OPHTHALMOLOGY

3.2 Ocular Manifestations (Dr. Barja)

Date: 13 October 2015
FEU-NRMF Institute of Medicine
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------STRABISMUS

to squint to look sideways or off center; not straight

ANATOMY AND PHYSIOLOGY

6 extra-ocular muscles (EOM)

o
4 recti

Medial rectus (MR)

Lateral rectus (LR)

Superior rectus (SR)

Inferior rectus (IR)

ALL have the same insertion and they form the Annulus of
Zinn
Each muscle is approximately 40mm long and 10 mm wide
o
2 obliques

Superior oblique (SO)

Inferior oblique (IO)

The 4 recti and the superior oblique originate from the apex of
the orbit.
The inferior oblique originates from the floor of the orbit.

Significance: during eye surgery

Medial rectus (nearest to the

corneal limbus)

5.5 mm

Inferior rectus

6.5 mm

Lateral rectus

7.0 mm

Superior rectus

8.0 mm

MUSCLE INNERVATIONS

If you want to view your EOMs, request for a CT Scan or MRI.

LR6 --- SO4 --- R3

EYE MOVEMENTS

3
2

Lateral rectus Abducens

Superior Oblique Trochlear
The Rest - Oculomotor

Ductions
o
monocular eye movement
o
adduction, abduction,etc
Versions
o
conjugate binocular eye movement
o
eyes move in the same direction
o
dextroversion, levoversion
Vergence
o
disconjugate binocular eye movement
o
eyes move in opposite directions
o
convergence, divergence

Pictures 1 and 2 show a normal EOM

o
Tapering at the origin and at the insertion
Picture 3 shows problematic EOMs specifically a thyroid eye
problem there is bulging of the belly

MUSCLE INSERTION

The EOMs insert in the sclera anteriorly

Most people would have the same distance of insertion from the
corneal limbus.

Faith Angeli J. Ladia (3A)

Out of the 6 movements, 4 are voluntary movements.

Intortion and extertion are involuntary.
When you tilt your head to the right, what happens to your eyes?
The RIGHT eye INTORTS and the LEFT eye EXTORTS.
Agonist
o
primary muscle moving the eye in a certain direction
o
when you move your eyes upward, the agonist muscle is
the SR. When looking down? IR.
Synergist
o
The helpers
o
muscle in same eye that acts with the agonist in the
same direction
o
When moving the eye up: Agonist? SR. Synergist? IO.
Antagonist
o
muscle in same eye acts in opposite direction as the
agonist
o
When moving the eye up: Agonist: SR. Synergist? IO.
Antagonist? IR.
MUSCLE

PRIMARY
SECONDARY
ACTION
ACTION
MR
Adduction
LR
Abduction
SR
Elevation
Incycloduction
IR
Depression
Excycloduction
SO
Incycloduction
Depression
IO
Excycloduction
Elevation
Table 1. Eye movements. MEMORIZE!

Yoke muscles
o
2 muscles one in each eye that are the prime movers
in their respective eyes in a given position of gaze
o
If you look the right, the 2 yoke muscles are? Right LR
and Left MR. To the left? Left LR and Right MR. Down
and right? Right IR and Left SO. Up and right? Right SR
and Left IO. Dont forget dexterity lalo na sa exams!

HERINGS LAW OF EQUAL INNERVATION OF MUSCLE

Applied for yoke muscles, for version

Equal innervation is supplied to
yoke muscles to move both eyes
into the same direction of gaze.

TERTIARY
ACTION

Adduction
Adduction
Abduction
Abduction

POSITIONS OF GAZE

Mnemonics: SINRAD
ALL Superiors are INTORTERS.
ALL
Vertical
ADDUCTORS.

RECTI

are

Primary position (straight gaze)

SHERRINGTON LAW OF RECIPROCAL INNERVATION

Secondary position ( up, down, right, left)

Tertiary position (right & up, right & down, left & up, left & down)

For monocular eye movement/ductions

In a certain movement, there is
increased innervations of the
agonist, and there is a decreased
innervations of the agonist.
The same amount of contraction of
the agonist has also the same
amount of relaxation of the
antagonist.

Diagnostic position (9 positions)

Always do all of these so as not to miss the muscle that is

problematic.
BINOCULAR VISION

BINOCULAR SINGLE VISION (BSV)

VERSIONS

An image coming from your L eye is

slightly different from that of the R
eye.
BSV is the ability to fuse these
slightly different images to be able
to see just one single image.

