Strabismus. A.Medghalchi,M.D Assistant professor of ophthalmology Gilan medical science university

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2 Strabismus A.Medghalchi,M.D Assistant professor of ophthalmology Gilan medical science university

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4 Anatomy Of The EOM s Six Extraocular muscles surround eye: Medial Rectus Lateral Rectus Superior Rectus Inferior Rectus Superior Oblique Inferior Oblique

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6 Eye Muscles Left eye Superior Oblique/Trochlear Muscle Superior Rectus Muscle Medial Rectus Muscle Lateral Rectus Muscle Inferior Rectus Muscle Inferior Oblique Muscle G.Vicente,MD

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8 Eye movement Duction Version vergence ۸

9 ۹ duction

10 ۱۰ version

11 ۱۱ vergence

12 ۱۲ vergence

13 Strabismus Pseudo strabismus:ocular axises of both eyes are aligned,but due to adnex anomaly (epicanthal fold,wide nasal bridge, ),eye seems deviated True strabismus:defined as one image formed at the foveola & other outsite it

14 Pseudo ET Orthophoria Esotropia G.Vicente,MD

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17 F2 0rthophoria F1 A

18 F2 P E.T F1 A2 A1

19 P F2 X.T F1 A2 A1

20 True strabimus Phoria(latent strabismus) Tropia(manifest strabismus

21 Diagnosis of phoria & tropia The most important test for diagnosis of phoria & tropia is cover test

22 Cover test If one eye covered & other eye moved,tropia is present Move in(exotropia=x.t) move out(esotropia=e.t) Move superior(hypotropia=h.o.t) move inferior(hypertropia=h.t) If one eye uncovered & the same eye moved, phoria is present Move in(exophoria=x) move out(esophoria=e) Move superior(hypophoria=h.o) Move inferior(hyperphoria=h)

23 Nomenclature Orthorphoria o Esophoria E Esotropia ET Intermittent Esotropia E(T) Exophoria X Exotropia XT Intermittent Exotropia X(T) At near X(T) Right Hypertropia RHT convergent divergent G.Vicente,MD

24 Cover Uncover test Orthophoria, normal No complaints, asymptomatic

25 Cover Uncover test Esophoria, abnormal, common Only seen when eye is covered Often asymptomatic, no complaints Note OS does not move.

26 Cover Uncover test Exophoria, abnormal, common Only seen when eye is covered Note OS does not move Often asymptomatic, no complaints.

27 Alternate cover test

28 Alternate Cover test Exotropia, intermittent May be visible with or without alternate cover May have intermittent diplopia, especially when tired or sick Mom sees misalignment every now and then.

29 Alternate Cover test Exotropia, Constant May be visible with or without alternate cover May or may not have constant diplopia

30 Cover Uncover test Left Exotropia, Constant May be visible with or without alternate cover Right eye preference G.Vicente,MD

31 Cover Uncover test Left Exotropia, Constant May be visible with or without alternate cover Right eye preference Note: no eye movement, so be sure to check both sides G.Vicente,MD

32 How much to operate Alternate Cover test with Prism Exotropia, Constant Use prism to quantitate the deviation. Change prism power until movement is neutralized. Use this number to plan surgery

33 Normal Convergence Convergence Insufficiency G.Vicente,MD

34 Prism is the unit of measurement of deviation 1m 1cm

35 The most important test for evaluation of tropia is CSM C=central,S=steady,M=maintain

36 CSM Normal eye fixated centrally when other eye occuluded Normal eye maintain steady fixation when other eye occuluded Normal eye maintain fixation when other eye uncovered CSM indicated good vision

37 Tropia Monocular Alternate Intermittent constant

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40 Cycloplegic refraction Any patient with any type of strabismus needs Cycloplegic refraction Cycloplegic refraction is done : Atropine( 0.5%-1):TDS for 3 days Cyclopentolate(0.5-1%) : 3times then refraction 45 minutes later One drop.then refraction 45 minutes,later

41 Incidence of strabismus 5% of general population 90% of strabismus is horizontal Over 50% of horizontal strabismus is ET

42 F2 0rthophoria F1 A

43 P F2 X.T F1 A2 A1

44 F2 P E.T F1 A2 A1

45 Esotropia Infantile(congenital) Accommodative Paralytic Restrictive Sensory Acquired Consecutive Residual Convergence exess Divergence paralysis Partially A Refractive A

46 Infantile esotropia Account for 20% of esotropia Begin under 6 months old Cycloplegic refraction under _+3.5 Deviation over 45 prism diopter May be associated inferior oblique overaction(70%),d.v.d(60%),nystagmus(10%) Usually no amblyopia Treatment is surgery Best time of surgery (under 1y old )

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49 Accommodative esotropia Average age is 18 months(1-3 y) Acounts for 50% of esotropia Average refractive error is +4 (2-10) diopter Deviation is less than 45 prism diopter & equal in far & near May be associated with oblique muscle dysfunction,nystagmus & D.V.D Glasses is the corn stone of treatment

50 Accommodative esotropia 1:Refractive A.ET 2:Partially A.ET Refractive A.ET: Glasses improve deviation (under 10 prism) No need surgery Partially A.ET: Glasses improve deviation(over 10 prism) Need surgery

