on squint
1. Disorders of Ocular Motility
Prithwiraj Maiti
Admin, Pgblaster India.
R.G.Kar. Medical College
Kolkata. India.
Email: prithwiraj2009@yahoo.In
Prithwiraj Maiti
2. Table Of Contents
• For the purpose of ease, we will divide the
lecture into 7 parts:
• Part 1: Anatomy and action of extraocular
muscles.
• Part 2: Normal physiological regulatory
mechanisms of eye movements.
• Part 3: Apparent and latent strabismus.
• Part 4: Comitant strabismus.
• Part 5: Incomitant strabismus.
• Part 6: Diagnostic approach in a suspected case
of squint.
• Part 7: Management of squint.
4. Anatomy of the Extraocular Muscles
• There are 6 extraocular muscles: 4 of them are
recti muscles and 2 of them are oblique
muscles.
• The primary action of recti muscles is to rotate
the eyeball in 4 directions: up, down, out, in.
• The primary action of oblique muscles is to
rotate the globe (intorsion and extorsion).
6. Origin of Extraocular Muscles
• All the 6 extraocular muscles (except Inferior
Oblique) originate at the orbital apex.
• The superior, inferior, medial and lateral rectus
muscles arise from the ANNULUS OF ZINN, an
oval, fibrous ring at the orbital apex.
• The 6th extraocular muscle, the Inferior
oblique, originates from the Maxillary bone,
adjacent to the lacrimal fossa, posterior to the
orbital rim.
7. Annulus of Zinn
• Structures passing through the annulus:
1. Oculomotor nerve (superior and inferior
divisions).
2. Abducens nerve.
3. Optic nerve.
4. Nasociliary nerve.
5. Ophthalmic artery.
8.
9. Insertion of Recti Muscles
• The rectus muscles insert into the sclera just
anterior to the equator of the globe.
• The spatial formation created by connecting
their insertion is called the spiral of Tillaux.
• Note that the medial rectus inserts closest to
the limbus, followed by the inferior, lateral,
and superior recti in that order. [MILS]
11. Insertion of Oblique Muscles
• The oblique muscles insert into the sclera posterior
to the equator of the globe.
• The superior oblique tendon inserts into the
posterior, superolateral sclera in a broad, fanshaped fashion under the superior rectus muscle.
• The insertion extends near the superotemporal
vortex vein.
• The inferior oblique muscle inserts into the
posterior, inferolateral sclera. The insertion lies in
close proximity to both the macula and the
inferotemporal vortex vein.
12.
13. Action of Extraocular Muscles
Muscle
Medial rectus
Lateral rectus
Superior rectus
Inferior rectus
Superior oblique
Inferior oblique
Action
Adduction
Abduction
Elevation
Depression
Intorsion
Extorsion
14.
15. Innervation of Extraocular Muscles
Nerves
Superior division of
Oculomotor (3rd ) nerve
Inferior division of
Oculomotor nerve
4th nerve
(Trochlear nerve)
6th nerve
(Abducens nerve)
Innervated muscles
Levator palpebrae and
Superior rectus muscles.
Medial rectus, Inferior
rectus and Inferior oblique
muscles.
Superior oblique.
Lateral rectus.
16. Star Topic 1: Vestibulo-Ocular Reflex (VOR)
• The vestibulo-ocular reflex (VOR) is
a reflex eye movement that stabilizes
images on the retina during head movement
by producing an eye movement in the
direction opposite to head movement, thus
preserving the image on the center of the
visual field.
17. A rotation of the head is detected, which triggers an inhibitory signal to
the extraocular muscles on one side and an excitatory signal to the
extraocular muscles on the other side. The result is a compensatory
movement of the eyes.
18. Blood Supply of Extraocular Muscles
• The blood vessels that supply the rectus
muscles are termed anterior ciliary arteries;
these arteries also supply the anterior
segment of the eye.
• The long posterior ciliary arteries also supply
the anterior segment of the eye with blood via
the major arterial circle of the iris.
• The blood vessels that supply the oblique
muscles do not carry any circulation to the
anterior segment.
19. Clinical Approach
• Surgical manipulation of the rectus muscles
permanently disrupts the anterior ciliary arteries.