Requirements for BSV:

binocular eye movements

clear visual axes

ability of the retino-cortical elements to fuse slightly different
images
coordination in movement of the two eyes in different
direction of gaze

Faith Angeli J. Ladia (3A)

AMBLYOPIA

lazy eye
In comparison to the other eye, one eye has poor vision
It is not corrected by glasses

CLASSIFICATION OF STRABISMUS

CLASSIFICATION

Strabismic
o
You grew up with one eye misaligned
o
One eye can see straight ahead while another eye
deviates creates confusion disregard other image
(usually patient chooses the image seen straight ahead)
Anisometropic
o
An- negative; -iso equal; -metropia measurement
o
Unequal measurements (grades) of the eyes
o
Ex: R eye is +8.00, L eye is -2.00
o
Patients tend to use the eye with the lesser grade and
disregard the image coming from the eye with a higher
grade
Stimulus deprivation
o
Ex: patients born w/ a cataract in one eye
Iso-ametropic
o
Equal grades but both eyes have very high grades
Meridional
o
Patients having more than 300 astigmatism

ACCORDING TO DIRECTION OF DEVIATION

Horizontal
o
Esodeviation
o
Exodeviation
Vertical
o
Hyperdeviation
o
Hypodeviation

Esotropia inward deviation

Exotropia outward
deviation
Hypertropia upward
deviation

Strabismus
o
ocular misalignment of whatever cause
Orthophoria
o
ideal condition of ocular balance/straight eyes

Torsional
o
Excyclodeviation
o
Incyclodeviation

ACCORDING TO AGE OF ONSET

Congenital/infantile
o
prior to age 6 months
Acquired

ACCORDING TO FUSION STATUS (WHETHER THE DEVIATION

CAN BE CONTROLLED BY FUSION MECHANISM)
In times of fusion, the eyes are aligned; in non-fusion, the eyes are
misaligned

1 strabismic
2 stimulus deprivation (cataract)]
3 congenital ptosis stimulus deprivation
4 severe astigmatism meridional

TREATMENT

Presents in childhood must be detected early to be able to

treat early because amblyopia can only be treated until age 8.
Present clear retinal image to amblyopic eye
o
in problems of refractive errors or cataracts correct
o
astigmatism give astigmatic correction
Make the child use the amblyopic eye
o
Patching

Cover the good eye so that the bad eye

would start working

Usually done 2 hrs every day

o
Penalization

Triad of accommodation:

Change in shape of the lens (more

spherical)

Eye convergence

Pupillary constriction

Put atropine (dilation) on the good eye loss

of accommodation blurring of vision
patient has no choice but to use the
amblyopic eye

Phoria
o
latent deviation; eyes remain aligned
o
there is a hidden strabismus
o
when you cover one eye, there is misalignment
Intermittent phoria or tropia
o
Obvious sometimes straight gaze, sometimes
misaligned
o
Fusion control present
Tropia
o
manifest deviation; fusion control not present
o
progression
from
phoria
to
intermittent
to
manifest/permanent

ACCORDING TO VARIATION
POSITION OR FIXATING EYE

OF

DEVIATION

WITH

GAZE

comitant
o
patient is cross-eyed: when patient is asked to look to
the R or L still cross-eyed
incomitant
o
patient is cross-eyed in straight gaze
o
when asked to look to the R straight. To the left
cross-eyed
o
there is a change in the amount of deviation in
different positions of gaze

Faith Angeli J. Ladia (3A)

ACCORDING TO FIXATION

A.

alternating
o
sometimes, patient has a deviated gaze in the L,
sometimes in the R; or sometimes an eye is straight,
sometimes deviated from time to time
monocular
EXAMINATION OF THE PATIENT
History taking

Chief complaint

Age of onset

Direction of deviation

Constant or intermittent

Alternating or monocular fixation

Magnitude of deviation

Antecedent or concurring illness

o
seizure, diabetes, hypertension

Associated eye complaints

o
diplopia, blurring, vision

Thyroid disease

Trauma

Previous consultation or treatment

o
patching, glasses, surgery

Maternal and birth history

Developmental history

Family history

Which one has strabismus? B. Patient A may look cross-eyed but when
you do the Hirschberg Test, the light falls on the center of both pupils.
In patient B, the light is displaced on the temporal side esotropia
KRIMSKY TEST

Makes use of prism glasses to neutralize the deviation. It moves

the corneal light back to the center.
COVER TEST

B. Ocular Examination

Visual acuity
Ocular motility exam
o
Do versions and ductions
o
Usually, versions are done first. When normal,
you dont have to do ductions anymore
Ocular alignment test
o
Corneal light reflex (Hirschberg)
o
Prism test (Krimsky)
o
Cover test

cover-uncover test

alternate cover test (prism and cover

test)
o
Ophthalmoscopy
o
Refraction

To know if patient has phoria (hidden/latent strabismus). Patient

comes to you straight gazed cover 1 eye when you uncover eye
movement back to center. L figure exophoria. R figure - esophoria

HIRSCHBERG TEST/CORNEAL LIGHT REFLEX TEST

Use your penlight. Normally, it should be at the center of the pupil. If

its slightly off your pupil, then most probably you have an eye
deviation.

A 1 mm deviation from the center (N pupil size = 2-3mm)

means a 7 eye deviation.