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54 Paralytic esotropia Deviation is great in far than near Due to 6 th nerve palsy Associated with face turn to same side Evaluation of causes is important First treatment is treatment of causes

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56 Causes of 6 th nerve palsy Neonatal: trauma of delivery,congenital If no improve in 3m,needs evaluation Infant:vaccination,viral infection,rarely tumor If no improve in 3w,needs evaluation Adolescence:trauma,tumor,infection,vascular needs evaluation Adult (40-60 y):check FBS & BP If no improve in 3m,needs evaluation Adult (over 60): tumor & S.V.A needs evaluation

57 Treatment of 6 th nerve palsy Patch Botux Surgery

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59 Restrective esotropia Causes: Surgery Tumor Trauma Inflammation Thyroid associated orbitopathy First treatment is treatment of causes

60 Acquired esotropia It may be seen in all ages No significant refractive error Deviation usually equal in near & far Needs complete evaluation First treatment is treatment of causes Last treatment is sergery

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62 Sensory esotropia Any esotropia due to visual loss under 2 y is called Sensory esotropia First treatment is restoration of vision Residual esotropia needs surgery

63 Suture tarsorrhaphy Comformer insertion for maintain fornix &prevent symblepharon Prescribtion an antiseptic mouth wash for 7-10 days

64 X.T Congenital Basic Paralytic Restrictive Sensory Acquired divergence excess (worse for distance) convergence weakness (worse for near) Residual Consecutive

65 Congenital X.T Incidence 1 over Begin under 6 months old Deviation greater than 50 prism Refractive error lessthan +2.5 Usually no amblyopia Often accompany with CNS disease

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67 Basic exotropia V.A is usually normal Deviation is equal in far & near Begins intermittently Treatment based on the age,refravtive error,amblyopia & compliance The last treatment is surgery

68 Paralytic exotropia Due to 3th nerve palsy Deviation greater in near than in far Face turn to opposite site Evaluation of pupile is important Evaluation of causes is important Age of patients is important

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72 Age) Children(<14y Ophthalmic Migraine Cyclic Palsy Vaccination Viral Infection Progressive,pupilary involvement & neurological signs need complete workup(brain M.R.I,in some cases M.R.A & CSF analysis

73 Age Adolescence(15-40y) 3th nerve palsy with Pupil involvement need Brain M.R.I & M.R.A or Angiography & in some cases CSF Analysis 3th nerve palsy without Pupil involvement need F.D.T, Tensilon & thyroid function testes

74 Age Adult(40-55) Without Pupil involvement,check for Diabetes& Hypertension,M.Gravis & T.A.O & need FBS,BP,Tensilon,F.D.T & Thyroid Tests With Pupil involvement, progressive Palsy,neurological signs, No resolving Palsy (3M) need M.R.I with gadolinium, M.R.A (aneurysm >4mm),angiography & in some cases C.SF analysis In elder patients(>55y), check E.S.R for G.C.A)

75 3th nerve palsy Any patients with acute 3th nerve palsy & pupilary involvement,need brain angiography for R/O aneurysm(posterior communocating A) Any patients with acute 3th nerve palsy & without pupilary involvement,needs brain MRI for R/O mass lesion,c.v.a,hemorrhage

76 3th nerve palsy with pupilary involvement

77 Restrictive exotropia Trauma Tumor Surgery Inflammation

78 Sensory exotropia Any visual loss over 2 y old can be result in exotropia: Ptosis Corneal haziness Hyphema Cataract Vitreous opasity Retinal disease

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80 With corneal involment Ceftriagone 1g,50mg/kg/bd/iv for 3days Oral fluroquinol(ciproflaxcin 500mg/bd/5days Allergy to penicillin,consider spectinomycin 2g/im/bd for 3 days Other treatment as the sams as previous group

81 Vertical strabismus The most common type is 4 th nerve palsy

82 Superior oblique palsy Congenital Acquired

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85 4 th nerve palsy Trauma is the most common cause In closed head trauma,it may be bilateral Vertical deviation that increase in same tilt & opposite gaze Face turn & tilt to opposite Accompany with face abnormality If no recovery 6-9months after trauma, consider brain imaging. If no recovery 3months in diabetic & hypertensive cases, consider brain imaging.

86 Symptoms Head tilt to contralateral side Diplopia(vertical or torsional) Asthenopia Cervical discomfort In bilateral cases.torsion is principle discomfort

87 Signs H.T over 5 prism V pattern less than 5 prism Head tilt to contralateral side Chin down in bilateral cases Facial asymmetry (shallow to tilt site) Head tilt disappeares in sleep

88 Management Nonsurgical Small deviation without torticoly or IOOA Surgical: important preoperative information Primary deviation Deviation in field of I.O & S.O Presence or absence of IOOA S.R contracture S.O tendon laxity

89 Approach patients with strabismus V.A (fixation & following, CSM, snellen chart ) Amblyopia Red reflex Cycloplegic refraction( atropine,cyclogyle) Refraction over +2 need prescription Cover tests: Cover & uncover Alternate cover & prism Simultaneous cover & prism Fundoscopy

90 cont.. Success rate defined : deviation under 10 prism in horizontal & 2.5 prism in vertical deviation. Surgery indicated: With full treatment, deviation over prism in horizontal & 5 prism in vertical deviation Amblyopia is treated

91 thanks for your attention