Literature review

Classification of Strabismus

Ida Muthmainnah

Consultant:
Dr. Linda Trisna, SpM

Ophthalmology Department, Medicine Faculty of Unsri

Mohammad Hoesin Hospital
2010
Introduction
Strabismus

a condition in which the eyes not properly aligned

with each other.
 AIM

To know classification of strabismus

Diagnosis and management

Extraoccular Muscle
ANATOMY and FISIOLOGY
• THE RECTUS MUSCLE
- THE MEDIAL RECTUS
- THE LATERAL RECTUS
- THE SUPERIOR RECTUS
- THE INFERIOR RECTUS
• THE OBLIQUE MUSCLE
- THE SUPERIOR OBLIQUE
- THE INFERIOR OBLIQUE
• LEVATOR PALPEBRA
Blood Supply and Innervation of extraoccular Muscle

Muscle Blood supply Innervation

Superior rectus Muscular lateral branch of A. ophthalmica N. III superior
Inferior rectus Muscular medial branch of A. N. III inferior
ophthalmica, infraorbita artery
Medial rectus Muscular medial branch of A. ophthalmica N. III inferior
Lateral rectus Muscular lateral branch of A. ophthalmica, N. VI
lacrimal artery
Superior oblique Muscular lateral branch of A. ophthalmica N. IV
Inferior oblique Muscular medial branch of A. N. III inferior
ophthalmica, infraorbita artery
Action of Extraoccular Muscles from Primary Position

Muscle Primary Secondary Tertiary

Medial rectus adduction - -
Lateral rectus abduction - -
Superior rectus elevation adduction intorsion
Inferior rectus depression Adduction extorsion
Superior oblique intorsion abduction depression
Inferior oblique extorsion abduction elevation
Classification of Strabismus
• Classification according to • According to fixation
fusion status ▫ Alternating
▫ Phoria ▫ Monocular
▫ Intermitten tropia • According to age of onset
▫ Tropia ▫ Congenital
• According to variation of ▫ Acquired
deviation w/ gaze • According to type of deviation
position/fixating eye ▫ Horizontal
▫ Comitant ▫ Vertical
▫ Incomitant ▫ Torsional
▫ Combined
 Horizontal deviation

