Ocular misalignment

Strabismus

squint

Anatomy of the eye musclesThe extraocular muscles rotate the eyes about three axes to produce vertical (elevation and depression), horizontal (adduction and abduction), and rotational (intorsion and extorsion) movement. The horizontal recti produce purely horizontal movements; the vertical recti and the obliques have vertical, rotational, and horizontal actions. Their principal effect depends upon the horizontal position of the eye in the orbit, and therefore varies with gaze position.

Extra ocular musclesanatomy.Normal human

eye, anterior aspect.

N, nasal; T, temporal. The cornea (a) is

anterior to the iris (b) and pupil (c).

Extraocular musclesanatomyDrawing of the

upper half of the eye. T, temporal; N, nasal.

Extraocular muscles anatomy

Structures at the orbital apex, showing muscle insertions into the anulus of Zinn and the location of various vessels and nerves.

All four recti and superior oblique have their origin at the apex of the orbit, while inferior oblique has its origin at the nasal end of the anterior orbital floor. The recti insert anterior to the equator, at 7.5 mm (superior), 7.0 mm (lateral), 6.5 mm (inferior), and 5.5 mm (medial) behind the limbus.

The obliques insert behind the equator; the insertion of the superior oblique tendon lies along the lateral border of superior rectus, having been reflected through the pulley of the trochlea at the anterior nasal orbital roof, and the insertion of inferior oblique lies external to the macula. The superior oblique tendon passes beneath the superior rectus, and the inferior oblique passes beneath the inferior rectus.

PRIMARY AND SECONDARY ACTIONS OF MUSCLES

The primary action of the horizontal rectus muscles is 99% horizontal. They have trivial secondary or tertiary actions.

The primary action of the vertical rectus muscles is 75% vertical, and they have secondary torsional and horizontal actions. The primary action of the oblique muscles is 60% cyclorotation (torsion) and they have secondary vertical and horizontal actions.

Horizontal movements (adduction and abduction) are produced by contractions of medial rectus (MR) and

lateral rectus (LR) muscles

Nerve supply of EOMSuperior oblique by 4th cranial nerve (trochlear N.)Lateral rectus by 6th cranial nerve (abducent N. )Others by 3rd cranial nerve (oculomotor N.)(LR6SO4)3Eye movementsHorizontal ductionsThe horizontal recti are mainly responsible for adduction and abduction.vertical ductionsThe vertical recti act as pure elevators and depressors in abduction.TorsionThe superior rectus and superior oblique act as intortors, and the inferior rectus and inferior oblique act as extortors.

Disorders of ocular motilityThe direction of the visual axis of each eye towards a fixation point is co-ordinated by the action of the extraocular muscles.Strabismus (squint): is a failure of the co-ordination of binocular alignment. It leads inevitably to loss of binocular single vision. Fusion of the two images is replaced either by diplopia or suppression of one image. Strabismus may be caused by orbit, muscle, motor nerve, or brainstem pathology.Primary positionGaze straight ahead, with the visual axes parallel.

HeterotropiaManifest deviation i.e. failure of the visual axes to meet at the fixation point.Manifest covergent squint is described as esotropia, and manifest divergent squint as exotropia. Vertical squint is hypertropia and hypotropia.

Incomitant(Paralytic)Variable angle of squint, according to gaze direction, paralytic squint is incomitant.

Concomitant(Non-paralytic)Constant angle of deviation irrespective of the direction of gaze (non-paralytic).

HeterophoriaLatent deviation, i.e. failure of the visual axes to meet at the fixation point when they are dissociated e.g. by monocular occlusion. Latent convergent and divergent squint are, respectively, esophoria and exophoria.

Assessment of ocular motility disorderThe extraocular muscle or muscles whose underaction, overaction, or restriction has led to ocular motor imbalance.The binocular sensory status, including any compensation which occurred (suppression or abnormal retinal correspondence).Muscle imbalanceWeakness of any of the 12 EOM causes diplopia which is maximal in the field of action of that muscle. Two muscles are active in any cardinal position; the paretic muscle is identified by finding the position in which diplopia is maximal.Binocular vision: describes the quality of simultaneous perception by the two eyes of an object in visual space.

Pseudosquint

Pseudo squint =apparent squint as example the Chinese or Japanese because of the epicanthal folds appeared esotropic(eyes inward deviated).

Pseudosquint(apparent squint).Epicanthal folds

Squint

Squint defined as any binocular misalignment

1. Nonparalytic( concomitant )

No definite muscle palsy The deviation equal in all direction of gaze.

Types of squint 1. Non paralytic=concommitant squint.

A. Esodeveation =esotropia=inward deviation.

1-Congenital.2-Accommodative (refractive, non-

refractive, mixed). B. Exodeveation = exotropia =outward deviation

1-Childhood-onset2-Sensory-deprivation.3-Convergence-insufficiency

Types of Squint2. Paralytic Squint :Paralytic (non commitant, incomitant)squint; or strabismus

1- 3RD( oculomotor)cranial nerve palsy(all extraocular muscles involved except the lateral rectus & the superior oblique muscle)

2- 6th cranial nerve (abducent)=paralysis of lateral rectus muscle .