If surgery is performed on multiple rectus
muscles simultaneously, anterior segment
ischemia may result.
• Anterior segment ischemia can lead to pain,
uveitis, or even phthisis bulbi.
• As the long posterior ciliary arteries also supply
the anterior segment of the eye with blood via
the major arterial circle of the iris, they allow
collateral blood flow after rectus muscle surgery.
20. End of “Disorders of Ocular
Motility” lecture Part 1.
We will now proceed to the
normal physiological
regulatory mechanisms of
eye movement….
22. Fixation
• “Fixation reflex" refers to the ability to fixate on a
target that is moving.
• When a distant object is looked at, the object
forms an image upon each fovea centralis.
• Any other object will form its image upon the
temporal side of one retina and the nasal side of
the other retina. These points are known as
Corresponding Points. (Please see next page)
• Points on 2 retinae, which are not corresponding
in sense; are called Disparate Points.
23. aL and aR;
bL and bR:
Corresponding
points.
aL and bR;
bL and aR:
Disparate
points.
F is the fovea.
24. • The corresponding points are visually
coordinated in the occipital cortex so that
such an object is seen with both eyes as a
single object.
• Since the most accurate vision is attained by
the foveae; it is necessary that the eyes be
rapidly oriented so that the image of an object
of interest falls upon them,
- This ascendancy of the foveae is maintained
by the Fixation Reflex.
• Whenever the image leaves the foveae, the
eyes are at once reoriented so that it falls
upon them.
25. Clinical Approach
• The occipital cortex can merge only 2
corresponding points; but it can’t merge 2
disparate points.
• So, if an objects forms 2 retinal images on 2
disparate points; the occipital cortex will be
unable to merge them and the object will be
seen double.
• This incident is called “Binocular Diplopia”.
26. Causes of binocular diplopia
1. Commonest causes: Paresis/ paralysis of
extraocular muscles.
2. Displacement of one eyeball (SOL/ fracture).
3. Mechanical obstruction of ocular movements
(Pterygium/ Symblepharon/ Thyroid
ophthalmopathy).
4. Deviation of ray of light in one eye
(decentred spectacles).
5. Anisometropia (Uniocular aphakia +
Spectacle correction).
27. Binocular Vision
• The previously discussed Fixation Reflex is
also responsible for binocular vision.
• It is obvious that the retinal images of both
the eyes can’t be identical.
• If the object is a sold body; then the right eye
sees right side of the object and the left eye
sees left side of the object.
• These 2 images are fused psychologically;
enabling the person to appreciate the solidity/
depth of the object.
28.
29. Clinical Approach: Physiologic Diplopia
• If both of the eye are fixing upon one particular
object, the other objects in surrounding areas
can’t fall upon corresponding points.
• The objects nearer and farther than the fixating
points will appear double; which is known as
“Physiologic Diplopia”.
Nearer objects will form retinal images on the
temporal side of the fovea (Fig. A in the next pic.).
It is called “Crossed Diplopia”.
Farther objects will form retinal images on the
nasal side of the fovea (Fig. B in the next pic.). It is
called “Uncrossed Diplopia”.
30. Physiologic diplopia:
A. Crossed diplopia of the object p, closer than the
fixation point F, imaged in temporal disparity.
B. Uncrossed diplopia of the object P, more distant than
the fixation point F and imaged in nasal disparity.
31. Convergence and Accommodation
• When an emmetropic (normal sighted) person
is looking at a distant object, accommodation
and convergence are resting. The axes of the
eyes are parallel, and there is no effort of
convergence (the angle of intersection is 0°).
• When the emmetropic person is looking at a
nearby object, some effort of accommodation
and convergence is necessary.
32.
33. Clinical Standpoint: Convergence Testing
• Clinically, convergence can be tested roughly
by making the patient fix a finger/ pencil
which is gradually brought nearer to the eyes
in the midline.
• The eyes should be able to maintain
convergence at a distance of 8 cm from the
eyes.
• If outward deviation of one eye occurs before
the point is reached, the power of
convergence is deficient. It is termed as
“Convergence insufficiency”.
34.
35. End of “Disorders of Ocular
Motility” lecture Part 2.
We will now proceed to
Strabismus….
