This document discusses restrictive strabismus, which is characterized by limited eye movement out of proportion to the ocular deviation. It can be caused by mechanical or neurological issues. The document then classifies restrictive strabismus as either congenital (e.g. Duane's retraction syndrome, Brown's syndrome) or acquired (e.g. thyroid ophthalmopathy, orbital injury, tumors). Specific conditions like Duane's retraction syndrome and Brown's syndrome are further described in terms of symptoms, prevalence, and management approaches including non-surgical and surgical options.

1. RESTRICTIVE
STRABISMUS
Dr. Debarati Dasgupta

2. – Characterised by limitation of movement which is out of
proportion to the ocular deviation in primary position.
– Can be mechanical or innervational anomaly.

4. – Medial Rectus – Adduction.
– Lateral Rectus – Abduction.
– Superior Rectus – Elevation , adduction , intortion.
– Inferior Rectus – Depression, adduction, extortion.
– Superior Oblique – Intortion , abduction, depression.
– Inferior oblique – Extortion , abduction, Elevation.

5. CLASSIFICATION
CONGENITAL
– DRS
– Brown’s syndrome
– CFEOM
– Mobius syndrome
ACQUIRED
– Thyroid ophthalmopathy
– Orbital injury
– Tumours
– Surgeries

6. DUANE’S RETRACTION
SYNDROME
– Stilling –Turk-Duane
syndrome.
– Congenital miswiring of
medial and lateral rectus
muscles.

9. – Prevalence – 1/1000.
– F >M.
– 4 % of all strabismic cases.
– 80 % are U/L.
– 30 % of cases a/w congenital
anomalies.
– 90 % sporadic, 10 %
inherited.
– Syndromic forms:
– Goldenhar syndrome.
– Moebius syndrome.
– Morning glory syndrome.

10. – Complete or partial abduction or adduction deficit.
– Retraction on adduction.
– Pseudotosis on adduction.
– Upshoot or downshoot on adduction.
– Abnormal head posture.

11. MANAGEMENT
NON SURGICAL
– Retractive error correction.
– Treatment of amblyopia.
– Prism glasses.
– Botulinum toxin – decreases
upshoot or downshoot of globe
with adduction.
 SURGERY
– Marked deviation.
– Significant head posture.
– Upshoot or downshoot.
– Severe globe retraction.

12. Type 1 & 3 with head turn –
– Recession of medial rectus or
horizontal transposition of vertical
rectus muscle.
Type 1 & 3 with upshoot or
downshoot or severe globe
retraction –
– Recession of both MR & LR with Y
splitting of LR.

13. Type 2 with head turn &
fixation with uninvolved
eye :
– Recession of I/L LR.
Type 2 with head turn &
fixation with involved eye:
– Recession of C/L LR.
 Type 2 with upshoot or
downshoot:
– Recession of LR with with Y
splitting.

15. – Congenital 6th Nerve Palsy –
– Infantile esotropia
– Mobius Syndrome

16. BROWN SYNDROME
– Tight or short superior
oblique tendon.
– Congenital or acquired.

17. – Limited elevation in adduction.
– Unaffected elevation in primary position & abduction.
– Divergnce in upgaze.
– FDT +ve.
– Widening of palpebral fissure on adduction.
– Ortho or hypo in primary position.
– Head posture.

18. – Indication of surgery:
– Hypotropia in primary
position
– Anomalous head posture.
– Surgery :
– SO Tendon sheath dissection.
– Chicken suture technique.
– Silicone expander.

20. – Inferior Oblique palsy – no divergence in upgaze, SO overaction.
– Congenital fibrosis of inferior rectus- limitation of elevation in
abduction.
– Grave’s disease.

21. CFEOM
– Fibrosis of extraocular muscles and tenon.
– Inelastic conjunctiva.
– Ptosis.
– Absent elevation.
– Perverted convergence on attempted upgaze.
– Choroidal coloboma, pendular nystagmus, optic nerve hypoplasia.

23. – supramaximal recession of I.R.
– Correction of S.O overaction.
– Correction of Exodeviations ,
– Perverted convergence – Faden procedure.

25. – CPEO – later onset with progression.
– Congenital ptosis
– Congenital myasthenia – fatigable ptosis.

26. MOBIUS SYNDROME
– 1.Orthotropia in primary position with marked deficits in
abduction and adduction (40% of cases)
– 2. Esotropia with cross-fixation and sparing of convergence and
adduction (50% of cases)
– 3. Large exotropia with absence of convergence (10% of cases)

27. – Medial rectus muscle recession
in large-angle esotropia.
– To improve abduction by
performing vertical rectus
muscle transposition
procedures after medial rectus
muscle restriction has been
relieve

28. THYROID
OPHTHALMOPATHY
– Lid retraction, proptosis.
– Limitation of EOM.
– Convergence insufficiency.
– GAG production &
deposition.
– Increase orbital pressure.
– Correction by prism or
occlusion.
– Steroid.
– Surgical decompression
– Ocular deviation by muscle
recession.
– Adjustable suture.

29. ORBITAL INJURY
– Most commonly inferior wall
is involved.
– Entrapment of orbital tissue.
– Limitation of EOM.
– Hypoesthesia

30. – Observe .
– Follow up with vision and
diplopia chart.
 Indication for surgery :
– Diplopia in primary position
or downgaze.
– Severe enophthalmos.
– Ocular deviation can be dealt
later.
– MRI
– Surgical exploration.

31. THANK YOU