INCOMITANT

SQUINT

It is a type of hetrotropia
(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 hetrotropias
3. Restrictive Squint.
PARALYTIC STRABISMUS

It refers to ocular deviation resulting

from complete or incomplete
paralysis of one or more extraocular
muscles.
ETIOLOGY
I. Neurogenic lesions
1. Congenital
2. Inflammatory lesions
3.Neoplastic lesions
4. Vascular lesions
5. Traumatic lesions
6. Toxic lesions
7. Demyelinating lesions
II. Myogenic lesions
1.Congenital lesions
2. Inflammatory lesions
3. Traumatic lesions
4. Myopathies lesions
III. Neuromuscular junction lesion
Myasthenia gravis
CLINICAL
FEATURES
1.DIPLOPIA
It may be
horizontal, vertical
or oblique
depending on the
muscle paralysed.
Diplopia occurs
due to formation of
image on dissimilar
points of the two
retina.
2.Confusion. It occurs due to formation of
image of two different objects on the
corresponding points of retina.

3.Nausea and vertigo

4.Ocular deviation
SIGNS
1.Primary Deviation:- It is deviation of the
affected eye and is away from the action
of paralysed muscle.
2.Secondary deviation:-It is deviation of the
normal eye seen under cover, when the
patient is made to fix with the squinting
eye.
IN PARALYTIC SQUINT IT IS GREATER
THAN THE PRIMARY DEVIATION
 Alternate cover test
Allow the pt time to fixate on the target, give them a minute.
Then quickly cover the other eye to prevent the pt from regaining
fusion.

Exotropia, Constant
May be visible with or without
alternate cover
Secondary deviation is more
than primary deviation
3.Restriction of ocular movement:- It occurs
in the direction of the action of paralysed
muscles.
4.Comensatory head posture – It is adopted
to avoid diplopia and confusion.
5.False projection or Orientation:- It is due to
incresed innervational impulse conveyed
to the paralysed muscle.
 PAHTOLOGICAL SEQUELAE OF AN
EXTRAOCULAR MUSCLE PALSY
These occur more in paralysis due to lesions
of nerves than the lesions of muscles.These
includes:
1.Overaction of the contralateral synergistic
muscle.
2.Contracture of the direct antagonist muscle.
3.Secondary Inhibitional palsy of the
contralateral antagonist muscle.
 Primary paresis
Overaction lateral rectus
medial rectus

Left Right

Secondary palsy Contracture

lateral rectus medial rectus

PAHTOLOGICAL SEQUELAE OF RIGHT

LATERAL RECTUS MUSCLE PALSY
 CLINICAL VARIETIES OF
OCULAR PALSIES
1. ISOLATED MUSCLE PARALYSIS - (Lateral
rectus and superior oblique most common)
2.PARALYSIS OF THIRD CRAINIAL NERVE –
Ptosis
Deviation ( down, out and slightly intorted)
Ocular movements restricted
Pupil is fixed and dilated.
Accomodation is completely lost
Crossed diplopia
3.DOUBLE ELEVATOR PALSY - It is a congenital
condition caused by third nerve nuclear lesion.
Characterised by paresis of superior rectus and
inferior oblique muscle of involved eye.

4.TOTAL OPHTHALMOPLEGIA – Due to

combined paralysis of 3rd, 4th & 6th cranial nerves
as in orbital apex syndrome and cavernous
sinus thrombosis. All extraocular muscles,
including LPS & intraocular muscles, viz.,
sphincter pupillae and ciliary muscles are
paralysed.
5. External ophthalmoplegia – Due to lesion at the
level of motor nuclei sparing the Edinger –
Westphal nucleus.

6. Intranuclear ophthalmoplegia – Due to lesion of

Medial longitudinal Bundle.
• Defective action of MR on the side of lesion
• Horizontal nystagmus of opposite eye
• Defective convergence
 INVESTIGATIONS
Every case of squint should be evaluated as previously
mentioned.
1. Inspection
2. Ocular movements
3. Pupillary reactions
4. Fundus examination
5. Refraction
6. Direct cover test
7. Alternate cover test
8. Examination of angle of deviation
9. Tests for the grade of binocular vision
ADDITIONAL TESTS
1. Diplopia charting

Position and the separation of the two images in

different fields in pt. with right lateral rectus palsy.
HESS SCREEN TEST
 SR IO IO SR

LR MR LR

IR SO SO IR
3. Field of binocular fixation – where applicable
i.e., if pt. has some field of single vision.
Using perimeter.
4. Forced duction test (FDT)

INVESTIGATIONS TO FIND OUT THE

CAUSE OF PARALYSIS
ORBITAL USG
ORBITAL AND SKULL CT SCANNING
NEUROLOGICAL INVESTIGATIONS
 DIFFERENCES BETWEEN PARALYTIC &
NON-PARALYTIC SQUINT

FEATURES PARALYTIC SQUINT NON-PARALYTIC

SQUINT

Onset Usually sudden Usually slow

Diplopia Usually present Usually absent
Ocular Limited in the Full
Movements direction of action of
paralysed muscle

