DR SIDRAH RIAZ

(MBBS, DOMS,FCPS,
FRCS,CHPE)
SQUINT
ASSOCIATE
PROFESSOR
AMDC
 The word strabismus comes from the
Greek word streblos meaning "turned"
or "twisted”

The prevalence of strabismus is 2 to 5

WHAT IS percent in the general population.
SQUINT
Squint is a disorder in which one eye
misaligns with the other focusing
eye ,in a primary direction of gaze.
It is an imbalance in the normal tone or
coordination of one or more extra
ocular muscle which results in a
manifest deviation of the affected eye.
Different types of
squint
The types of squint are:
1. Convergent squint - the
affected
eye looks inwards
2. Divergent squint - the
affected
eye looks outwards towards
the
BASIC • EACH EYE IS SURROUNDED BY SIX DIFFERENT
MUSCLES THAT WORK TOGETHER TO FOCUS
CONCEPT BOTH EYES ON ONE THING AT A TIME. BUT IN
STRABISMUS, THE MUSCLES DON’T WORK AS
A TEAM. AS ONE EYE FOCUSES ON ONE
THING, THE OTHER FOCUSES ON SOMETHING
ELSE. WHEN THIS HAPPENS, THE BRAIN
RECEIVES ONE IMAGE FROM EACH EYE. BUT IT
LEARNS TO IGNORE ONE OF THEM TO AVOID
CONFUSION LEADING TO AMBLYOPIA
 a genetic component

Refractive error, uncorrected

CAUSES Cerebral palsy

OF Apert syndrome, trisomy 18,

noonas syndrome
SQUINT Diabetes

Stroke/ brain injury/ trauma

Botulism toxins
 TYPES OF SQUINT
• ESSENTIAL INFANTILE ESOTROPIA (CONGENITAL ESOTROPIA):
• LARGE ANGLE STABLE ESOTROPIA
• WITHIN SIX MONTHS OF AGE WITH POSITIVE FAMILY HISTORY AND NO
NEUROLOGICAL DEFICIT.
• REFRACTIVE ERROR IS UNCOMMON WITH POOR POTENTIAL FOR BSV.
• CROSS FIXATION, ASYMMETRICAL LATENT HORIZONTAL NYSTAGMUS.
DISSOCIATED VERTICAL DEVIATION (DVD) DEVELOPS IN 80% OF CHILDREN
BY THREE YEARS OF AGE.
• TREATMENT IS AIMED AT CORRECTING HYPEROPIA AND TREATING
AMBLYOPIA.
• MUSCLE SURGERY SHOULD BE PERFORMED EARLY BETWEEN 6 MONTHS
Accommodative esotropia:
• Onset between 2-5 years of age
• Precipitated by trauma or illness.
• Family history and amblyopia are common.
• Mechanisms: uncorrected hypermetropia, accommodative
convergence, and poor fusional divergence. Normal
accommodation convergence/accommodation ratio (AC/A
ratio) with hyperopia of more than 2 Diopters (D) is seen in
refractive type, while non-refractive type shows a high AC/A
ratio with no clinically significant hyperopia.
• Treatment includes full cycloplegic correction and short term
miotics if children are intolerant to spectacles. If AC/A ratio is
high, Bifocals are prescribed with minimum plus add given for
near vision. Surgery is indicated if the residual esotropia
Intermittent exotropia:
• This presents around two years with exophoria,
which breaks down to exotropia under conditions of
visual inattention, bright light, and fatigue, or ill-
health.
• Other features are headache, asthenopia, diplopia,
photo-diplopia, micropsia, abnormal stereopsis, and
temporal retinal hemisuppression.
• Treatment should begin with correcting refractive
error and treating amblyopia.
• Orthoptic exercises with pencil pushups help to some
extent.
 Hirschberg test: The Hirshberg
test gives a rough estimate of the
angle of manifest strabismus by
noting the position of the corneal
light reflex produced by shining a
MEASUREME torchlight over the cornea. 7 to 15
NT OF degree
DEVIATION Krimsky test: This test uses
prisms placed in front of the fixating
eye to measure the deviation. The
modified Krimsky test is done by
holding the prism in front of the
deviating eye. This test is
essentially used to measure tropias
and not for phorias.
Cover test: The cover test is done to detect heterotropia. The
fixating eye is covered, and movement of the uncovered eye is
noted both for distance and near.
Uncover test: Uncover test detects heterophoria. After
covering an eye for 2 to 3 seconds, the same eye movement is
observed on uncovering. This test is done for both distance and
near. Most examiners do the cover test and uncover test
sequentially; hence it is called the “cover-uncover” test.
Alternate cover test: This is a dissociation test that reveals
the total deviation when fusion is interrupted and should be
performed only after the cover-uncover test. Patients with poor
fusional control may decompensate to a manifest deviation
when this test is done. The speed and smoothness of recovery
are noted following a fast cover-uncover test done alternatively
to both eyes.
Maddox wing: This test dissociates the eyes for near
fixation (33cm) and measures heterophoria. When seeing
through this instrument, the right eye sees only the arrows
(white vertical and red horizontal), while the left eye sees
only rows of numbers (horizontal and vertical). The white
arrow position denotes horizontal deviation, and a red arrow
denotes the vertical deviation. By aligning the red arrow
parallel to the horizontal row of a number, cyclophoria can
be measured.
Maddox rod: Maddox rod converts a white light spot into a
perpendicular red streak by a series of fused cylindrical red
glass rods. The amount of dissociation is calculated by the
superimposition of the two images using the prisms.
 COMPLICATION OF SQUINT