36. Part 3
Strabismus/ Squint
In this part, we will discuss
only the first two types of
strabismus (Apparent and
latent strabismus).
37. What is Strabismus?
• Strabismus (also known as squint/ crooked
eye) is a generic term applied to all those
conditions in which the visual axes assume a
position relative to each other different from
that conforming to physiological conditions.
39. What is the difference between tropia and phoria?
It is one of the most commonly asked questions
and often, students can’t answer it correctly….
• In tropia, the eyes are deviated all the time.
• In phoria, eye deviations are present only
some of the time; usually under conditions of
stress/ illness/ fatigue/ interruption of
binocular vision.
40. Apparent/ Pseudo-strabismus
• It is also known as “Pseudostrabismus”.
• This is nothing but an optical illusion caused
by prominent epicanthal folds/ wide
interpupillary distances (IPD). [See next page]
• It is of 2 types:
1. Pseudo-esotropia/ Apparent convergent
squint.
2. Pseudo-exotropia/ Apparent divergent
squint.
41. Associations
• In pseudoesotropia, the optical illusion is created
by prominent epicanthal fold.
• In pseudoexotropia, the optical illusion is created
by wide interpupillary distance.
42. Latent strabismus/ Heterophoria
• It is defined as a condition in which there is a
tendency to misalignment of the visual axis,
which is corrected by the fusional capacity;
therefore, when the influence of fusion is
removed, the visual axis of one eye deviates
away (by covering one eye).
• Orthophoria is a condition of perfect
alignment of the two eyes which is maintained
even after the removal of influence of fusion.
44. Note that, appearances
of esophoria &
esotropia are same.
Appearances of
exophoria & exotropia
are same.
45. Etiology of Heterophoria:
A. Anatomical Factors
1. Orbital asymmetry.
2. Abnormal IPD:
A. Wide IPD: Exophoria.
B. Small IPD: Esophoria.
3. Extraocular muscles:
A. Faulty insertion,
B. Mild weakness,
C. Abnormal innervation.
4. Anatomical variation in the position of
macula in relation to optical axis of the eye.
46. B. Physiological factors
1. Age:
A. Old age: Exophoria.
B. Younger age: Esophoria.
2. Role of accommodation and convergence:
A. Increased accommodation and excessive use of
convergence: Esophoria.
B. Decreased accommodation and decreased use of
convergence: Exophoria.
3. Dissociation factor: Prolonged constant use of
one eye may result in exophoria (as in case of
persons working with uniocular microscope/
magnifying glass).
47. Symptoms of heterophoria
• Depending upon the symptoms, heterophoria
can be divided into compensated and
decompensated heterophoria.
• In compensated heterophoria, no subjective
symptoms are present.
• In decompensated heterophoria, the
symptoms which will be present are:
49. Treatment of a heterophoria case
1.
2.
3.
4.
Correction of refractive error.
Orthoptic exercises.
Prescription of prism in glasses.
Surgical treatment.
50. Orthoptic exercise
• Orthoptics is part of a broader type of therapy
known as vision therapy.
• Orthoptics aims to strengthen the eye muscles
to correct common eye problems such as
convergence insufficiency.
• It includes:
1. Barrel cards.
2. Brock string.
3. Stereograms etc.
52. What is a manifest/ true strabismus?
• In apparent strabismus/ heterophoria, the
alignment of the eyes is maintained by
continuing efforts of fusion and it becomes
manifest only when the fusional capacity is
withdrawn (by covering one eye in “Cover
test”).
• On the other hand, when the maintenance of
alignment of the eyes becomes impossible by
means of fusional capacity alone, a true/
manifest strabismus develops.
54. Comitant strabismus
What is it?
It is a type of manifest strabismus in which the
amount of deviation in the squinting eye
remains constant in all the directions of gaze
and there is no associated limitation in ocular
movement.
55. Types of comitant squint
2 common types of comitant squint are:
1. Esotropia (convergent squint),
2. Exotropia (divergent squint).
58. Accommodative Esotropia
It occurs due to overaction of convergence associated with
accommodation reflex.
Types
Refractive
accommodative
Non refractive
accommodative
Description
Associated with high hypermetropia
in children of 2-3 years of age.
Caused by abnormal AC/A ratio
(accommodative convergence/
accommodation); may occur even in
patients with no refractive error.
