Squint

STRABISMUS

Muscle Primary Secondary Tertiary
action action action
MR Adduction
LR Abduction
SR Elevation Intorsion Adduction
IR Depression Extorsion Adduction
SO Intorsion Depression Abduction
IO Extorsion Elevation Abduction
Vergences, also called disjugate movements, are
synchronous and symmetric movements of both eyes
in opposite directions e.g.:

1. Convergence. It is simultaneous inward movement
of both eyes which results from contraction of
the medial recti.

2. Divergence. It is simultaneous outward movement
of both eyes produced by contraction of the
lateral recti.
Synergists, antagonists and yoke muscles
1. Synergists. It refers to the muscles having the
same primary action in the same eye; e.g.,
superior rectus and inferior oblique of the
same eye act as synergistic elevators.

2. Antagonists. These are the muscles having
opposite actions in the same eye. For
example, medial
and lateral recti,

3. Yoke muscles (contralateral synergists). It refers
to the pair of muscles (one from each eye) which
contract simultaneously during version movements.
For example, right lateral rectus and left medial rectus
act as yoke muscles for dextroversion movements.


4. Contralateral antagonists. These are a pair of
muscles (one from each eye) having opposite action;
for example, right LR and left LR, right MR and
left MR.
Diagnostic positions of gaze: primary position (e); secondary positions (b, d, f, h);
tertiary positions (a, c, g, i); cardinal positions (a, c, d, f, g, i).
STRABISMUS (SQUINT)
Definition

A misalignment of the visual axes of the two
eyes is called squint or strabismus.
Classification of strabismus


Broadly, strabismus can be classified as below:
I. Apparent squint or pseudostrabismus.
II. Latent squint (Heterophoria)
III. Manifest squint (Heterotropia)
1. Concomitant squint
2. Incomitant squint.
HETEROPHORIA
Heterophoria also known as latent strabismus, is a
Types of heterophoria
1. Esophoria. It is a tendency to converge. It may be:
i Convergence excess type (esophoria greater for near than
distance).
ii Divergence weakness type (esophoria greater fordistance
than near).
iii Non-specific type (esophoria which does not vary
significantly in degree for any distance).
2. Exophoria. It is a tendency to diverge. It may be:
i Convergence weakness type (exophoria greater for near
than distance).
ii Divergence excess type (exophoria greater on
distant fixation than the near).
3. Hyperphoria. It is a tendency to deviate
upwards,
while hypophoria is a tendency to deviate
downwards.

4. Cyclophoria. It is a tendency to rotate around
the anteroposterior axis.
B. Physiological factors
1. Age. Esophoria is more common in younger age
group as compared to exophoria which is more
often seen in elderly.
2. Role of accommodation. Increased
accommodation Is associated with esophoria and
decreased accommodation with exophoria (as
seen in simple myopes).
3. Role of convergence..
4. Dissociation factor such as prolonged constant
use of one eye may result in exophoria
Symptoms
divided into compensated and decompensated.

Compensated heterophoria. It is associated with no
subjective symptoms. maintenance of binocular vision.

Decompensated heterophoria. It is associated with
multiple symptoms which may be grouped as under:
1. Symptoms of muscular fatigue.
Headache and eyeache
DIfficulty in changing the focus from near to
distant objects
Photophobia due to muscular fatigue
2. Symptoms of failure to maintain binocular
single vision are:
Blurring or crowding of words while reading;
Intermittent diplopia due to temporary
manifest
deviation under conditions of fatigue; and
Intermittent squint (without diplopia)
3. Symptoms of defective postural sensations
cause
problems in judging distances and positions
CONCOMITANT STRABISMUS
I
Etiology
1. Sensory obstacles. These are the factors which
Refractive errors,
Prolonged use of incorrect spectacles,
Anisometropia,
Corneal opacities,
Lenticular opacities,
Diseases of macula (e.g., central chorioretinitis),
Optic atrophy, and Obstruction in the pupillary area
due to congenital
ptosis.

2. Motor obstacles.
3. CENTRAL OBSTACLES
Clinical features of concomitant
strabismus
1. Ocular deviation.
2. Ocular movements are not limited in any
direction.
3. Refractive error may or may not be
associated.
4. Suppression and amblyopia
5. A-V patterns
Types of concomitant squint
Three common types of concomitant squint
are :
1. Convergent squint (esotropia),
2. Divergent squint (exotropia), and
3. Vertical squint (hypertropia).
EVALUATION OF A CASE OF CONCOMITANT
STRABISMUS
I. History
II. Examination
1. Inspection. Large degree squint
2. Ocular movements.
3. Pupillary reactions.
4. Media and fundus examination.
5. Testing of vision and refractive error. It is most
important,
6. Cover tests
7. Estimation of angle of deviation

Hirschberg corneal reflex test
TREATMENT OF CONCOMITANT STRABISMUS
Goals of treatment. These are to achieve
good
cosmetic correction, to improve visual acuity
and to
maintain binocular single vision.
Treatment modalities. These include the
following:
1. Spectacles with full correction of refractive
error
2. Occlusion therapy.
3. Preoperative orthoptic exercises. These are
given
after the correction of amblyopia to overcome
suppression.
4. Squint surgery. It is required in most of the
cases
PARALYTIC STRABISMUS
Etiology
The lesions may be neurogenic, myogenic or at
the
level of neuromuscular junction.
I. Neurogenic lesions
1. Congenital.
2. Inflammatory lesions. These may be in the form
of encephalitis, meningitis, neurosyphilis or
3. Neoplastic lesions. These include brain tumours

INCOMITANT SQUINT
It is a type of heterotropia (manifest squint) in
which
the amount of deviation varies in different
directions
of gaze. It includes following conditions:
1. Paralytic squint,
2. A and V pattern heterotropias,
3. Restrictive squint.
II. Myogenic lesions
1. Congenital lesions.
2. Traumatic lesions.
3. Inflammatory lesions. Myositis
4. Myopathies.

III. Neuromuscular junction lesion
myasthenia gravis.
Clinical features
Symptoms
1. Diplopia.
2. Confusion.
3. Nausea and vertigo. These result from
diplopia and confusion.
4. Ocular deviation. It is of sudden onset.
Signs
1. Primary deviation.
2. Secondary deviation.
3. Restriction of ocular movement.
direction of the action of paralysed muscles
4. Compensatory head posture.
5. False projection or orientation
Management
1. Treatment of the cause.
2. Conservative measures. These include: wait
and
watch , vitamin B-complex as neurotonic; and
systemic steroids for non-specific inflammations.
3. Treatment of annoying diplopia.
4. Surgical treatment. not occur in 6 months.