MANAGEMENT MANAGEMENT OF STRABISMUSOF STRABISMUS

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Why We TreatWhy We Treat1- Restore Stereopsis1- Restore Stereopsis

2- Prevent Amblyopia2- Prevent Amblyopia

3- Prevent Confusion and Diplopia3- Prevent Confusion and Diplopia

4- Appearance4- Appearance

Why We TreatWhy We Treat1- Restore Stereopsis1- Restore Stereopsis

Three dimensional vision..Three dimensional vision..

Why We TreatWhy We Treat2- Amblyopia2- Amblyopia

Amblyopia is the unilateral or bilateral decrease Amblyopia is the unilateral or bilateral decrease of of

Vision caused by form vision deprivation and/or Vision caused by form vision deprivation and/or abnormal binocular interaction for which there is abnormal binocular interaction for which there is no obvious cause found by physical examination no obvious cause found by physical examination of the eye.of the eye.

Why We TreatWhy We Treat3- Confusion and Diplopia3- Confusion and Diplopia

.Confusion is the simultaneous appreciation .Confusion is the simultaneous appreciation of two superimposed but dissimilar of two superimposed but dissimilar images caused by stimulation of images caused by stimulation of corresponding points (usually foveae) by corresponding points (usually foveae) by images of different objects.images of different objects.

. Diplopia is the simultaneous appreciation . Diplopia is the simultaneous appreciation of two images of one object. Jt results of two images of one object. Jt results from a failure to maintain binocular from a failure to maintain binocular vision.vision.

Why We TreatWhy We Treat4- Appearance4- Appearance

Treatment of Treatment of heterophoria heterophoria

indicated in indicated in decompensated decompensated

heterophoria (i.e., heterophoria (i.e., symptomatic cases). symptomatic cases).

1. Correction of 1. Correction of refractive error when refractive error when

detected is most detected is most important. important.

2. Orthoptic treatment. 2. Orthoptic treatment. heterophoria without heterophoria without

refractive error refractive error not corrected by glassess not corrected by glassess

to improve convergence to improve convergence insufficiency and the insufficiency and the

fusional reserve. fusional reserve. Orthoptic exercises can Orthoptic exercises can

be done with be done with synoptophore. Simple synoptophore. Simple exercises to be carried exercises to be carried

out at homeout at home

synoptophoresynoptophore

3. Prescription of prism 3. Prescription of prism in glassesin glasses

selected cases Prism is selected cases Prism is prescribed with apex prescribed with apex

towards the direction of towards the direction of phoria , two-thirds of phoria , two-thirds of

heterophoriaheterophoria

4. Surgical treatment. 4. Surgical treatment. marked symptoms which marked symptoms which are not relieved by other are not relieved by other

measures. measures. strengthen the weak strengthen the weak

muscle or weaken the muscle or weaken the strong musclestrong muscle

TREATMENT OF TREATMENT OF CONCOMITANT CONCOMITANT STRABISMUSSTRABISMUS

Goals Goalsachieve good cosmetic achieve good cosmetic correction, to improve correction, to improve

visual acuity and to visual acuity and to maintain binocular maintain binocular

vision.vision.

1.Spectacles 1.Spectacles full correction of full correction of

refractive error, every refractive error, every case.case.

improve visual acuity, improve visual acuity, may correct the squint may correct the squint partially or completely partially or completely (as in accommodative (as in accommodative

squint). squint).

2.Occlution 2.Occlution therapytherapy

Sensitive period during which Sensitive period during which the amblyopia can be cured is the amblyopia can be cured is

below 10 years of agebelow 10 years of age#. occlusion of the normal #. occlusion of the normal

eye to encourage the use of eye to encourage the use of the abnormal eye is the most the abnormal eye is the most

effective treatment effective treatment

it should be it should be ensured that: ensured that:

Opacity in the media Opacity in the media (e.g., cataract), if any, (e.g., cataract), if any,

should be removed first,should be removed first,Refractive error, if any, Refractive error, if any,

should be fully correctedshould be fully corrected

schedule for occlusion schedule for occlusion therapy depending up on therapy depending up on

the age is as below:the age is as below: Upto 2 years, the Upto 2 years, the

occlusion should be done occlusion should be done in 2:1, i.e., 2 days in in 2:1, i.e., 2 days in

sound eye and one day in sound eye and one day in amblyopic eye. At the age amblyopic eye. At the age 3years, 3:1At the age of 4 3years, 3:1At the age of 4

years, 4:1,years, 4:1,At the age of 5 years, 5:1, At the age of 5 years, 5:1,

and After the age of 6 and After the age of 6 years, 6:1 years, 6:1

Duration of occlusion Duration of occlusion should be until the visual should be until the visual acuity develops fully, or acuity develops fully, or

there is no further there is no further improvement of vision improvement of vision

for 3 months.for 3 months.

