StrabismusPrepared by:

Adolf Joshua Oliveros

Definition

• A disorder in which the eyes do not line up in the same direction when focusing

• Commonly known as CROSSED EYES, WALL EYE

Description

• Lack of coordination between the eyes

The eyes look in different directions and do not focus at the same time on a single point

Etymology

• Strabismus to squint

Causes

• Unknown

• Hereditary

In Adults:

• May develop strabismus from eye or blood vessel damage. Loss of vision, an eye or brain tumor, stroke, and various muscle and nerve disorders can also cause strabismus in an adult.

Risk Factors

• Family with strabismus

Symptoms

• Crossed eyes• Double vision• Eyes that do not align in the same

direction• Uncoordinated eye movements (eyes do

not move together)• Vision loss in one eye, includes a loss of

the ability to see in 3-D (loss of depth perception)

Types

1. Horizontal Strabismus– Exotropic is outwards (away from the midline)– Esotropic is inwards (towards the nose)

2. Vertical Strabismus– Hypertropia is upward– Hypotropia is downward

Diagnostic Tests 1. Hirschberg test (Hirschberg corneal reflex test)

Is a screening test that can be used to assess whether a person has strabismus (ocular misalignment) Developed by German ophthalmologist Julius Hirschberg who in 1886 used a candle to observe the light reflex in an eye with strabismus

Steps:A flashlight is shone in the patient's eyeWhen the patient is looking at the light, a reflection can be seen on the front surface of the pupil.

Interpretation:(+) Positive Hirschberg sign: the light falls on the

centre of the right pupil, but is medial to the centre of the left pupil

(-) Negative Hirschberg sign: the light reflects from congruent points in both lenses.

2. Alternating Cover Test Objective determination of the presence and

amount of ocular deviation Steps:

Having the child (typically) focusing on a near object.

A cover is placed over an eye for a short moment then removed while observing both eyes for movement.

The "lazy eye" will wander inwards or outwards, as it begins to favor its perceptive visual preference.

The process is repeated on both eyes and then with the child focusing on a distant objects.

Medical Management

1. Botulinum toxin (Botox)• Classification: Muscle relaxants• Indication: Treatment of disorders of ocular

muscle including strabismus• Adverse Effects: Localized pain, tenderness &/or

bruising, local weakness• Intervention:

a. Inform patient that it may cause excessive weakness or atrophy in target muscle

2. Atropine (Isopto eyedrops)• Classification: Mydriatic Drugs• Action: Atropine is an anticholinergic agent which

competitively blocks the muscarinic receptors in peripheral tissues such as the heart, intestines, bronchial muscles, iris and secretory glands.

• Adverse Reaction: dry mouth, dysphagia, constipation, flushing and dryness of skin, tachycardia, palpitations, arrhythmias, mydriasis, photophobia, cycloplegia, raised intraocular pressure

• Intervention:• a. May be taken with or without food. (Take w/ food

or water.)

Surgical Management

• Surgeon loosens or tightens the muscles attached to the eye by changing their length or position. Changing the pull of the muscles can bring the eyes back into line with each other.

• A child may need more than one surgery to realign the eyes and improve vision and may have to start or continue wearing glasses after the surgery.

• Strabismus in very young children sometimes disappears on its own as development continues.

Nursing Management

A. Situational Low Self Esteem R/T Disturbed Body Image• Planning: To be able to express positive self-appraisal• Interventions:

a. Convey confidence in client’s ability to cope with current situationb. Encourage use of visualization, guided imagery and relaxationc. Assist client to problem solve situation, developing plan of action and setting goals to achieve desired outcome

B. Risk for loneliness R/T Social Isolation

• Planning: To be able to engage in social activities

• Interventions:

a. Convey confidence in client’s ability to cope with current situation

b. Involve in classes such as assertiveness, language and social skills.

C. Impaired social interaction R/T Self-concept disturbance

• Planning: To be able to give self positive reinforcements for changes that are achieved

• Interventions:a. Have client list behaviors that cause discomfortb. Help client prioritize those behaviors needing changec. Provide positive reinforcement for improvement in social behaviors and interactions

Prognosis

• When strabismus is congenital or develops in infancy, it can cause amblyopia, in which the brain ignores input from

the deviated eye. Strabismus can lead to a permanent weakening of vision in the strabismic eye called amblyopia

sometimes referred to as lazy eye. The appearance of strabismus may also be a cosmetic problem. One study reported that 85% of adult strabismus patients "reported

that they had problems with work, school and sports because of their strabismus." The same study also

reported that 70% said strabismus "had a negative effect on their self-image.

• With early diagnosis and treatment, the problem can usually be corrected. Delayed treatment may lead to

permanent vision loss in one eye.

Research • Strabismus in Adults• (Nov.3,2007-David Marshall)• Dr. David Guyton at the Wilmer Eye Institue of Johns Hopkins sent

this to me along with some other articles, but this one is a very powerful reminder of how crippling strabismus can be to those of us who suffer from it. It is a study conducted by George R Beauchamp, MD, Joost Felius, PhD, David R Stager, Sr, MD,and Cynthia L Beauchamp, MD from the Department of Ophthalmology, University of Texas Southwestern Medical Center (Dr G. Beauchamp, Dr Felius, Dr Stager, Dr C. Beauchamp), and the Retina Foundation of the Southwest (Dr Felius), Dallas, Texas.

• About 60% of all patients indicated willingness to trade part of their life expectancy in return for being rid of strabismus and its associated effects.

Thank you!