christopher tinley red cross war memorial children’s ... · christopher tinley red cross war...
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The Squinting Child
Christopher Tinley
Red Cross War Memorial Children’s Hospital
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Strabismus saunter...
� Definitions
� Diagnosis
� Classification
� Strabismus at RCWMCH
� Management
� Squint cases
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Definitions
� Strabismus = squint, cross-eye, skeeloog,
ulithoba
� Deviation in ocular alignment� Deviation in ocular alignment
� Esotropia = inwards
� Exotropia = outwards
� Hypertropia = upwards
� Hypotropia = downwards
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Corneal light reflex
The light reflection from the cornea should be central
Straight
Esotropia
Exotropia
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Classification - Comitant
Esotropia
� Accommodative� Partially
� Fully
Exotropia
� Intermittent� True
� Simulated� Fully
� Non-accommodative� Congenital
� Acquired
� Sensory
� CNS defects
� Simulated
� Convergence insufficiency
� Constant� Congenital
� Acquired
� Sensory
� CNS defects
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Classification - Incomitant
� Paralytic
� III
� IV
� VI� VI
� Multiple cranial nerve palsies
� Strabismus syndromes
� Duane’s
� Brown’s
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Accommodative esotropia
� In order to produce a clear image for near, a hyperopic child exerts accommodative power
� Eyes converge � Eyes converge simultaneously due to accommodative reflex
� Correcting the hyperopiarelaxes this reflex and eyes straighten
� Cycloplegic refraction = NB
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Strabismus at RCCH, 1997–2007
� 3429 squint referrals
� 25% pseudostrabismus
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Strabismus types n=2566
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Non-accommodatives
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Prevalence of strabismus
� ? South Africa
� 1% Oman schoolchildren
� 1% Japanese schoolchildren
� 5.3% Welsh schoolchildren
� 0.8% Exo
� 3.6% Eso
� 0.9% other
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Esotropias:Exotropias
15
29
1724
37
63
72 7360%
70%
80%
90%
100%
85
71
8376
63
37
28 27
0%
10%
20%
30%
40%
50%
60%
SA Black
n=449
SA Mixed
n=1921
Egypt Arab
n=957
US White
n=968
US Black
n=709
Cameroon
Black
n=137
Singapore
Asian
n=682
Hong Kong
Chinese
n=2704
Exotropia
Esotropia
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Ethnic proportions: Eso type
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Ethnic proportions: Exo type
*
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GP squint referrals
� Age of child?
� Squinting after 3 months is abnormal
� Duration of onset?
Constant or intermittent?� Constant or intermittent?
� Red reflex present?
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Management
History Examination
� Age at onset
� Perinatal history
Developmental history
� VA /fixation assessment
� Ocular deviation in prism
dioptres� Developmental history
� Family history
dioptres
� Ocular movements
� Cycloplegic refraction
� Anterior and posterior
segment examination
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Cycloplegic refraction = NB
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Dilated fundoscopy = NB
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Management
� Treat any pathology
� Prescribe glasses as
needed
� Amblyopia therapy� Amblyopia therapy
� Occlude - days per week
� Atropine penalisation
� Surgery @ age 4
� Follow until age 7
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Strabismus surgery
Overwhelming
majority �majority �PSYCHOSOCIAL
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Surgery – rectus recession
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Summary
� A squint after the age of 3 months = abnormal
� should be referred
� Primary healthcare level
Corneal light reflex = NB� Corneal light reflex = NB
� Red reflex = NB
� Secondary/Tertiary level
� Cycloplegic refraction = NB
� Dilated fundoscopy = NB