OcularMotor

Anomalies


102strabismus
Definitions
Orthophoria
Strabismus(squint) misalignment
Heterophoria(phoria) latentsquint,
maintainedbyeffort
Heterotropia(tropia) manifestsquint,
uncontrolledbybinocularvision
Eso Exo Hyper Hypo Incyclo Excyclo
Visualaxis,anatomicalaxis(Anglekappa)
102strabismus
AnatomyofExtraocular Muscles
4rectusand
2obliquemuscles
anatomy
SpiralofTillaux
innervation
LR 6thCr.N.
SO 4th
others 3rd
Primaryaction majoreffectinprimaryposition
Subsidiaryactions additionaleffects
Musclepulleys
102strabismus
Listingplane&axesofFick
(ref.Kanski.ClinicalOphthalmology5thed.P517519)
MuscularActionfromtheprimaryposition:
MusclesPrimarySecondary
MRAdduction
LRAbduction
IRDepressionExtorsion&Adduction
SRElevationIntorsion&Adduction
IOExtorsionElevation&Abduction
SOIntorsionDepression&Abduction
102strabismus
OcularMovements
Ductions:
monoculareyemovementsaroundtheaxesofFick
Ad,abduction,elevation,depression,intortion,andextortion
Agonist:primarymuscle
Synergist:sameeye,samedirection
Antagonist:sameeye,oppositedirection
Versions:
binocular simutaneous,conjugatemovement
Dextro (right),laevo(left),upgaze,downgaze 2
nd
position
Dextro orlaevo elevation/depression 3rdposition
Dextro orlaevo cycloversion
102strabismus
OcularMovements
Vergences:
disjunctive(disjugate)binocular movement,
oppositedirection
Convergence(reflexorvoluntary)ordivergence
FourcomponentsofReflexconvergence:
Tonic:MR
Proximal:nearobject
Fusional :binocularsinglevision
Accommodative:synkineticnearreflex
102strabismus
101strabismus
9(Diagnostic)PositionsofGaze
Primary(1):
straightahead
Secondary(4):
R,L,U,D
Teritary(4):
U&R,D&R,U&L,
D&L
Cardinal(6)
102strabismus
Cardinalpositionsandyokemuscles
(synergisticmusclesintwoeyes,
primemoversinagivenpositionofgaze)
RSRRIO
LIO LSR
OD RLR RMR OS
R LMR LLR L
RIRRSO
LSO LIR
102strabismus
SherringtonsLaw
theextraocularmuscles
showreciprocal
innervationof
antagonisticmuscles
(except:Duanesyn)
102strabismus
Herings Law
equalandsimultaneous
innervationflowsto
synergistic muscles
concernedwiththe
desireddirectionofgaze
(except:Dissociated
VerticalDeviation)
102strabismus
ClinicalapplicationofHerings Law
Primarydeviation:
thenormaleyefixing
Secondarydeviation:
thepareticeyefixing
For palsy
Acute stage: 2
nd
>1
st
Chronic stage: 2
nd
1
st
102strabismus
102strabismus
SensoryFusionwithBinocularVision
Firstdegree fusion:
simultaneous
perception
Seconddegree fusion:
flatfusion
Thirddegreefusion:
stereopsis
102strabismus
FunctionalConsequencesofStrabismus
Amblyopia
Confusion two
dissimilarimagesattwo
foveae
Diplopia twoimagesof
thesameobject
Sensoryadaptationto
strabismus
Suppression
Abnormalretinal
correspondence(ARC)
Motoradaptationto
strabismus
Faceturn,chinupor
down,headtilt
102strabismus
Examination
History
Familyhistory,ageofonset,typeofonset,typeof
deviation,fixation,predisposingfactors
Visualacuity
Refractiveerror(withmydriactics)
Inspection
Ocularexamination
Slitlamp
fundus
specialexam
102strabismus
MeasurementofDeviation
Corneallightreflex(reflection)tests
Hirschbergsmethod
modifiedKrimskys method
Brucknertest
Majoramblyoscope method
Covertest
Covertest:tropia
Uncovertest:phoria
Alternatecover(prismandcover)test:tropia
plusphoria
Simultaneousprismcovertest
102strabismus
Hirschbergtest
Pseudoesotropia epicanthicfolds,short
interpupillarydistance,negativeanglekappa
Pseudoexotropia wideinterpupillarydistance,
positiveanglekappa
102strabismus
Angle kappa
Positive angle kappa retinopathy of prematurity
102strabismus
cover /uncover test
Indication:notamblyopic,cooperativetofixationonatarget
Uncover test:
check the covered eye
102strabismus
Alternate cover test:
measure total deviation
Indication Corneallight
reflex
Cover/Uncover Alternate
Cover
Sensory
Fusion
Orthotropia Straight Noshift Noshift Yes
Phoria Straight Noshift Shift Yes
Tropia Deviation Shift Shift No
Monofixation Smalldeviation Smallshift Largershift Yes
102strabismus
Krimsky testPrismCovertest
102strabismus
Prismdiopter()
unitofprismpower
theamountofdeviationproducedbyalightray
transversestheprism
Centimetersofdeflectionmeasured100cmfrom
theprism
Foranglesunder100(45),each2 (1.7pd)are
approximatelyequalto1.
cm=prismdiopter