Reduced Asthenopi
Amblyopia Diplopia
stereopsis a

Abnormal Impaired
Nystagmu head and social and
s neck mental
posture growth
 TREATMENT OF SQUINT

• OBSERVATION
• CORRECTION OF REFRACTIVE ERRORS
• TREATMENT OF AMBLYOPIA
• ORTHOPTIC EXERCISES
• BOTULINUM TOXINS
• EXTRAOCULAR MUSCLES SURGERY
(RESECTION/RECESSION)
 SURGICAL TREATMENT OF SQUINT
THE THREE MAIN TYPES OF STRABISMUS SURGERY ARE
• WEAKENING PROCEDURES: THESE DECREASE THE EFFECTIVE STRENGTH OF
MUSCLE ACTION. RECESSION, RETRO EQUATORIAL MYOPEXY OR POSTERIOR
FIXATION (FADEN PROCEDURE), MARGINAL MYECTOMY, AND MYECTOMY
(DISINSERTION) ARE SOME OF THE WEAKENING PROCEDURES.
• STRENGTHENING PROCEDURES: THESE PROCEDURES ENHANCE THE PULL OF
THE MUSCLE. RESECTION, ADVANCEMENT, DOUBLE-BREASTING OR
TENOPLICATION, AND CINCHING ARE THE STRENGTHENING PROCEDURES.
• VECTOR ADJUSTMENT PROCEDURES. THESE ARE TRANSPOSITIONING
PROCEDURES THAT ALTER THE DIRECTION OF MUSCLE ACTION. HUMMELSCHEIM,
JENSEN, O’CONNOR, KNAPP, CALLAHAN, PETER, AND HELVESTON ARE SOME OF
THE TRANSPOSITIONING PROCEDURES.
 COMPLICATIONS OF SQUINT SURGERY

Conjunctival
scarring,
Under/over- Scleral
Diplopia granuloma, Corneal Dellen
correction perforation
and chronic
inflammation

Anterior
Endophthalmiti Retrobulbar
Lost muscle segment
s hemorrhage
ischemia
 AMBLYOPIA
• AMBLYOPIA IS CLINICALLY DEFINED AS REDUCTION OF VISUAL ACUITY IN ONE
OR BOTH EYES, CAUSED BY ABNORMAL BINOCULAR INTERACTION DURING
THE CRITICAL PERIOD OF VISUAL DEVELOPMENT, THAT CANNOT BE
ATTRIBUTED TO ANY OCULAR OR VISUAL SYSTEM ABNORMALITY OR TO
REFRACTIVE ERROR
• THE AMERICAN ACADEMY OF OPHTHALMOLOGY CONSIDERS AMBLYOPIA AN
INTEROCULAR DIFFERENCE OF 2 LINES OR MORE IN A VISUAL ACUITY TABLE
(WITHOUT SPECIFYING ANY), OR VISUAL ACUITY WORSE THAN OR EQUAL TO
20/30 WITH THE BEST OPTICAL CORRECTION.
• WITH AN INCIDENCE OF 3% TO 6%, AMBLYOPIA IS THE MOST COMMON CAUSE
OF LOW VISUAL ACUITY IN CHILDREN AND ADULTS IN DEVELOPED COUNTRIES
AND HAS GREAT ECONOMIC AND SOCIAL IMPACT.3-5 INDIVIDUALS WITH
AMBLYOPIA OFTEN HAVE RESTRICTED CAREER OPTIONS AND REDUCED
QUALITY OF LIFE, INCLUDING LESS SOCIAL CONTACT, COSMETIC DISTRESS (IF
ASSOCIATED WITH STRABISMUS), LOW SELF-ESTEEM, VISUAL
DISORIENTATION, AND FEAR OF LOSING VISION IN THE OTHER EYE
 TYPES OF AMBLYOPIA
• DEPRIVATION AMBLYOPIA
• ANISOMETROPIC AMBLYOPIA
• STRABISMIC AMBLYOPIA
• MIXED AMBLYOPIA
 DEPRIVATION AMBLYOPIA

