Basic Strabismus

Rasha Eltanamly
Consultant Ophthalmologist

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Basic strabismus

What is strabismus?
Manifest misalignment of the eyes which can
be unilateral/alternating , constant /
intermittent, comitant or incomitant.

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Basic strabismus

Why is squint a problem?

Amblyopia
Cosmetic appearance
Loss of binocularity

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Basic strabismus

Examination of strabismus

Visual acuity assessment

Ocular alignment assessment
Ocular motility assessment
Others e.g. stereopsis & binocularity

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Basic strabismus

Visual acuity assessment in children

Age (yrs)
0-2

Test used
VEP

Normal
20/30

0-2

Preferential look

20/30

0-2

Fixation behavior CSM

2-5

Allen Pictures

20/40-20/20

2-5

HOTV

20/40-20/20

2-5

E game

20/40-20/20

5+

Snellen

20/30-20/20

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Basic strabismus

Examination of strabismus

Cover test
Cover uncover test
Simultaneous prism & cover

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Basic strabismus

Examination of
strabismus

Cover test (phoria)

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Basic strabismus

Examination of strabismus

Cover uncover test (tropia)

Measures the exact heterotropic deviation
The patient is made to fixate at a target, then one eye is
covered. If the uncovered eye moves to take fixation, then
heterotropia is diagnosed.
-If the eye moves nasally: exotropia
-If the eye moves temporally: esotropia
-If the eye doesnt deviate, repeat same for the fellow
eye

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Basic strabismus

Examination of strabismus

Simultaneous prism & cover

Measures actual angle of squint (tropia)

Cover fixating eye, apply prism in front of deviating eye
simultaneously
Repeat increasing prism power, till the eye no longer
shifts

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Basic strabismus

Examination of strabismus

Hirschberg test
Krimsky test

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Basic strabismus

Examination of strabismus

Hirschberg test

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Basic strabismus

Examination of strabismus

Hirschberg test

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Basic strabismus

Examination of strabismus

Krimsky test

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Basic strabismus

Examination of strabismus

Ocular motility assessment

Monocular /binocular
6 cardinal positions of gaze

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Basic strabismus

Amblyopia
Types

Strabismic
Anisometropic
Deprivation

Diagnosis
Treatment

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Basic strabismus

Amblyopia
Types
Diagnosis

Unexplained difference of visual acuity of 2 lines

Drop of VA with crowding

Treatment

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Basic strabismus

Amblyopia
Types
Diagnosis
Treatment

Removal of the cause

Full correction with glasses
Patching the stronger eye

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Basic strabismus

Common types of horizontal strabismus

Esotropia (convergant squint)

Exotropia (divergant squint)

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Esotropia

Infantile (congenital) esotropia

Accomodative esotropia
Pseudo esotropia

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Esotropia

Pseudo esotropia

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Esotropia

Infantile (congenital) esotropia

large constant angle (>40PD)
birth-6 months
amblyopia common (50-60%)
assocciated with
IOOA
DVD
latent nystagmus

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Esotropia

Infantile (congenital) esotropia

Surgery
Bilateral MR recession
6 months - 1 year

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Esotropia

Accomodative esotropia

Acquired 2 4yrs of age (infancy)

Moderate to large angle (20-50 PD)
Variable angle, intermittent
Hypermetropia +2.00 - +6.00

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Esotropia

Accomodative esotropia

Full hyperopic correction >+2.00

Response :

Full correction for distance & near

Residual angle for near
Residual angle for distance & near

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

glasses
bifocal add
glasses &surgery

Esotropia

Accomodative esotropia

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Exotropia

Intermittent exotropia
Congenital exotropia
Sensory exotropia

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Exotropia

Intermittent exotropia

Most common form of XT

Presents after 1 yr of age
Large exophoria
manifest XT
High grade stereopsis when fusing
Suppression when tropic

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Exotropia

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Exotropia

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Exotropia

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Exotropia

Non surgical treatment

Occlusion
Over minus
Full correction of hyperopia
Orthoptics (convergence insufficiency)

Surgical treatment

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Exotropia

Surgical treatment

Age
4yrs
Indication

XT> 50% of waking hrs

Increasing tropia phase
Poor fusion recovery on cover/ uncover test
Asthenopia OR diplopia

Type of surgery

Bilateral LR-Unilateral LR -- & MR ++

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Summary

Strabismus is a common pediatric eye

problem which may lead to amblyopia.
Early diagnosis and proper management
preserves vision and binocularity.
The role of the pediatrician is crucial in early
detection of strabismus.

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital

Thank you

Copyright 1982 - 2009 Dr. Erfan & Bagedo Hospital