100cm
102strabismus
FresnelPrism
102strabismus
SensoryExamination
Stereopsistests
Randomdotstereograms
Disparateimagewithpolaroidglassed
Suppressiontests
Worth4dottest
Bagolini striatedglasstest
ARCtests
Afterimagetest
Bagolini striatedglasstest
Amblyoscope
102strabismus

Disparateimagewithpolaroid
glassed:Titmus test
Randomdotstereograms:
TNOtest
102strabismus
Amblyoscope ()
102strabismus
Maddoxrodtest
102strabismus
Worth4dotstest
No change
2 Red or 3 Green:
suppression
2 Red and 3 Green
diplopia (crossing-
XT)
102strabismus
ChildhoodEsotropia (ET)
Pseudoesotropia widernasalbridge
InfantileET
AccommodativeET
Refractive
nonrefractive
mixed
NonaccommodativeET
Sensorydeprivation
divergenceinsufficiency
stressinduced
sixthnervepalsy
102strabismus
EssentialInfantileEsotropia
Onset<6m/o
deviation 30pd
usuallycomitant
associatedwithDVDorInferiorOblique
Overaction
associatedwithnystagmus
lowtomoderatehyperopia(<3D)
crossfixationforlargeangleET
bilateralequalvision
Amblyopia(40%)
Tx:surgery(before2y/o)
102strabismus
AccommodativeET
RefractiveAcc ET
excessivehypermetropia (+4~+7D)
normalAC/Aratio(Distancenear<10PD)
Tx:spectacles(sameatnear&far)
Nonrefractive Acc ET
normalrefraction(<+3D)
highAC/Aratio(Distance:littleornoET)
Tx:nearspectacles
MixedAcc ET
combinedhypermetropia andhighAC/A
ratio
Distance:ET&markedETfornear
Tx:bifocalspectacles
102strabismus
Childhood Exotropia (XT)
Pseudoexotropia
positiveanglekappa
widerinterpupillarydistance
Intermittent&Constant
BasicXT(Near=Distance)
Divergenceexcess(worseforD.)
Convergenceinsufficiency (worseforN.)
Pseudodivergenceexcess
102strabismus
CongenitalXT
Presentatbirth(incontrasttoinfantileesotropia)
largeandconstantangle
homonymousfixation
uncommonamblyopia
normalrefraction
associatedwithneurologicalabnormality(in
contrasttoinfantileesotropia)
Tx:surgery
101strabismus
IntermittentXT
Fluctation betweenphoria andtropia
mostonsetaround2y/o
precipitatedbybrightlight,daydreaming,
fatigue,illness,visualdistraction
withtimepassing,angle&timeofXT
increase
rareamblyopia
Tx:spectacles,
orthoptic treatment,
surgery
101strabismus
PrinciplesofStrabismusSurgery
Weakeningprocedures
recession
marginalmyotomy
myectomy
posteriorfixationsuture
Strengtheningprocedures
resection
tucking
Advancement
Adjustablesuture
Botulinumtoxinchemodenervation
101strabismus
DuanesRetractionSyndrome
CongenitalanomalyofinnervationofLR
(absenceof6thneuronswithLR
innervationbybrof3rdnerve)
20%bilateral,femalepredilection,OSmore
Sherringtonslaw()
Severelimitationofabduction,variable
abnormalitiesofadduction,global
retractionandnarrowingofpalpebral
fissureonadduction,up ordownshoot
101strabismus
DuanesRetractionSyndrome
Type1.themostcommon:
limitedorabsentabduction
normalormildlylimitedadduction
StraightorslightET
Type2.theleastcommon:
limitedadduction
normalormildlylimitedabduction
straightorslightXT
Type3:
limitedab &adduction
straightorslightesotropia
Mayhaveheadturn
Diplopiaandamblyopiaarerare
101strabismus
DuanesyndromeType1(OS)
101strabismus
(Amblyopia)

0.5 ()
0.6 ()
0.7 ()
0.8 ()

Amblyopia
Etiology
Refraction:anisometropia,highrefractive
errors(myopia>6D,hyperopia>3D,astigmatism>2D)
vs.

Strabismus:
Occlusion:ptosis,cornealleucoma,cataract
Timing
Therapy
101strabismus