Mixed
Both hypermetropia and abnormal
accommodative AC/A ratio are present.
59. Non-Accommodative Esotropia
The amount of deviation is not affected by power of
accommodation.
Types
Essential infantile type
Description
Presents at 1-2 months of age;
fairly large amount of squint
(>30°).
Late onset type (Presents after 6 months of age)
Basic type
Deviation is equal for near and
far vision.
Convergence excess type
Deviation is large for near
vision.
Divergence insufficiency type Deviation is large for far vision.
60. Secondary Esotropia
It occurs due to monoocular lesions that prevents the
development of binocular vision/ maintenance of it.
Ex.:
Cataract,
Aphakia,
Anisometropia,
Severe congenital ptosis,
Retinoblastoma etc.
[* Note that in Retinoblastoma, strabismus is the second
most common manifestation after leukocoria.]
64. Congenital Exotropia
•
•
•
•
It is rare.
It almost always presents at birth.
It presents with a fairly large angle of squint.
It is usually alternating in character with no
amblyopia (partial loss of sight in one/ both
eyes in the absence of any marked
ophthalmoscopic signs).
66. Primary Exotropia
Type
Description
According to character
Basic type
Exotropia is equal in near and far
vision.
Divergence
Exotropia is greater in far vision.
excess type
Convergence Exotropia is greater in near
insufficiency type vision.
67. Secondary Exotropia
It is an unilateral constant exotropia resulting
from long standing monoocular lesions in
adults.
Common causes are:
Traumatic cataract,
Corneal opacity,
Retinal detachments,
Macular lesions etc.
68. Consecutive Exotropia
It is an uniocular constant exotropia resulting
from:
1. Surgical overcorrection of esotropia,
2. Spontaneous conversion of (small degree of
esotropia + amblyopia) into exotropia.
69. Treatment of Comitant Strabismus
Goals of treatment:
To achieve good cosmetic correction.
To improve visual acuity.
To maintain binocular single vision.
• Treatment modalities:
Full correction of refractive error.
Occlusion therapy: It is indicated in the presence of
amblyopia. After correction of refractive error, the
normal eye is occluded and the squinting eye is
advised to be used.
Orthoptic exercises.
Squint surgery.
71. What is an incomitant strabismus?
• It is a type of manifest squint in which the
amount of deviation varies in different
directions of gaze.
72. Types of Incomitant Strabismus
Incomitant
strabismus
Paralytic
Squint
Restrictive
squint
A and V
pattern
heterotropia
73. Paralytic Squint
• It refers to ocular deviation resulting from
complete/ incomplete paralysis of one/ more
extraocular muscles.
74. Etiology Of Paralytic Squint (1)
Cause
Disorder
Neurogenic •Congenital hypoplasia/ absence of 3rd/ 6th nerve
nucleus.
•Meningitis/ Encephalitis/ Syphilis.
•Brain tumors involving 3rd/6th nerve nucleus.
•Vascular lesions (Hypertension/DM/
Atherosclerosis).
•Head injury involving nerve trunks.
•Demyelination in MS (Multiple sclerosis).
NeuroMyasthenia Gravis.
muscular
junction
75. Etiology Of Paralytic Squint (2)
Cause
Myogenic
Disorder
•Congenital abnormality/ traumatic lesions
involving the extraocular muscles.
•Viral: Influenza/ measles.
•Myopathies:
Thyroid myopathy.
Carcinomtous myopathy.
Progressive external ophthalmoplegia.
76. Symptoms Of Paralytic Squint
1. Diplopia: It occurs due to formation of image
on disparate points of the retina of two eyes.
2. Confusion.
3. Nausea and vertigo.
4. Ocular deviation.
77. Signs Of Paralytic Squint
1. Primary deviation:
It is deviation of the affected eye and is away
from the action of paralyzed muscles.
Ex.: If Lateral rectus is paralyzed, the eye is
converged because action of LR is abduction.
• At this point, we should once again
recapitulate the actions of extraocular
muscles to determine the effects of their
getting paralyzed.
78.
79. 2. Secondary deviation:
• It is the deviation of the normal eye seen
undercover, when the patient is made to fix
with the squinting eye.
• It is greater than primary deviation.
