strabismus mohamad abdelzaher msc. the reason why so few good books are written is that so few...
TRANSCRIPT
Strabismus
Mohamad Abdelzaher
MSc
The reason why so few good books are written is that so few people who can write know anything.
Walter Bagehot
Anatomy of EOMs
• 4 recti• 2 obliques
• Origin
• Annulus of Zinn
• Course of EOMs
• Insertion of recti:
Spiral of Tilluax
• Insertion of obliques
• Nerve Supply:
III nerve: all except,
L6 SO4
• Rotation of the eye:
center of rotation 12-13 mm behind corneaAdduction (Z)
Abduction (Z)
Elevation (X)
Depression (X)
Intorsion (Y)
Extorsion (Y)
• Action of EOMs
• Orbital vs Visual axes * Action of right SR
• Action of right SO
• Regarding the torsion movement:
“There is only on (I) in the sentence”
SO -------- Intorsion
IO --------- Extorsion
SR -------- Intorsion
IR --------- Extorsion
• Action of EOMs
• Binocular movement
• Diagnostic positions of gaze
Binocular Vision
Pseudo Strabismus
• Pseudo eso• Pseudo exo• Pseudo hyper• Pseudo hypo
CORNEAL LIGHT REFLEX
• Epicanthus
• Ptosis
Heterophoria• Definition “binocular vision”
• Types• Aetiology• Clinical picture
- compesated vs decompensated
-- how to dissociate binocular vision:
1) cover test
2) Maddox rod
3) Maddox wing
Cover – Uncover test
Orthophoria, normal
No complaints, asymptomatic
Cover test
Cover – Uncover test
Esophoria, abnormal, common
Only seen when eye is covered
Often asymptomatic, no complaints
Note OS does not move.
Cover – Uncover test
Exophoria, abnormal, common
Only seen when eye is covered
Note OS does not move
Often asymptomatic, no complaints.
• Maddox rod
• Maddox wing
• Treatment:- Indications- Lines:
1) correct refractive error
2) orthoptic exercise: pencil-nose exercise
exercising prism
synoptophore
3) Relieving prisms
4) Surgery
• Exercising prismse.g. base-out prism to exercise exophoria
• synoptophore
Paralytic squint• Definition “angle of deviation”
• Aetiology: LMNL - nuclear
- nerve
- muscle
1) Congenital2) Traumatic3) Inflammatory4) Vascular5) Neoplastic6) Metabolic7) Toxic
• Symptoms:- Diplopia- Ocular deviation- Abnormal head posture
• Signs:1) Ocular deviation: “Hering law” “Angle of deviation”
2) Limitation of movement “9 diagnostic positions of gaze”
3) Binocular diplopia - homonymous
- heteronymous
4) Diplopia chart
• Complications:
Direct antagonist ------------- contractureIndirect synergist ------------- contractureContralateral antagonist --- underaction
False projection (Hess screen)
OD LR Palsy
Clinical features of nerve palsies
• 6th nerve palsy:- Ocular deviation- Binocular diplopia- Limitation of ocular movement- Abnormal head posture
• 4th nerve palsy:- Ocular deviation- Binocular diplopia- Limitation of ocular movement- Abnormal head posture
• 3rd nerve palsy:- Ocular deviation- Binocular diplopia- Limitation of ocular movement- Abnormal head posture
Pupil
• Treatment:
- Treat the cause- Temporary treatment: occlusion, prisms- Surgical treatment: weakening ----------------> recession
strengthening -----------> resection
1. You have a patient with diplopia. His left eye is turned down and out and his lid is ptotic on that side. What nerve do you suspect and what should you check next?
• This sounds like a CN3 palsy, and you should check his pupillary reflex. Pupillary involvement means the lesion is from a compressive source such as an aneurysm.
Questions
2. This 32 year old overweight woman complains of several months of headaches, nausea, and now double vision. What cranial nerve lesion do you see in this drawing. What other findings might you expect on fundus exam and what other tests might you get?
• This looks like an abducens palsy … actually a bilateral 6th nerve palsy as the patient can’t get either eye to move laterally. While the majority of abducens palsies occur secondary to ischemic events from diabetes, this seems unlikely in a young patient. Her symptoms sound suspicious for pseudotumor (obese, headaches). You should like for papilledema of the optic nerve, get imaging, and possibly send her to neurology for a lumbar puncture with opening pressure.
3. A patient is sent to your neurology clinic with a complaint of double vision. Other than trace cataract changes, the exam seems remarkable normal with good extraocular muscle movement. On covering the left eye with your hand, the doubling remains in the right eye. What do you think is causing this case of diplopia?
• The first question you must answer with a case of diplopia is whether it’s monocular or binocular. This patient has a monocular diplopia. After grumbing to yourself about this patient being inappropriately referred to your neurologic clinic, you should look for refractive problems in the tear film, cornea, lens, etc..
12. A young man complains of complete vision loss (no light perception) in one eye, however, he has no pupil defect. Is this possible? How might you check whether this patient is “faking it?”
• Assuming the rest of the eye exam is normal (i.e. the eye isn’t filled with blood or other media opacity) this patient should have an afferent pupil defect if he can’t see light. There are many tests to check for malingering: you can try eliciting a reflexive blink by moving your fingers near the eye. One of my favorite techniques is to hold a mirror in front of the eye. A seeing eye will fixate on an object in the mirror. Gentle movement of the mirror will result in a synchronous ocular movement as the eye unconsciously tracks the object in the mirror.
Concomitant squint• Definition “angle of deviation”
• Types:- Acc to direction of deviation: esotropia exotropia
hypertropia hypotropia- Acc to laterality of deviation: unilateral alternating
• Clinical picture - ocular deviation
- defective vision
- diplopia???