• DEPRIVATION HAPPENS WHEN EYE DISEASES PREVENT THE LIGHT STIMULUS

FROM REACHING THE RETINA, THUS FORESTALLING THE NORMAL VISUAL
PROCESS. IT ALSO MAY OCCUR DUE TO ANATOMIC DEFICITS OF THE RETINA
OR OPTIC NERVE, OR ABNORMAL MOVEMENT DISORDERS OF THE EYE
(NYSTAGMUS). WHEN IT OCCURS DURING THE CRITICAL PERIOD OF VISUAL
DEVELOPMENT, IT CAN CAUSE AMBLYOPIA. THE MAIN DISEASES THAT CAUSE
THIS ARE CONGENITAL CATARACT, BLEPHAROPTOSIS, NYSTAGMUS
DISORDERS, OPTIC NERVE COLOBOMA AND HYPOPLASIA, RETINAL
DISORDERS, PERSISTENT FETAL VASCULATURE; OTHER DISEASE PROCESSES
CAN ALSO RESULT IN AMBLYOPIA.
 ANISOMETROPIC AMBLYOPIA
• ANISOMETROPIA IS A DIFFERENCE IN THE STATE OF REFRACTION OF AT LEAST
1 DIOPTER BETWEEN 2 EYES. THE PREVALENCE OF ANISOMETROPIC
AMBLYOPIA IS ABOUT 4.7% IN CHILDREN AND MAY BE MYOPIC, ASTIGMATIC, OR
HYPERMETROPIC. THE MOST COMMON TYPE OF ANISOMETROPIA SEEMS TO
VARY WITH THE AGE, ETHNICITY, AND OCULAR PATHOLOGIES OF THE
ANALYZED SAMPLE.
• HYPERMETROPIC ANISOMETROPIA IS THE MOST LIKELY TYPE TO CAUSE
AMBLYOPIA, SINCE THE RETINA OF THE MORE AMETROPIC EYE NEVER
RECEIVES A CLEAR AND DEFINED IMAGE: THE FOVEA OF THE GOOD EYE IS
FOCUSED AND THERE WILL BE NO STIMULUS OF ACCOMMODATIVE EFFORT TO
ADJUST THE FOCUS OF THE MORE HYPEROPIC EYE. IN MYOPIC ANISOMETROPIA,
THE MORE AMETROPIC EYE CAN BE USED FOR NEAR VISION, PREVENTING THE
SAME LEVELS OF AMBLYOPIA AS SEEN WITH HYPEROPIA.
 STRABISMIC AMBLYOPIA
• STRABISMUS IS A DEVIATION OF ONE EYE WITH LOSS OF EYE PARALLELISM. AS A
RESULT, THE EYES DO NOT RECEIVE EQUAL IMAGES, LEADING THE VISUAL SYSTEM
TO ADAPT TO THIS CHANGE.
• WHEN THE VISUAL SYSTEM IS COMPLETELY FORMED (WHEN THE PERSON REACHES
ADULTHOOD), THE PERCEPTION OF NON-CORRESPONDING IMAGES BY 2 EYES LEADS
TO DOUBLE VISION, BUT WHEN THE VISUAL SYSTEM IS IN ITS CRITICAL PERIOD OF
DEVELOPMENT (IN CHILDHOOD), THE BRAIN IS STILL CAPABLE OF USING
MECHANISMS TO AVOID DIPLOPIA OR RIVALRY BY INHIBITING THE ACTIVATION OF
THE RETINOCORTICAL PATHWAYS ORIGINATING FROM THE FOVEA OF ​THE DEVIATING
EYE. THIS ADAPTIVE MECHANISM AVOIDS DIPLOPIA, BUT IT CAUSES A
RESTRUCTURING OF THE VISUAL CORTICAL CIRCUITS IN THE VISUAL CORTEX THAT
IN TURN CAUSES AMBLYOPIA.
• IN STRABISMIC AMBLYOPIA, THE CORTICAL OCULAR DOMINANCE COLUMNS REMAIN
STRUCTURED, EVEN IN CASES OF MODERATE AMBLYOPIA. ONLY IN CASES OF DEEP
AMBLYOPIA ARE THERE REPORTS OF ALTERATION OF DOMINANCE COLUMNS.
 TREATMENT OF AMBLYOPIA

Optical correction alone is successful in improving the

amblyopia in nearly 1/3 of patients (anisometropic,
strabismic, or mixed)

Patching is an effective treatment for

amblyopia .Treatment of amblyopia is most effective
with children under 7 years of age. Children up to 13
years of age showed significant improvement in vision
with patching.The ideal number of hours of patching
was evaluated. Children 3 to 7 years old with
moderate amblyopia were randomized to 2 hours of
patching per day compared with 6 hours of patching
daily.

Atropine for penalization proved to be as effective as

occlusion
THANK YOU