3- 4th cranial nerve (trochlear)=paralysis of superior oblique muscle

Paralytic (non commitant, incomitant)squint; or strabismusAbducent nerve palsy.

TYPES OF Non-paralytic (concomitant)1-Congenital EsotropiaInfants with congenital esotropia develop a large angle of esotropia at several months of age. Because it is not present at birth, some ophthalmologists prefer to name this condition infantile esotropia. The cause is unknown. It occurs in otherwise normal infants, but it is more common in infants with developmental delay and in infants with hydrocephalus.

Congenital EsotropiaThe treatment for this condition is surgery. Most physicians recess each medial rectus muscle a graded amount, depending on the angle of deviation. Some also resect one or both lateral rectus muscles for large deviations.

Congenital Esotropia Most agree that surgery should be performed before 2 years of age to enhance the chance for the infant to gain some binocular function, and most perform surgery any time after the child is 6 months of age, if the vision is equal, if the child is healthy, and if proper facilities for safe anesthesia are available.

Esotropia congenitalAGE OF ONSET AT BIRTH OR SHORTLY AFTER

Treatment of accommodative esotropia(inward deviated eye).Full cycloplegic refraction measurement of the plus glass

Exam. Under Anasthesia(EUA)

1-Cycloplegic refraction, use of atropine eye drops for 3 days three times a day.

2. Fundoscopy(exam.of the retina, optic nerve.

CORRECTION OF ACCOMODATIVE SQUINT BY GLASSES & TREATMENT OF AMBLIOPIA BY PATCHINGSO BOTH EYE NOW HAVE GOOG VISUAL ACUITY AND NORMAL ALIGNED

EXOTROPIA(OUTWARD DEVEATION)

1-Childhood-onset exotropia is the most common type of exotropia. Many children develop an exotropia that typically begins intermittently . The average age of onset is about 2.5 years (range, 6 months-6 years), about the same time of onset as for accommodative esotropia.

1-Childhood-onset exotropia The cause is unknown. It may be weakly hereditary, because few children with this condition have parents or siblings with the same condition. It is useful to think of this entity as passing through several phases or stages.

1-Childhood-Onset Exotropia

1-Childhood-Onset ExotropiaThe first phase of this condition is exophoria only-latent deviation not seen until one eye covered-preventing the fusion of the two images into one image. It is rarely seen because it is rarely symptomatic.

1-Childhood-Onset Exotropia

If a child happened to be examined at this time in the evolution of this condition, the examiner would find only an exophoria. Testing would reveal a latent deviation, detected only by the cover test.

1-Childhood-Onset Exotropia

Several months later, the child may progress into the second phase: intermittent exotropia. With fatigue, illness, or inattention and when looking at a distance of several meters or more, one of the eyes turns out for several seconds. The child then becomes aware of diplopia and makes some unconscious effort to restore the alignment of the eyes.

EXODEVEATION (EXOTROPIA)ALTERNATING WHEN FIXATE WITH THE RIGHT EYE THE LEFT DEVIATED & VISE VERSA, BOTH EYES NOT COOPERATE TOGETHER TO FORM SINGLE IMAGE(NO BINOCULAR SINGLE VISION-BSV)

2-Sensory Exotropia

This is another common type of exotropia, especially in adults. The name suggests that the primary etiologic factor is not a motor abnormality but some defect in the afferent or sensory system. If two eyes do not have good binocular function, it is likely that the poorer or nondominant eye will gradually turn out or become exotropic

EXODEVEATION (EXOTROPIA )SENSORY DEPRIVATION=POOR SEEING EYE

3-Convergence Insufficiency.Students usually suffer from this problem.

A third type of exotropia is an apparent weakness of convergence, called convergence insufficiency. The entity frequently affects young adults and is a major cause of asthenopia, or tired eyes, while doing near work in this age group. In this condition, the eyes are straight at distant fixation and without symptoms.

3-Convergence Insufficiency However, at near viewing, there is an exodeviation, sometimes an exophoria or sometimes an intermittent exotropia with transient diplopia. The deviation at near viewing is relatively small, never larger than 18 prism diopters, as determined by alternate cover testing. However, even a much smaller deviation can produce asthenopic symptoms.

Complication of strabismus is AmblyopiaTreatment of amblyopic eye. (lazy eye)Patching of normal eye

Causes of acquired ocular motility disorderNeurogenic (ocular motor nerve lesion):Vascular (diabetes or hypertention).Demyelinating (multiple sclerosis).InflammatoryCompressive (aneurysm or tumour)Trauma or surgery.MyogenicMyasthenia gravisOcular myopathyRestriction Dysthyroid ophthalmopathyTraumaInflammationOrbitalOrbital mass restricting eye movement

References.1-lecture notes in ophthalmology. Bruce

James, Chris Chew, Anthony Bron,9th edition 2003,blackwell publications.

2-eye movement disorders.Wong,Agnes M.F,1st edition,2007.

3-ABC in ophthalmology.4-Basic Ophthalmology5-Atlas of ophthalmology,C.D atlas, Mosby.