Restrictive strabismus is form of squint which is rare in origin. Here various form of restrictive squint have been explained, its diagnosis and its management is briefly explained.

1. Optom. Ankit S. Varshney
B.Optom, M.Optom, Ph.D. in Optometry (pursuing) Fellow of IACLE (Aus.), Fellow of ASCO(Mum.)
Prof. at (Shree Bharatimaiya College of Optometry & Physiotherapy, Surat)
Life Member of Indian Optometric Association (IOA)
Associate Member of Association of Schools and Colleges of Optometry(ASCO)
Member of Optometry Council of India(OCI)
Educator Member of International Association of Contact lense Educators (Australia)(IACLE)
Mail id: ankitsvarshney@yahoo.com
Whatsapp no. +918155955820

2.  Binocular vision & strabismus –gk von
noorden
 Clinical mangement of strabismus elezabeth
e.Calarossa & michael w. Rouse
 Aao- section: pediatric ophthalmology &
strabismus
 Strabismus simplified- pradeep sharma
 Practical orthoptics in the treatment of squint-
lyle and jackson’s15 July 2020 Optom.AnkitVarshney 2

3. Skin
Conjunctiva
Tenon’s layer
Eye Muscles
Left eye
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4. Eye Muscles
Left eye
Superior Oblique/Trochlear Muscle
Superior Rectus Muscle
Lateral Rectus Muscle
Inferior Rectus Muscle
Inferior Oblique Muscle
Medial Rectus Muscle
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5.  AKA Squint/ Crooked eye
 Refers to an ocular condition in which the visual
axes of the two eyes do not meet at the point of
regards. (Misalignment of visual axes).
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6.  1. Apparent/ Pseudo Strabismus: nothing but an optical illusion caused by
prominent epicanthal folds (pseudo eso)/ wide IPD (pseudo exo).
Pseudo ET Initially the baby has a
“button nose, with a
very flat nasal bridge.
As the nasal bridge
develops and grows
forward it will drag the
medial portion of the
lids inward reducing
the appearance of the
eyes being crossed.
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7.  2. Latent Strabismus (Phoria): deviations are
present only some of the time: (interruption of
BV, fatigue, illness, stress)
Orthophoria
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8.  3. Manifest Strabismus (tropia):
eyes deviated all the time
 Concomitant ( Non-paralytic)
 Incomitant strabismus (Paralytic/ Restrictive/
A &V pattern)
Esotropia
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9.  Manifest squint in which the amount of deviation
in squinting eye remains constant in all directions
of the gaze and there is no associated limitation in
ocular movement.
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10.  Manifest squint in which the amount of deviation
varies in different directions of gaze.
1. Paralytic squint: It refers to ocular deviation resulting
from complete/incomplete paralysis of one or more
EOM.
2. Restrictive squint: in this, the EOM involved is not
paralyzed but its movement is mechanically restricted.
It is differentiate by smaller amount of ocular
deviation and a Positive FDT.
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11. Classified in two types:
1. Congenital causes (Musculo-fascial innervational anomalies):
DRS, Brown’s SO sheath Syndrome, Strabismus fixus & muscle
fibrosis syndrome.
2. Acquired causes: Dysthyroid orbito myopathy, pseudotumor,
orbital tumors, fibrosis of EOM secondary to trauma or surgery.
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13.  Duane syndrome is a rare, congenital disorder of
eye movement
 Stilling andTurk : described it first
 Duane popularised it
 Affecting the Horizontally acting muscle: so it
Horizontal strabismus.
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14.  Incidence 1-4 percent of all strabismus
 Mostly Sporadic
 Female > Males (3:2)
 Left eye > Right eye (60-75%) where unilateral
 Bilateral 18-22%
 Many associated congenital anomalies
 Occasionally familial
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15.  Goldenhar Syndrome :
Hemifacial microsomia, ocular dermoids, ear
anomalies, preauricular skin tags, upper eyelid
colobomas.
 Wildervanck Syndrome :
Sensorineural hearing loss, Klippel Fiel anomaly
with fused cervical vertebrae, epibulbar dermoid.
 Klippel-feil syndrome
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16. “ Musculo Fascial
Innervational
Anomaly ”
Fibrosis of LR/MR
Fibrous bands
Co contraction –
Paradoxical
innervation
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17.  Type I (d): Failure or limitation of abduction.
 Type II (dd): Failure or limitation of adduction.
 Type III (ddd): Failure of abduction and adduction
Classic features
Retraction of globe on adduction
Adduction narrowing of palpebral fissure
Upshoot / downshoot of eye in adduction
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19. OS OD
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20. OS OD
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24.  Squinting
 Head tilt
 Loss of binocular vision
 Reduced ocular movement
 Facial asymmetry
 Picture of paralytic squint
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25.  AHP
 Strabismus ( 77% of cases)
 Globe retraction
 Palpebral fissure narrowing
 Anisometropia /amblyopia
 Sensory adaptation with excellent binocular functions
-suppression without diplopia in gaze of abnormal
muscle
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26. Right gaze,
Left face turn…
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27.  30 PD LET actually,
 But can fuse in right
gaze, left head turn
Check his ductions…
Primary gaze
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28.  30 PD LET actually,
 But can fuse in right
gaze, left head turn
 Notice the limited
abduction and narrow
fissure in adduction
Left gaze,
Right face turn…
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29.  Bilateral DRS
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30. DRS
 ET small angle
 Narrowing
 Saccadic velocities
SIXTH N PALSY (LR)
 ET large angle
 -ve
 Slow in abduction only
MOBIUS SYNDROME:
Rare condition affecting bilateral sixth and seventh (facial) cranial nerve palsy.
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31.  Treat refractive error
/amblyopia
 Conservative : Age 5-6 yrs
 Prisms: up to 25 error
 Special seating arrangement for
children in schools
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32.  Conservative : Age 5-6 yrs
 Vision therapy for secondary convergence insufficiency
Normal Convergence
Convergence Insufficiency
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33.  Anomalous head posture
 Strabismus in primary gaze
 Significant upshoot or downshoot in adduction
 Cosmetically significant palpebral fissure
narrowing in adduction.
“ Limited Goals ”
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34. Eso DRS
Small angle <15
PD
Single MR
recession
Larger angle
Bilateral MR
recession
Asymmetric
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35. Exo DRS
Small angle <15
PD
Single LR
recession
Larger angle
Bilateral LR
recession
Symmetric
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36. Upshoots
Downshoots
Globe retraction
Recession of MR
and LR
Y split
Posterior fixation
suture to LR
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37. Duction
Improvement
Transposition of
SR /IR
FOSTER’S
modification
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38.  A very rare condition, in which both eyes are fixed
(in extreme duction), by fibrous tightening of MR
(Convergent strabismus fixus) or LR (Divergent
strabismus fixus).
 FDT confirms their immobility.
 Affecting the Horizontally acting muscle.
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40.  Convergent strabismus fixus: Complete
disinsertion of MR and resection of LR.
 Divergent strabismus fixus: just reverse of above
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41. Brown Syndrome