Concomitant EsotropiasNon Accommodative Accommodative
1) Essential: 6 mo, >15ᵒ, ref +2D, DVD,IO overaction Cross fixation
2) Sensory (Amblyopia)3) Convergence excess4) Divergence insuffeciency5) Basic6) Microtropia7) Acute
Refractive (normal AC/A ratio)
- Full- Partial
Non-refractive(abnormal AC/A
ratio)-Convergence excess-Accommodation weakness
• IO overaction
• DVD
AC/A Ratio
Refractive Accommodative Esotropia
Refractive Partially Accommodative Esotropia
Convergence excess esotropia
Concomitant Exotropias• Early onset: at birth, normal refraction, large angle,
associated neurological manifestations, surgical ttt
• Intermittent: around 2 years, decompesated exophoria
• Sensory: older children & adults
• Consecutive: following surgical correction of ET
Management of strabismus• History: age of onset, duration, glasses
• Exam ocular media: cornea, lens, …
• Fundus exam & refraction (cycloplegic)
• VA: Amblyopia
• Motility in 9 directions of gaze
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.
Cover test
Alternate Cover test
Exotropia, Constant
May be visible with or without alternate cover
May or may not have constant diplopia
• Measurement of angle of deviation:- Corneal reflex: pupillary magin -----15ᵒ
midway ----------------30ᵒ
limbus -----------------45ᵒ
- Prism: 1ᵒ = 2 ∆
- Synoptophore
Alternate Cover test with Prism
Exotropia, Constant
Use prism to quantitate the deviation.
Change prism power until movement is neutralized.
20
Prism cover test
• Worth 4 dot test (Binocular vision)
Treatment• Aims:1) Restore binocular vision
2) Improve VA
3) Restore normal appearance
• Lines:1) Cycloplegic refraction & error correction
2) Treat amblyopia: occlusion – penalization
3) Treat eccentric fixation (Pleoptics)
4) Orthoptics
5) Surgery
Nystagmus• Definition
• Types
Pendular Jerky
Vestibular Central Ocular
Physiological Pathological
Clinical Approach to squint
History
1) Age of onset: - Documentation - Significance
2) Direction of deviation: Eso, Exo, Hyper, Hypo
3) Which eye: Alternate? Always the same eye?
4) Mode of onset: sudden? Gradual? Ppt factors
5) Type of deviation: Constant? Intermittent?
Family photos
Amblyopia
H/O trauma, fever, neurologic disorder
Intermittent fusion present good prognosis
Essential ET (6mo) – Accommodative ET (3yrs)
6) Prior treatment: Glasses? Occlusion? Prisms? E.D? Surgery?
7) Medical History: Birth weight, Incubation, Neurological
ROPMysthenia
Clinical Approach to squintFamily photos
Amblyopia
H/O trauma, fever, neurologic disorder
Intermittent fusion present good prognosis
Intermittent exotropia, corneal or conj disease
ROPMysthenia
Inspection of the patient
1) Lid fissure:- Ptosis
III nerve palsy - mysthenia
- Exophthalmos - Enophthalmos
Graves’ blow out fracture
- Hypertelorism - Epicanthal folds
Pseudo Exotropia Pseudo Esotropia
2) Head posture
Face turn Head tilt Chin up/down
Right VI palsy
3) Fixation preference:Alternating Unilateral
Amblyopia
Alternate Cover test
Exotropia, Constant
4) Constancy of deviation:
Constant Variable
- Incomitant- Uncorrected refractive errorHering law
5) Nystagmus
Essential ET
Oscillopsia
III nerve palsy - mysthenia
Graves’ – blow out fracture
III nerve palsy
Pseudo strabismus
Amblyopia
- Incomitant- Uncorrected ref error
Assessment of vision in non verbal children
Fixation and following Preferential looking Catford drum
VEP
Visual Acuity
StereopsisBinocular Vision
Titmus Fly test
• Duction movement
Ductions & Versions
• Binocular movement
• Diagnostic positions of gaze
Cover – Uncover test
Orthophoria, normal
No complaints, asymptomatic
Cover test
Cover – Uncover test
Esophoria, abnormal, common
Only seen when eye is covered
Often asymptomatic, no complaints
Note OS does not move.
Cover – Uncover test
Exophoria, abnormal, common
Only seen when eye is covered
Note OS does not move
Often asymptomatic, no complaints.
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.
Cover test
Alternate Cover test
Exotropia, Constant
May be visible with or without alternate cover
May or may not have constant diplopia
Alternate Cover test with Prism
Exotropia, Constant
Use prism to quantitate the deviation.
Change prism power until movement is neutralized.
20
Prism cover test
• A mother brings in her 5-month-old boy because his eyes have been tearing for a couple of months. On further questioning, she reports no discharge or redness, but he squints and turns away from bright lights. He has no significant past ocular or medical history.
1 What is the differential diagnosis?
2 What exam findings would you look for?
Questions
• You are asked to see a 3-year-old girl with an eye turn. Apparently the child's eyes have turned inward since she was a baby, but now the mother notices that the left eye also goes up.
1 What is the differential diagnosis?
2 What exam findings would enable you to determine the correct diagnosis?
Additional information: her best-corrected visual acuity is 6/6 OU with +1.00 D OD and +1.50 D OS. The AC/A ratio is normal. The ET is comitant and measures 35 prism diopters at distance and near. She does cross fixate, and there is inferior oblique overaction. There is also no dissociated vertical deviation (DVD) or latent nystagmus present. Worth 4 dot testing demonstrates suppression OS
3 What type of esotropia does this girl have?
Thank you