• Esodeviation
▫ Most common type, almost 50% of ocular
deviation in West
▫ 3 forms: esophoria, intermittent esotropia,
esotropia
▫ Etiology: innervations, anatomic, mechanic,
refractive, genetic, accommodative disturbances
• Pseudotropia
▫ Not a real strabismus, looks like strabismus
▫ Hirschberg, cover test  normal
▫ Pseudotropia improves in infantile & childhood
period
• Esotropia
▫ Comitant/incomitant; comitant = 5 PD in
horizontal gaze; incomitant  deviation varies
• Early onset congenital
esotropia
▫ First 6 months of life, no
refractive anomaly, no
resistance in eyeball
movement
▫ Diagnosis: large, stable
deviation (> 30 PD); ▫ Early surgery required before
alternating fixation in
primary position; cross-
fixating; abduction (+);
▫ Patching needed; horizontal
nystagmus may present;
latent nystagmus, by
occluding one eye; normal
refraction; asymmetric
optokinetic nystagmus;
inferior oblique overaction
1 y, 2 y at most
• Accomodative esotropia
▫ Near fixation  accomodation + convergence
▫ Onset 6 mo-7 y, mean 2.5 y
▫ Intermittent at onset  constant
▫ Mostly hereditary
▫ Sometimes invoked by trauma/illness
▫ Related to amblyopia
▫ 3 types: refractive accommodative, non refractive
accommodative, partial accommodative
• Refractive accommodative esotropia
▫ High hypermetropia (+2.00 to +7.00), AC/A ratio
normal, onset 18 mo-3 y (6 mo-7 y)
▫ Near & distant deviation relatively the same
▫ 2 types: fully accommodative, constant
accommodative
• Non refractive accommodative esotropia
▫ AC/A ratio high, disproportional convergence
excess
▫ 2 types: convergence excess, hypo-accommodative
convergence excess
▫ Treatment: refractive error correction; under 6 y
 full correction w/ cycloplegics & reduction for
working distance, after 8 y  w/o cycloplegics;
convergen excess  bifocal
• Non accomodative esotropia
▫ Basic esotropia: after 6 mo, not related to
accommodative component, near & distant
deviation is the same, central lesion must be
suspected
▫ Acute esotropia: onset 5-6 y, rapid onset of
esotropia & diplopia, normal eye movement, no
significant refractive error, treat to recover
binocular sensory function
▫ Cyclic esotropia: rare, incidence 1:3000 – 1:5000
strabismus cases, alternating manifest esotropia
ends in 24 hr, persist for months or years 
constant esotropia, treat for amblyopia &
hyperopia
▫ Sensory deprivation esodeviation: all the things
causing retinal image to blur, treat immediately
▫ Divergence insufficiency: larger esodeviation in
distant than near, deviation constant regarding
vertical or horizontal gaze, less fusional
divergence; treat w/ base out prism
▫ Spasm of the near synkinetic reflex: functional
etiology, psychological factors, sometimes organic;
gaze movement in horizontal version 
substitution of the convergence movement;
monocular abduction  normal; treat w/
cycloplegics
▫ Surgical esodeviation: frequently  spontaneous
resolution, base-out prism may be used +
lenses/miotics
• Incomitant esodeviation
▫ N VI paralysis: congenital  related to raised ICP
in birth, spontaneous resolution; in children 
more frequent than in infant; related to
intracranial lesion, infectious or immunologic
processes; press on prism of Frensel to correct
diplopia
 Exodeviation
• A divergent strabismus, may be latent or
manifest, etiology is mostly unknown, hereditary
is a probability. Several types:
▫ Pseudoextotropia
▫ Exophoria
 Intermittent exotropia
 Constant exotropia
• Pseudoexotropia
▫ Not a real exotropia, positive kappa angle w/o any
other disorder, wide interpupillary distance,
positive kappa angle w/ other disorder as
temporal macular traction in ROP
• Exophoria
▫ Fusion controlled exodeviation
▫ Manifest if binocular vision hampered
▫ Several types of it:
 Intermittent exotropia
 Constant exotropia
▫ Intermittent exotropia
 Latent, manifest sometimes (illness, stress, dozing);
early onset (before 5 y); in children, deviation is
greater in distant than near
 No treatment  constant exotropia
 Treatment: spectacles correction in myopic patients,
occlusion in deviating eye, surgery if fusion control
worsen progressively
▫ Constant exotropia
 In older patient w/ sensory or intermittent
decompensatory exotropia
 Treatment: bilateral resection of rectus muscles
involved or unilateral resection of lateral rectus w/
resection of medial rectus muscle
 Congenital, sensory, consecutive exotropia, and also
convergence insufficiency & paralysis
 Vertical deviation
• Vertical deviation to visual axis
▫ Comitant
▫ Incomitant (most of cases)
▫ Unrelated or related to horizontal deviation
• Etiology:
▫ Superior & inferior oblique muscle dysfunction
▫ Paresis or contracture of one or more cyclovertical
mucles
▫ Mechanical restriction
• Clinical illustration
▫ Nearly all is incomitant at onset  comitant if
there was no mechanical restriction, deviation in
various gaze  differ
▫ Naming  according to vertical deviation of non
fixing eye
• Inferior oblique muscle overaction
▫ Etiology: mechanical, innervational or both
▫ Clinical illustration: onset at 1-6 y, 2/3 patient w/
congenital esotropia, overelevation in adduction
(lateral gaze of abduction of fixating eye), ACT 
refixating eye moves down
▫ Treatment: surgery if significant hyperdeviation at
adduction
• Superior oblique muscle overaction (SOOA)
▫ Primary
▫ Clinical illustration: hypotropia in primary
position w/ unilateral or bilateral but assymetric
SOOA; may be accompanied by horizontal
deviation
▫ Treament: tenotomy, silicon expander insertion
• Dissociated vertical deviation (DVD)
▫ Common in congenital esotropia patients
▫ Etiology: unknown, related to early binocular
development disorder, may be a compensatory
mechanism of latent nystagmus and dorsal light
reflex
▫ Clinical illustration: spontaneous movement of the
eye to upper & lateral side w/ simultaneous
extorsion if one eye is closed or in visual
inattention w/o occlusion
▫ Hering law is not applicable in DVD
▫ Treatment: if vertical deviation is spontaneous &
cosmetically significant; non surgical  patching;
surgery  may improve but not eliminate DVD
• Superior oblique muscle palsy
▫ Commonly found in trochlear (n IV) palsy
▫ Congenital or acquired
▫ Unilateral or bilateral palsy
▫ Clinical illustration: hyperopia (unilateral),
abnormal head posture, amblyopia, extorsion
▫ Diagnosis: three step test, double Maddorx rod
test, deviation in 9 positions
▫ Treatment: if AHP, significant vertical deviation,
& diplopia present
Diagnostic Techniques for
Strabismus
• important to obtain information regarding

- history of illness & trauma

- family history
- mother’s pregnancy
- neonatal history etc.
 Diagnostic Techniques for Strabismus

• The following questions about the deviation or

symptom

- Did its onset coincide with trauma or illness?