3. Restriction of ocular movements:
• It occurs in the direction of the action of
paralyzed muscles.
4. Compensatory head posture:
• Head is turned towards the action of
paralyzed muscle as an attempt to avoid
diplopia and confusion.
80. 5. False projection:
• It is due to increased innervation impulse
conveyed to the paralyzed muscle.
Demonstration of false projection:
• Ask the patient to close the sound eye.
• Ask the patient to fix an object placed on the side
of the paralyzed muscle.
• Patient will locate it further away in the same
direction.
• For example, a patient with RLR paralysis will
point towards more right than where the object
actually is.
81. Clinical Varieties Of Ocular Palsies
Isolated muscle paralysis
LR and SO are the most common muscles to be
paralyzed singly as they have separate nerve
supply.
82. Paralysis of 3rd cranial nerve
Clinical features are:
1. Ptosis (due to paralysis of Levator Palpebrae
Superioris muscle).
2. Eyeball is turned downwards, outwards and slightly
intorted (due to actions of LR and SO).
3. Ocular movements are restricted in all directions
except outwards.
4. Pupil is fixed and dilated (due to paralysis of
sphincter pupillae muscle).
5. Accommodation is completely lost (due to paralysis
of ciliary muscle).
83.
84. Total Ophthalmoplegia
• In this condition, all extraocular and
intraocular muscles are paralyzed.
• It results from combined paralysis of 3rd , 4th
and 6th cranial nerve.
• It is a common feature of cavernous sinus
thrombosis and orbital apex syndrome.
85.
86. External Ophthalmoplegia
• In this condition, all extraocular muscles are
paralyzed (sparing intraocular muscles).
• It results from lesion at the level of motor
nuclei sparing the Edinger-Westphal Nucleus.
87. Restrictive Squint
• In restrictive squint, the extraocular muscle
involved is not paralyzed but its movement is
mechanically restricted.
• It is characterized by a smaller amount of
ocular deviation and a positive Forced Duction
Test (see next presentation).
88. A and V pattern heterotropias
• In this point, just remember a mnemonic,
otherwise there is high chance that you mix
up everything in the next 2 pages.
* AXDID/ VSDID:
A Exotropia/ V esotropia denotes that
deviation will increase in downward gaze.
89. A pattern heterotropias
In A esotropia
the deviation
increases in
upward gaze
and decreases
in downward
gaze.
In A exotropia
the deviation
increases in
downward gaze
and decreases in
upward gaze.
90. V pattern heterotropias
The deviation
in V esotropia
increases in
downward
gaze and
decreases in
upward gaze.
The deviation
in V exotropia
increases in
upward gaze
and decreases
in downward
gaze.
92. 1. Take the history of the presenting condition.
2. Assess the visual acuity.
Test of choice in assessing visual acuity in children
≤2 years of age
Teller acuity cards
3-5 years of age
Cardiff cards/ Lea symbol visual
acuity test
3-7 years of age* HOTV letters with surround bars/
ETDRS** vision test with surround
bars.
*According to Pediatric Eye Disease Investigator Group.
**ETRRS: Early treatment diabetic retinopathy study.
93. 3. Assessment of the ocular motility.
4. General examination of the eye (including a
fundus examination).
5. In a child with squint, a refraction testing
under cycloplegia and a repeat fundus
examination with a dilated pupil is
mandatory.
94. 6. The next step is to differentiate between a
pseudostrabismus and a real strabismus.
Do a cover test to differentiate between these 2
conditions:
Steps of a cover test:
Observe the alignment of the eyes.
Cover the apparently fixing eye and watch for
any movement in the fellow eye.
Cover the squinting eye and watch for any
movement in the fellow eye.
95. Interpretation of the cover test
In pseudostrabismus, no restitutional movement will be
seen on covering/ uncovering the eyes as there is no actual
deviation but just an optical illusion.
If there is a real deviation, then classify it according to the
following points:
Points
Direction
Differentiates between
Esotropia (convergent), exotropia (divergent),
hypertropia (upward), Hypotropia (downwards).
Frequency
Latent and manifest strabismus/ intermittent and
constant strabismus.
Comitancy Comitant strabismus/ Incomitant strabismus.
Laterality
Unilateral/ Alternating.