Also done to know which eye is fixating. L figure Right esotropia

w/ Left eye preference. Cover L eye R eye takes fixation Uncover
L eye takes fixation. The L eye is the better eye because it is always
the one fixating.
R figure: Alternating fixation. R eye deviated cover L eye R eye
fixates Cover R eye L eye fixates

Faith Angeli J. Ladia (3A)

COMMON TYPES OF STRABISMUS

COMITANT STRABISMUS (NON PARALYTIC/NON-RESTRICTIVE)

Congenital or infantile esotropia

o
Shortly after birth up to 6 months of age
o
Deviation is big and constant

> 30 prism diopters, > 4mm

o
Cross fixation

If patient wants to look at the L visual field,

patient uses the R eye and vice versa
o
Over-action of inferior obliques

congenital
motility
disorder
usually
unilateral
Major problem: paralysis of the LR because
th
the 6 CN did not develop
limited abduction or limited adduction or
both
globe may retract and eyelid fissure may
narrow on adduction
there may be up-shooting or down-shooting
of the eye
face turns to allow patient to use both eyes
together

Refractive Accommodative Esotropia

o
Acquired, usually > 6 mos of age
o
2 years of age
o
hyperopia of +3.00 to +10.00 diopters
o
magnitude of esodeviation is moderate
o
constant non-alternating accommodative esotropia can
cause amblyopia
Left LR palsy: At left gaze, L eye did not move. There is up-shooting of
the IO. There is narrowing of the palpebral fissure bc the aberrant CN 3
w/c innervates the MR may also innervate the LR abnormal globe
retraction. There is also limitation in the R gaze.
o

Patient is asked to look L and up. L

eye is fine. R eye cannot elevate. It
could be a palsy of the IO or a
restriction of the SO.

Patient will try to make objects look clearer by accommodating eye

convergence cross-eye. Over-accommodation can bring about
over-convergence eye deviation

Sensory esotropia
o
Anything that blocks vision on 1 eye can cause eye
deviation
o
A non-seeing eye would be deviated either inward or
outward
o
Corneal opacity, cataract, retinal scars, inflammation,
tumors, optic neuropathy, anisometropia

It is common in trauma
improves within 6 months

and

Mobius syndrome

palsy of CN VI and VII

mask-like
abduction

Intermittent exotropia
o
More common in Asians
o
Most number of cases seen
o
Starts as intermittent and becomes manifest (fatigue,
sleepy, or inattentive)
o
Closes 1 eye when exposed to bright sunlight
o
Frequency increases as patient grows older
Sensory exotropia
o
Eye that does not see well for any reason may turn
outward

Brown syndrome

restriction of superior oblique tendon

sheath limiting elevation in adduction

facies

and

limited

patient has bilateral LR palsy and a

flat face

Congenital fibrosis syndrome

restriction of 1 or more extraocular muscles

muscle fibers are replaced with fibrous

tissue
usually familial
they cannot look
up

INCOMITANT STRABISMUS (MUSCLE PARALYSIS/RESTRICTION)

Paralytic strabismus
o
Limitation of action of the involved muscle
o
Patients should have neurologic and systemic
evaluation
o
Patients may have diabetes and/or hypertension

Strabismic syndromes
o
Duane syndrome

Faith Angeli J. Ladia (3A)

SYSTEMIC ILLNESSES ASSOCIATED WITH STRABISMUS

Thyroid disease
o
Graves ophthalmopathy
o
EOMs undergo swelling and inflammation and later
replaced by fibrous tissue
o
IR is affected first Medial Superior Lateral
Obliques (IMSLO)
Diabetes mellitus
o
Acute onset of diplopia
o
Most commonly seen here in the Phils.
o
Improves within 6 months
Myasthenia gravis
o
Abnormal fatigability of striated muscles
Neurologic

Transposition

If you have an LR palsy, you can join fibers from your working SR and
IR join it with the weak/paralyzed LR to make the LR straight.
rd

In patients w/ 3 nerve palsy (eye that is down and out), only the SO
and LR are working. In this case, you can manipulate your LR and SO
to make your patients eyes aligned again.

Thyroid eye dse: fibrotic Left IR L hypotopia

Myasthenia: at the end of the day, all muscles are tired
How to diagnose MG in the clinics: tire the patient by asking him to
look up/down continuously. You can also diagnose by putting ice in the
patients eyes and then you can see that the eyes will open up.
MANAGEMENT

Aims
o
o
o

Good vision
Binocularity
Good alignment

PRINCIPLES OF MANAGEMENT OF A STRABISMIC PATIENT

Enhance vision
o
Spectacles
o
Treat amblyopia

Patching
Manipulation of Accommodation
o
Esodeviation

Anti-accommodative therapy

plus lenses for hyperopia

o
Exodeviation

Stimulate accommodation

overcorrect myopia, undercorrect hyperopia

Prism
o
Acute onset of strabismus, diplopia, small deviation
Surgery
o
Recession

muscle weakening procedure

from its original insertion, you move it back

you lengthen it weaker pull
o
Resection

muscle strengthening procedure

you shorten the muscle stronger pull

Faith Angeli J. Ladia (3A)