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Strabismus For Medical Students & GP. Samir Jamal MD, FRCSC KAUH. Strabismus. Misalignment of one or both eyes so as the eye (eyes) is not looking straight at the object of regard. . Significance In Children. Children need normally aligned eyes to develop vision.
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Strabismus For Medical Students & GP Samir Jamal MD, FRCSC KAUH
Strabismus • Misalignment of one or both eyes so as the eye (eyes) is not looking straight at the object of regard.
Significance In Children • Children need normally aligned eyes to develop vision. • Strabismus in childhood is the second most common presentation of retinoblastoma. • Strabismus is a common presentation for refractive errors.
Significance in Adults • Frequent sign of neurological disease • Frequent presentation of systemic disease ( Thyroid disease & Myasthenia) • Cosmetology
Types of Eye Movements • Horizontal direction • Vertical direction • Torsional direction All superior muscles are intortors. All inferior muscles are extortors.
Types of Strabismus • Esodeviation eye turned in • Exodeviation eye turned out • Hyperdeviation eye turned up • Hpodeviation eye turned down
Classification of Strabismus • Constant or intermittent • Latent or manifest (phoria or tropia) • Unilateral or alternating • Comitant or incomitant (restrictive or paralytic) • Paralytic or non-paralytic • Nuclear or supranuclear
Causes of Strabismus • Congenital: imbalance between innervations and contraction • Refractive errors • Loss of vision • Paralysis or Neuromuscular • Restrictive: thyroid eye disease • Tumors
Strabismus secondary to loss of vision from Cataract in Lt. eye
Presenting symptoms of Strabismus • Deviation of the eye (cosmesis) • Double vision • Torticollis (abnormal head posture) • Unexplained visual loss in a normal looking eye (Microtropia)
Role of GP • Confirm Diagnosis • Decide on urgency • Teach patients • Referral to Ophthalmologist
Management of Strabismus History: 4 most important questions: • Age of onset • Constant or intermittent • Unilateral or alternating • Diplopia or torticollis
Management of Strabismus Examination: Three objectives: • Confirm the diagnosis • Diagnose type of strabismus • Differentiate paralysis from no paralysis
Examination of Strab Patient To achieve the first and second objectives we do: • Simple observation for the nasal white of the eye • Corneal light reflex • Cover test
Examination of Strab Patient To achieve the 3 rd objective we look for: • Presence of torticollis • Answer the following question: Is the strabismus the same in all directions of gaze or not i.e. comitant or incomitant? • Same = no paralysis. • Different = paralysis or restriction.
Examination • Test the extraocular movements in all directions of gaze. • Paralysis / restriction Limitation • No Paralysis No limitation
Doll's Head Manoeuvre • Used for testing the eye movement when the patient is uncooperative. • The eyes move in opposite direction to the head movement.
Common Forms of Esotropia • Congenital (No-Accommodative) Surgery. • Accommodative R/ Glasses. • P. Accommodative Glasses then surgery. • Sixth Nerve Palsy observation for 6 M surgery.
Accommodative Esotropia Before Glasses After Glasses
Non-Accommodative Squint Non-Accommodative Esotropia Before and After Surgery
Common Forms of Exotropia • Congenital exotropia Surgery • Sensory deprivation exotropia • Third nerve paralysis
Common Causes of Hypertropia or Hypotropia • Fourth nerve palsy • Third nerve palsy • Thyroid disease • Myasthenia gravis • Orbital floor fracture