AC/A ratio
High/ normal/ low.
96. A. For exotropia, covering the right eye drives inward movement of the left eye to take
up fixation; uncovering the right eye shows recovery of fixation by the right eye and leftward
movement of both eyes; covering the left eye discloses no shift of the preferred right eye. B. For
esotropia, covering the right eye drives outward movement of the left eye to take up fixation;
uncovering the right eye shows recovery of fixation by the right eye and rightward movement of
both eyes; covering the left eye discloses no shift of the preferred right eye. C. For hypertropia,
covering the right eye drives downward movement of the left eye to take up fixation; uncovering
the right eye shows recovery of fixation by the right eye and upward movement of both eyes;
covering the left eye shows no shift of the preferred right eye. D. For exophoria, the left eye
deviates outward behind a cover and returns to primary position when the cover is removed. An
immediate inward movement denotes a phoria, a delayed inward movement denotes an
intermittent exotropia.
97. 7. Differentiate between a comitant and an
incomitant squint: Cover-Uncover Test
• Either eye is covered and then uncovered.
• In case of comitant strabismus, deviation
suffered by each eye will be same in any
direction.
• In case of incomitant strabismus, deviation
suffered by each eye will be different in
different directions.
98. 8. Detect the cause of the defective eye
movement: Whether muscle weakness or
physical restriction: Forced Duction Test (FDT)
• The forced duction test is an attempt by the examiner
to move a patient’s eye farther in a given direction
than the patient can move it.
• Topical anesthetic is placed on the appropriate limbal
location with a small cotton swab and the limbal
conjunctiva is grasped firmly with a toothed forceps.
• The patient is asked to rotate the eye fully in the
direction of the limited duction.
• An attempt is then made by the examiner to rotate the
eye beyond the position attained by the patient while
avoiding globe retraction. Care must be taken not to
abrade the cornea.
99. The patient has left esotropia and limited abduction. The patient
is abducting her left eye from a position of maximal adduction
and the examiner is attempting to abduct the eye farther than
the patient can.
100. Interpretation of FDT
• Patients who have pure nerve palsy exhibit no
restriction to full movement by the examiner
(termed as a -Ve FDT).
• Patients who have pure restriction (dysthyroid
orbitopathy/ entrapment of ocular contents after
blowout fracture) exhibit restricted movements
(termed as a +Ve FDT).
• Some patients initially have a pure nerve palsy,
but contracture of the antagonist muscle results
in secondary mechanical restriction of
movement.
101. Active Force Generation Test
• This test is done when there is a chance of mixed
condition involving both paralysis and entrapment of
muscles as in case of orbital blow out fractures.
• Active force generation testing may be used to
evaluate the ability of a muscle to move the eye
against a resisting force.
• The forceps is placed at the limbus of the anesthetized
globe in the meridian of the muscle whose duction is
limited and the patient requested to rotate the eye in
the direction of the limited duction; the examiner
judges through the forceps the relative amount of force
generated.
• Strain gauges have been devised that enable
quantization of this force.
102. Active force generation test: The patient has left esotropia and
limited abduction. The patient abducts her left eye from a
position of maximal abduction and the examiner estimates the
force of abduction through the forceps.
103. 9. Measurement of angle of deviation
A. Hirschberg test (approximate)
• A rough estimation of the angle of deviation in
squint can be obtained from the position of
the corneal reflex.
• Light is thrown into the eye from a distance of
60 cm with the ophthalmoscope/ focused light
beam from a torch.
• The patient is asked to look at the light.
• In the fixing eye, the corneal reflex will be in
the centre of the pupil.
104. • A light reflection at the pupillary border
signifies a 15° deviation.
• At the midiris a deviation of 30°, and at the
limbus a deviation of 45°.
• Each millimeter of light displacement across
the cornea is equivalent to 7° of decentration.
105. ①
Hirschberg light reflex method: The patient has a left
esotropia. Note the corneal light reflex at the temporal
pupillary border of the left eye while the reflex is
centered in the pupil of the right eye.
106. B. Krimsky’s Light Reflex Method (to accurately
measure the angle of deviation)
• It is the most commonly used method to
accurately quantify the angle of deviation in a
squinting eye.