3 preoperative orthoptic 3 preoperative orthoptic exerciseexercise

4 squint surgery4 squint surgery

5 postoperative orthoptic 5 postoperative orthoptic exerciseexercise

Management of paralytic Management of paralytic strabismusstrabismus

1.Treatment of the cause 1.Treatment of the cause investigative work-up. investigative work-up.

2.Conservative measures.2.Conservative measures. wait and watch for self- wait and watch for self-

improvement to occur for improvement to occur for a period of 6 months, a period of 6 months, vitamin B-complex as vitamin B-complex as

neurotonic; and systemic neurotonic; and systemic steroids for non-specific steroids for non-specific

inflammationsinflammations

3.Treatment of annoying 3.Treatment of annoying diplopia.diplopia.

occluder on the affected occluder on the affected eye, with intermittent eye, with intermittent use of both eyes ,to use of both eyes ,to prevent suppression prevent suppression

amblyopiai.e. partial loss amblyopiai.e. partial loss of vision ,in one of vision ,in one

eye,cortical supretion of eye,cortical supretion of central vision to prevent central vision to prevent

diplopiadiplopia

... 4.Surgical treatment.. 4.Surgical treatment.

in case the recovery does in case the recovery does not occur in 6 months. not occur in 6 months. provide a comfortable provide a comfortable

field of binocular field of binocular fixation,fixation,

strengthening of the strengthening of the paralysed muscle by paralysed muscle by

resection; and weakening resection; and weakening of the overacting muscle of the overacting muscle

by recession.by recession.

STRABISMUS SURGERY

Surgical techniques Surgical techniques 1.Muscle weakening 1.Muscle weakening procedures include procedures include recession, marginal recession, marginal

myotomy and myectomy. myotomy and myectomy. 2.Muscle strengthening 2.Muscle strengthening

procedures are resection, procedures are resection, tucking and tucking and

advancement.advancement.

3.Procedures that 3.Procedures that change direction of change direction of

muscle action. These muscle action. These include (a) vertical include (a) vertical

transposition of transposition of horizontal recti to horizontal recti to correct ‘A’ and ‘V’ correct ‘A’ and ‘V’

patterns (b) posterior patterns (b) posterior fixation suture (Faden fixation suture (Faden operation) to correct operation) to correct dissociated vertical dissociated vertical deviation; and (c) deviation; and (c) transplantation of transplantation of

muscles in paralytic muscles in paralytic squints.squints.

Steps of resectionSteps of resection1.Muscle is exposed as for 1.Muscle is exposed as for

recession and the amount to be recession and the amount to be resected is measured with resected is measured with

callipers and marked. 2.Two callipers and marked. 2.Two absorbable sutures are passed absorbable sutures are passed

through the outer quarters of the through the outer quarters of the muscles at the marked site. 3.The muscles at the marked site. 3.The muscle tendon is disinserted from muscle tendon is disinserted from the sclera and the portion of the the sclera and the portion of the

muscle anterior to sutures is muscle anterior to sutures is excised. 4.The muscle stump is excised. 4.The muscle stump is sutured with the sclera at the sutured with the sclera at the

original insertion site. original insertion site. 5.Conjunctival flap is sutured back5.Conjunctival flap is sutured back

Steps of recessionSteps of recession1.Muscle is exposed by reflecting a 1.Muscle is exposed by reflecting a flap of overlying conjunctiva and flap of overlying conjunctiva and

Tenon’s capsule. 2.Two vicryl Tenon’s capsule. 2.Two vicryl sutures are passed through the sutures are passed through the

outer quarters of the muscle outer quarters of the muscle tendon near the insertion. 3.The tendon near the insertion. 3.The

muscle tendon is disinserted from muscle tendon is disinserted from the sclera with the help of the sclera with the help of

tenotomy scissors. 4.The amount tenotomy scissors. 4.The amount of recession is measured with the of recession is measured with the

callipers and marked on the callipers and marked on the sclera. 5.The muscle tendon is sclera. 5.The muscle tendon is sutured with the sclera at the sutured with the sclera at the

marked site posterior to original marked site posterior to original insertion. 6.Conjunctival flap is insertion. 6.Conjunctival flap is

sutured back.sutured back.

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