False Positive Negative

Projection
Head Posture Changed depending upon the Normal
muscle paralysed

Nausea & Vertigo Present Absent

Secondary DeviationMore than the primary deviation Equal to primary

deviation

Pathological Present Absent

Sequelae in the
Muscles
MANAGEMENT
1. Treatment of the cause
2. Conservative measures –
• Wait and watch for 6 months.
• Vitamin B complex
• Systemic steroids
3. Treatment of annoying diplopia –
Use of occluder on the affected
eye, with intermittent use of both
eyes with changed head posture
to avoid suppression amblyopia.
4. Surgical treatment
 ‘A’ AND ‘V’ PATTERN
HETEROPHORIA
• It is labelled when the amount of deviation in squinting eye varies by
more than 100 and 150 ,respectively, between upward and downward
gaze.
• ‘A’ AND ‘V’ ESOTROPIA – In ‘A’ esotropia the amount of deviation
increases in upward gaze & decreases in downward gaze. The reverse
occur in ‘V’ esotropia.
• ‘A’ AND ‘V’ EXOTROPIA – In ‘A’ exotropia the amount of deviation
decreases in upward gaze & increases in downward gaze. The reverse
occur in ‘V’ exotropia.
• C/F – It refers to vertically incomitant stabismus associated with
horizontally concomitant strabismus
 RESTRICTIVE SQUINT
Here, the extraocular muscle is not paralysed but its movement is
mechanically restricted.
1. Smaller primary deviation in proportion to limitation of movement
2. FDT positive
CAUSES –
• Duane’s retraction syndrome
• Brown’s superior oblique tendon sheath syndrome
• Strabismus fixus
• Dysthyroid ophthalmopathy
• Incarceration of extraocular muscle in blow out fracture of the orbit.
1. Duane’s restriction syndrome – It is a congenital motility defect occuring due to fibrous
tightening of lateral or medial or both rectus muscle.
• Limitation of abduction ( Type I ) or adduction (Type II ) or both (Type III ).
• Retraction of globe and narrowing of palpabral fissure on attempted adduction.
• Eye in primary position may be orthotropic, esotropic or exotropic
2. Brown’ superior oblique tendon sheath syndrome - It is a congenital motility defect due
to fibrous tightening of superior oblique tendon.
Limitation of elevation of the eye in adduction ( positive FDT)
3. Strabismus fixus- Bilateral fixation of eyes in convergent position due to fibrous
tightening of the medial recti.
STRABISMU
S SURGERY
• Strabismus surgery is surgery on the extraocular muscles to
correct the misalignment of the eyes.
• Eye muscle surgeries typically correct strabismus and include the
following:
• Loosening / weakening procedures
• Recession involves moving the insertion of a muscle
posteriorly towards its origin.
• Myectomy
• Myotomy
• Tenectomy
• Tenotomy
• Tightening / strengthening procedures
• Resection involves detaching one of the eye muscles, removing a
portion of the muscle from the distal end of the muscle and
reattaching the muscle to the eye.
• Tucking
• Advancement is the movement of an eye muscle from its original
place of attachment on the eyeball to a more forward position.
• Transposition / repositioning procedures
• Adjustable suture surgery is a method of reattaching an extraocular
muscle by means of a stitch that can be shortened or lengthened within
the first post-operative day, to obtain better ocular alignment.
• Posterior fixation suture (FADEN OPERATION ) to correct dissociated
vertical deviation.
• Transplantation of muscles in paralytic squint.
• Indications:
• The most common indications for surgical treatment of
strabismus include:
• Development or restoration of normal binocularity: near-
normal alignment is a prerequisite for development of
binocular vision and stereopsis. Alignment before two
years of age allows the greatest chance for binocularity
in children with congenital strabismus. Functional
benefits of binocularity include stereopsis, expanded
binocular visual fields and prevention of amblyopia.
• Treatment of diplopia
• Restoration of normal facial appearance
• Treatment of abnormal head posture, mainly that related
to an abnormality of ocular alignment
• Surgical Techniques: the muscles can be reached through a limbal or a fornix-based
approach. The four recti insertions merge into the sclera; the average insertion
distances from the limbus are:
• medial rectus 5.5mm
• inferior rectus 6.5mm
• lateral rectus 6.9mm
• superior rectus 7.7mm
• Type and amount of muscle surgery :
• It depends upon the type and angle of squint, age of the patient, duration of squint and
visual status.
• 1 mm resection of MR will correct about 1 -1.5 (Max. 8mm)
o o

• 1 mm recession of MR will correct about 2 -2.5 (Max. 5.5mm)

o o

• 1 mm resection and recession of LR will correct about 1 -2 (Max. 10 and 8mm)

o o
How much to operate…

20

Alternate Cover test with Prism

Exotropia, Constant
Use prism to quantitate the
deviation.
Change prism power until
movement is neutralized.
Use this number to plan surgery
 How much to operate?
How much to operate • Dosages (surgical)
• Tables: • bilat , 2 muscles
• ie for ET 40PD recess 5.5mm both
MR
• ET XT
• PD Rec Rst Rec Resect
• 15 3 3 4 2.5
• 20 3.5 4 5 3
• 25 4 5 6 4
• 30 4.5 6 7 5
• 35 5 7 7.5 5.5
• 40 5.5 7.5 8 6
• 50 6 8 9* 7
• Personal
• 60 6.5 8.5 10* 8
experience
STEPS OF RECESSION
STEPS OF RESECTION
RESECTION
 Complications and Risks of surgery
• Infection (1 in 3 years )
• Nausea (Tx: Phenergan, etc.)
• Blood loss
• Loss of sight? (globe perforation)
• Scar tissue
• Diplopia
• Residual or consecutive strabismus due to overcorrection and undercorrection
• Oculo-Cardiac Reflex – Bradycardia
• Lost and slipped muscles
• Anterior segment ischemia: Much of the anterior segment circulation derives from ciliary
arteries which are affected by surgery involving the extraocular muscles. This occasionally
leads to a peculiar complication called anterior segment ischemia manifesting with a
significant anterior chamber reaction, iris atrophy, and various degrees of cataract
formation.
• Conjunctival granulomas and cysts