• It is done by holding prisms of different
strengths in front of the fixing eye with the
apex pointed towards the deviation.
• This procedure is repeated till the corrective
movement of the squinting eye is neutralized.
107. Krimsky light reflex method [same patient as in
previous photograph ①]. The strength of a baseout prism over the fixing right eye sufficient to
center the pupillary light reflex in the esotropic
left eye is defined as the amount of left esotropia.
108. 10. Maddox Rod Test in case of
heterophoria
STEPS TO PERFORM THE TEST
1. Patient wears best corrected Rx.
2. Maddox rod is held in front of patient’s eye (select to
measure the horizontal or vertical deviation first).
3. Transilluminator is focused on the midline of the
patient’s face.
4. Explain to patient: “You will see a red line and a white
dot. Is the dot superimposed on the red line?”
109. Maddox rod: A series of aligned
strong cylinders, here placed in a
paddle handle.
A red Maddox rod in a
trial frame may be
used to evaluate
subjective ocular
torsion. The grooves
must be aligned with
the mark on the rim,
as they tend to rotate
within.
110. Always Remember
• When measuring a phoria using a Maddox rod , the
direction of the red line viewed by the patient is
perpendicular to the direction of the red cylinders.
111. Interpretation of Maddox Rod Test
- If the patent answers “Yes, the dot is
superimposed on the line,” then no deviation is
present (proceed in checking the other
orientation).
- If the patent answers “No, the dot is not
superimposed on the line,” then a deviation is
present (proceed with identifying and quantifying
the deviation by holding up loose prisms in the
proper orientation until the dot is superimposed
on the line).
112. How do you determine which direction to hold your prisms to
quantify the horizontal deviation?
(Assume Maddox rod is placed over patient’s OD.)
What does OD, OS and OU stand for?
OD ………………… Oulus dexter (the right eye),
OS ………………… Oulus sinister (the left eye),
OU ………………… Oculus uterque (both eyes).
What patient sees
Graphical
Representation
What you will do
The white light
superimposed on the
red line.
No deviation.
The red line to the left,
white light on right side.
Exophoria (Use BI prism
to quantify).
The red line to the right,
white light on left side.
Esophoria (Use BO prism
to quantify).
113. How do you determine which direction to hold your prisms to
quantify the vertical deviation?
(Assume Maddox rod is placed over patient’s OD.)
What does OD, OS and OU stand for?
OD ………………… Oulus dexter (the right eye),
OS ………………… Oulus sinister (the left eye),
OU ………………… Oculus uterque (both eyes).
What patient sees
Graphical
Representation
What you will do
The white light
superimposed on the
red line.
No deviation.
The red line is above the
white light.
Hyperphoria (Use BD
prism to quantify).
The red line is below the
white light.
Hypophoria (Use BU
prism to quantify).
114. Concept of Various Types of Prisms
BU/ BD:
Base up/ Base down.
BI/ BO:
Base in/ Base out.
116. Goals of treatment and management
1. Obtaining normal visual acuity in each eye.
2. Obtaining and/or improving fusion.
3. Eliminating any associated sensory
adaptations, and
4. Obtaining a favorable functional appearance
of the alignment of the eyes.
118. Optical Correction
• Regardless of the cause of the strabismus, the
goal for strabismic patients, especially very
young patients, is to allow binocularity to
develop.
• The best optical correction that allows
equally clear retinal images to be formed in
each eye is generally the starting point for all
treatment and management.
• Anisometropia and astigmatism should also
be fully corrected.
119. • Whereas a full correction of refractive
error is often prescribed for esotropia and
hyperopia, the presence of exotropia and
hyperopia may require a more conservative
approach.
• The clinician should continue to re-evaluate
the prescribed lenses periodically to assess
the effect on the angle of deviation and
fusion.
• The patient should be advised that changes
in the lenses may be needed during
treatment and management.
120. Added lens power
• Lenses can also be used to take advantage of
the AC/A ratio to help obtain or maintain
binocular vision.
• Bifocals are often prescribed for the patient
with esotropia who has a high AC/A ratio, to
eliminate or decrease the angle of strabismus
at near to an amount controllable by
compensating divergence.
121. • Added minus lens power can be
temporarily prescribed in young children
for intermittent exotropia that measures
the same for distance and near or is larger
for distance.
