Strabismus & Amblyopia

Dr. Linda Trisna, SpM(K)

Strabismus

Definition :

Ocular misalignment, whether due to

abnormalities in binocular vision or
anomalies of neuromuscular control of
ocular motility

When the eyes become dissociated

(not aligned) Strabismus

The Advantages of Binocular Vision :

Better visual acuity

Exp. : - One eye 0,8 -- Both eyes 1,0

- One eye 1,0 -- Both eyes 1,2

Wider field of view

Stereoscopic vision

Normal condition of muscle balance

Orthophoria producing single
binocular vision

Extra Ocular Muscles

A TEAM OF SIX MUSCLES CONTROLS THE MOVEMENT OF EACH EYE and BALANCING THE EYE
THE RECTUS MUSCLE
- THE MEDIAL RECTUS adduction
- THE LATERAL RECTUS abduction
- THE SUPERIOR RECTUS supraduction
- THE INFERIOR RECTUS infraduction
THE OBLIQUE MUSCLE
- THE SUPERIOR OBLIQUE intorsion
- THE INFERIOR OBLIQUE extorsion

Single Binocular Vision

Is a condition when retinal images

from two eyes integrating into a
single three-dimensional visual
perception
Prerequisites for binocular vision :

Visual acuity of the two eyes after

corrected are the same or slightly
different and anisokonia not present
Good coordination of eye muscles on the
both eyes same direction of viewing
Fusion capabilities of the brain

Nomenclature of Strabismus

Prefixes :

Eso- : rotated nasally

Exo- : rotated temporally
Hypo- : rotated inferiorly
Hyper- : rotated superiorly
Incyclo-: torted nasally
Exyclo- : torted temporally

Nomenclature (Cont.)

Suffixes :

-phoria : A latent deviation that is controlled by

the fusional mechanism so that under normal
binocular vision of the eyes remain aligned

Exp : Exophoria, Esophoria, etc

-tropia : A manifest deviation that exceeds the

control of the fusional mechanism so that the
eyes are not aligned

Exp. : Hypotropia, Esotropia, etc

Classification of Strabismus

According to fixation :

Alternating : Spontaneous alternation of

fixation from one eye to the other
Monocular : Definite preference for
fixation with one eye

According to age of onset :

Congenital prior of 6 months of age

Acquired after 6 months of age

Classification (Cont.)

According to the type of deviation :

Horizontal : Esodeviation or
Exodeviation
Vertical : Hyperdeviation or
hypodeviation
Torsional : Incyclodeviation or
excyclodeviation
Combined : Horizontal, vertical, and/or
torsional

Classification (Cont.)

According to variation of the

deviation with fixating eye :

Comitant (concomitant) :does not vary

with eye direction
Incomitant : varies with eye direction

Etiology of Strabismus

Heterophoria :

Muscle weakness :
Congenital
Acquired

Muscle spasm
Refraction anomalies
Anomalies of anatomy of the eye muscle

Etiology of Strabismus (Cont.)

Heterotropia :

Congenital :

Eye muscle or neural anomalies

Disturbances of accommodation
Infection
Trauma
Head/brain neoplasm
Specific eye disease that attack macula
toxoplasmosis

Clinical Symptom

Subjective :

Heterophoria :
Blurred vision, especially when tired
Headache after reading

Heterotopia :
Diplopia
Eye balls range of movement limited
Changing the position of the head

Assessment of Strabismus

Patients eye ball appearance

(simplest methods)
Corneal light reflex test :

Hirschberg test
Modified Krimskys method test

Assessment (Cont.)
Cover tests
Cover-uncover test
Alternate cover test

Therapy of Strabismus

Main goal of therapy Single

binocular vision
Other goal cosmetic reason
Treatment :

Congenital strabismus surgery as

soon as possible
Refraction disturbances correction
Orthoptic exercises
Surgery

Complication
Amblyopia
Cosmetic
Head posture
disturbances

Amblyopia

Definition :

Unilateral or bilateral reduction of visual

acuity (with best refractive correction)
that cannot be attributed directly to the
effect of any structural abnormality of
the eye or the posterior visual pathway

Caused by abnormal visual

experience early in life

Developmental Period of The Eye

Period of development :

Intra uterine development

Period I : 0 6 months critical
Period II : 6 months 2 years
Period III : 2 years 5 years
Period IV : 5 years 9 years
Period V : 9 years 12 years

Good development Macula lutea have

to well trained by rays that straight
focused onto macula, before 6 years old

Types of Amblyopia

Strabismic amblyopia

Most common form

Anisometropic amblyopia
Isoametropic amblyopia
Deprivation Amblyopia (amblyopia ex
anopsia)

Severity of Amblyopia

Mild Amblyopia :

Moderate Amblyopia :

Visual acuity : 0,6 or better

Visual acuity : 0,2 0,6

Severe Amblyopia

Visual acuity : 0,1 0,2

Therapy of Amblyopia

Goal of therapy :

Normal visual acuity of both eye

Perfect eye ball position of both of eye
Streoscopic eye

Prognosis of the therapy is depend

on :

Age onset of Amblyopia

When the treatment begin
Severity of amblyop
Fixation type
Patients compliance

Therapy (Cont.)

Principal of therapy train the

amblyopic eyes with :

Occlude fellow eyes (the health eyes)

Cyclopegic on fellow eye (Penalization)
CAM stimulator (still controversial)

Recurrence 50%