42. 1. Absence of elevation in adduction
2. Downshoot or hypotropia in attempting elevation
in adduction
3. Unaffected elevation in primary and abducted
position
4. Y pattern with divergence in upgaze
5. Anomalous head posture (Often seen with chin up
position)
6. Positive FDT
7. 2/3 are mild and do not require treatment if ortho
in primary15 July 2020 Optom.AnkitVarshney 42

43.  Trauma or
 Infection ofTrochlear area
 SO tucking Sx
 Canine tooth syndrome: Dog bites- scarring SO
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44. Divergence in upgaze
Down shoot in attempted elevation in adduction?
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45.  Mild: Restricted elevation in adduction but no downshoot
or hypotropia in primary position.
 Moderate: Restricted elevation in adduction with
downshoot but no hypotropia in primary position.
 Severe: Restricted elevation & downshoot in adduction
with hypotropia in primary position.
 To understand Brown’s syndrome
 We need to understand relationship between the
superior and inferior oblique.
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48. Restriction of the superior oblique tendon at the
trochlear pulley
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50. 1-I O PALSY
2-DOUBLE ELEVATOR PALSY
3- CONGENITAL FIBROSIS SYNDROM
4-BLOW OUT FX
5-THYROID OPHTHALMOPATY
5-ADHERENCE SYNDROM
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51.  If associated with other disease
 ie rheumatoid arthritis or sinusitis
 Treat the underlying condition.
 Surgery if:
 Hypotropia in primary
 Anomalous head posture: severe chin up.
 Consider
▪ SO tendon tenotomy,
▪ SO tendon silicone expander
▪ SO tendon chicken suture (mercilene, nonabsorbable)
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52. SR
MR
LR
IR
SR
LR
RM
IR
IOIO
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55. Divergence in upgaze
Down shoot in attempted elevation in adduction?
Down shoot in attempted elev. in adduct. (different than IO palsy)15 July 2020 Optom.AnkitVarshney 55

56.  Rare, Nonprogressive, Autosomal dominant.
 Characterized by hypoplasia and fibrosis of EOM & LPS.
 Bilateral congenital Ptosis.
 In primary position each eye is fixed below the horizontal
by about 10 o due to Congenital fibrosis of the inferior
rectus.
 Thus hypotropic eye may be severe exotropic or esotropic
due to involvement of the horizontal recti.
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58.  Surgery is difficult and requires release of the
restricted muscles;
 A good surgical result aligns the eyes in primary
position, but full ocular rotations cannot be
restored and the outcome is unpredictable.
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59.  Developmental anomaly occurring between the
EOMs and their fascial sheaths.
 Abnormal connections most commonly occur
between the LR and IO, and between the SR and
SO muscles.
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60.  Diagnosis often mysterious SO LOOK for it !
 Treat Ref Error , amblyopia
 Risk benefit ratio of surgery to be well understood
by patients and surgeon
 Tailor made surgery required for every case
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61.  Thank you
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