• Management with added minus lens
power should be discontinued when the
frequency of the exotropia remains
unchanged despite the wearing of added
minus lens power, or when fusion at near
becomes disrupted.
122. Prisms
• Ophthalmic prisms can aid in the establishment
or maintenance of sensory fusion, by moving the
image of the target of regard onto or closer to the
fovea of each eye.
• Prisms are generally prescribed for patients
with strabismic deviations of less than 20 PD
(Prism Dioptre) who are capable of fusion.
• The presence of amblyopia/ deep suppression/
/anomalous retinal correspondence generally
contraindicates the use of prisms.
123. • The maximum prism power that can be
incorporated into spectacle lenses is
approximately 10–12 PD in each lens.
• Prisms may also be used to reduce or
eliminate mild compensatory head postures in
patients with incomitant strabismus.
• Older patients who have diplopia in
association with acquired extraocular muscle
palsy/ muscle restriction/ phoria
decompensation also benefit from prisms.
124. Vision therapy/ Orthoptic Training
• It involves active training procedures to:
1. Improve the patient's fixation ability and
oculomotor control,
2. To help eliminate amblyopia,
3. To improve sensory and motor fusion, and
4. To increase facility and the range of
accommodation and convergence responses.
125. • Vision therapy is successful in the treatment
of many forms of strabismus.
• The prognosis is most favorable for patients
with :
1. Intermittent exotropia, and
2. Those who recently developed strabismus.
• Patients are usually treated for 30−60 minutes
once or twice a week in the office.
126. Pharmacological agents
• Treatment with a pharmacological agent has
proven less effective and less desirable than using
corrective glasses and bifocal lenses, because of
the possibility of both local and systemic
adverse effects.
• Such treatment is rarely used in contemporary
practice and should be considered for only those
patients with accommodative esotropia who
cannot wear glasses due to facial deformities, for
children who continually remove, lose, or break
their spectacles or for other special cases.
127. • Atropine 1% is put in the non-amblyopic eye
on either a daily or weekend only basis. The
child wears his/her spectacles while
undergoing this treatment.
• By dilating the pupil and inhibiting
accommodation in the non-amblyopic eye,
the atropine drops force the child to use only
the amblyopic eye for near viewing.
128. Extraocular muscle surgery
• The clinician should consider all aspects of the
nonsurgical treatment of strabismus before
recommending surgery.
• Surgical consultation is appropriate for
patients whose strabismus is cosmetically
objectionable.
129. Candidates for surgery
• In general, surgery is preferred for patients
with esotropia when the deviation exceeds
15 PD in the primary position at both
distance and near while the patient is
wearing the full refractive correction.
• For patients with exotropia, deviation
exceeding 20 PD in the primary position are
possible candidates for surgery.
130. • Patients with smaller deviations usually should
not be considered for surgery, except when
adults have acquired symptomatic deviations
that do not respond to nonsurgical therapy.
• Patients with totally accommodative
esotropia should not be considered for
extraocular muscle surgery, because of the
risk of inducing consecutive exotropia.
131. Possible complications following surgery
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Diplopia,
Undercorrection,
Overcorrection,
Chronic inflammation of the conjunctiva,
Excessive scar tissue,
Lost muscle(s),
Perforation of the globe,
Endophthalmitis,
Anterior segment ischemia,
Retrobulbar hemorrhage,
Conjunctival pyogenic granulomas, and
Corneal dellen.
132. Chemodenervation
• The injection of botulinum toxin type A
(Oculinum, Botox®) has been used as either an
alternative or an adjunct to conventional
incisional surgery in selected strabismic patients.
• The toxin selectively binds to nerve terminals
and interferes with the release of acetylcholine,
thereby functionally denervating muscles
injected with small amounts of the drug.
133. • The dose-related but temporary paralysis of an
extraocular muscle leads to a change in eye
position, followed by some degree of contracture
of the opposing muscle.
• Chemodenervation leads to result in long-lasting
and permanent alteration in ocular alignment.
• Although one injection is often sufficient to
produce positive results.
• Transient ptosis and vertical strabismus may
develop after chemodenervation.
• This technique has been most successfully used in
patients who have acute abducens nerve palsy and
in adults with small angle deviations.