- Is the deviation constant or intermittent?
- Is it present for distance, near or both?
- Is it unilateral or alternating?
- Is the deviation associated with double
vision?
 Diagnostic Techniques for Strabismus

1. Assessment of VA

- Snellen letters or numbers, the HOTV test,

LEA symbols, the illiterate E test and Allen
pictures.
- Uncorrective lenses  a pinhole used.
- VA assesment of children is difficult 
CSM method
 Diagnostic Techniques for Strabismus

2. Assessment of Eye Movements

A. Test of ocular alignment

- Cover tests
- Corneal light reflex tests
- Dissimilar image tests
- Dissimilar target tests
 Cover test

3 types

- Cover-uncover test
- The alternate cover test
- Prism alternate cover test

-
• Cover-uncover test

Detecting the presence of manifest strabismus and

for differentiating a phoria from a tropia.

As 1 eye is covered, the examiner watches

carefully for any movement in the opposite
• Alternate cover test

Measure the total deviations

The cover is placed alternately in front of each

eye several times to dissociate the eyes and
maximize the deviation.

at both distance and near fixation

• Prism alternate cover test

By covering the fixating eye at the same the

prism is placed in front of the deviating eye

The test is repeated using increasing prism

The power of the prism is the measure of the

deviation
 Light Reflex Tests

1. Hirschberg Method
2. Modified Krimsky
3. Bruckner Test
• Hirschberg Method

Assess eye alignment by the noting the location

of the corneal light reflex within the pupil

performed by holding a light source in front of the

examiner’s eye and directing the light into
patient’s eye

Based on the premise that 1 mm of decentration

of the corneal light reflection correspondends to
about 7°
• Modified Krimsky

Use of the prism to the Hirschberg test to measure

strabismus

Placing prism in front of the dominant eye

Will cause a version movement in the direction of

the apex of prism
• Bruckner Reflex Test

Direct ophthalmoscope

Obtain a red reflex from both eyes

Show asymmetrical reflex

A brighter reflex coming from the deviated eye

 Dissimilar image test

• Maddox rod test

• The double Maddox rod test
• The red glass test
• Maddox rod test

A single Maddox rod is placed horizontally and

fixates on a distanst spot of white light

See a vertical red line and white spot

If the image is crossed : exophoria

If the line is to the right :esophoria
• The double Maddox rod

Used to determine cyclodeviation

Placed horizontally in front of each eye

(1 red,1white)

Rotated until the patient report that is vertical

The rotation indicates the size of torsion

 Dissimilar Target Test

1. Lancester red-green projection test

2. The Hess screen test
• Lancester red-green projection test

Uses red-green goggles, a red slit projector, a

green-slit projector and a screen ruled into squares
of 7 cm
Distance of 2m, each square subtends 2°

The examiner projects a red slit onto the

screen,the patient asked to place the green slit so
appears to coincide with the red slit

The relative positions of the 2 streak are recorded

• The Hess screen test

Evaluating patient with paretic or paralytic

uses red-green goggles, a special screen that has

a red dot in 8 inner and 16 outer position, a green
slit projector

Distance 50 cm

Patient is asked to place the green slit light so

appears to coincide with red dots
B. Convergence

• Alignment at near at 33 cm
• Directly in front of the patient
• Determined by placing a fixation object at 40cm
• Object is moved toward until 1 eyes loses
fixation and turns out
• The eye that is able to maintain fixation is
dominant eye
• Accommodative convergence/accommodation
Ratio (AC/A)

- The gradient method

- Heterophoria method
- Clinical distance-near relationship method
C. 3-step test

Marshall Parks in 1958

Diagnosis of cyclovertical muscle palsies

• First step
Determine which paretic muscle cause a
hyperdeviation in primary position

• Second step
Where the hypertropia is greatest, in rightgaze
or leftgaze

• Third step
On the Bielschowsky head tilt test as previously
described
 WRIGHT’S
RULE

if the hyperdeviation increases on head tilt to

the same side  an oblique muscle is paretic
opposite side  vertical rectus is paretic
D. Test of Binocular Sensory
Cooperation

• Worth 4-dot testing

Consists of an illuminated box (1 red, 2 greens

and 1 white)

Distance 33cm and 6 m

Red-green goggles (red in RE, green in LE)

WFDT

- Patient sees 4 ( 1 red,1 green, and the fourth

either yellow, pink) : normal

- Sees only 2 red lights : RE is dominant and LE

is suppressed

- Sees 3 green lights : LE is dominant, RE is

suppressed

- Sees 5 lights: presence of diplopia

• Stereo acuity testing

Asesses the use of the 2 eyes for binocular depth

perception

Stereopsis occurs when the 2 retinal images,

slightly disparate because of the normally different
views provided by the horizontal separation of the
2 eyes

Wirst Titmus Stereo Vectogram

Lancester red-green test
Titmus fly and wirt circles