Congenital Strabismus: S. Vanitha, B.optom, 3 Year

Congenital Strabismus
S. Vanitha,
B.optom,
3rd year
Overview
• Introduction
• Development of strabismus
• Causes
• Types of strabismus
• Symptoms
• Signs
• Diagnosis
• Treatment
Introduction
• Strabismus also known as “squint” is an eye condition, where the eyes do not look in
same direction.
• This means that one eye may not focus on an object someone is looking at.
• While one eye looks forward to focus on an object the other eye turns inwards,
outwards, upwards or downwards.
• Most squints occur in young children.
• It can also occur later in life,it may run in families however many people with
strabismus have no relatives with the problem.
• It usually occurs in people who have ‘poor eye muscle control’ or are very farsighted.
• 6 muscles attached to each eye to control how it moves, this muscles receive signals
from brain that direct their movements.
• Normally the eye works together both point at same place. When problems develop
with eye movement control may eye turn in,out ,up down.
• The some cases Same eye turn each time,in other cases the eye may alternate turning.
….continues
….continues
• Proper eye alignment is important to avoid seeing double for good depth perception
and prevent the development of poor vn in turned eye.
• When the eyes are misaligned the brain receives two different images.
• At first this may create double VN & Confusion,but overtime brain will learn ignore the
images from the turned eye.
• Untreated eye turning can leads to permanently reduce to vn,this is called
“Amplyopia”or lazy eye.
• Some babies eyes may appear to misaligned,but they are actually both aiming at the
same object ,this is called pseudostrabismus.
Development of strabismus
• Strabismus usually develops in infants and young children ,Most often by age
3years.But older children& adults can also develop this condition.
• In fact strabismus is may get worse ,without treatment.
• An examiner should examine any child older than 4 months whose eyes do not appear
to be straight all the time.
• Strabismus can also be caused by a disorder in the brain which cannot coordinate the
eyes correctly.
• Squint usually develops during their first 18-36months of life or sometimes it later.
• Sometimes a squint adulthood even though it had been successfully treated ,when the
patient was a child
• In such cases the adult may have double vision , bcz by that time the brain is trained to
gather data from both eyes ,it cannot ignore One of them.
Causes
a) Family history
b) Prematurity
c) Refractive errors
d) Cataract Or eye surgeries
e) Other conditions
a) Family history
Some squint may be run in families so if a parent has a squint Or needed glasses from an
early age there may be increased chance that their child is also affected.
b) Prematurity
Children that are born early means before 12weeks may be at more risk of developing
squint.
C) Cataract or eye surgery

• Congenital cataract or injury which damage the retina can cause eye to have poor vn.
• This may also cause squint to develop in this eyes.
d) Refractive errors
• Refractive errors are the condition where the problem with the focusing power of the
eye.
• These are usually corrected by spectacles.
Common types are,

• Myopia
• Hypermetropia
• Astigmatism.
• Hypermetropia and sometimes myopia in children may cause a squint to develop
where the eye turns inwards (esotropia).
• Having glasses to correct their Hypermetropia makes their focusing more relaxed and
gives clear vision.
• At the same time the glasses may also straighten their eyes and remove squint
e) Other Conditions
• Strabismus is especially common children with disorders that may affect the brain such as,
• Cereberal palsy
• Down syndrome
• Hydrocephalus
• brain tumours
most common forms are

1.Cross fixation esotropia
2.Accomodative esotropia
3.Intermittent esotropia
1.CROSS FIXATION ESOTROPIA

Is the use of RE to view the left visual field ,in the use of LE to view the right visual field.
2.Accomodative esotropia
• It occurs because of uncorrected hyperopia
• So children who are farsighted are focusing extra hard to keep images clear
• This may cause the eyes turns inwards.
Symptoms:
• Double vn
• Turning head.
3) Intermittent esotropia
• May develop when a person cannot coordinate both eyes together,the eye may point beyond
the object being viewed.
Symptoms:
• Headache
• Difficulty reading
• Eye strain
TYPES
TYPES OF STRABISMUS
A)when squint appear
Constant If its visible all the time
Intermittent If it comes and goes
B)When squint noticed in life

Infantile If it develops within first 6
months of life
Acquired If it occurs at later age
C)When squint by visual disturbance

Refractive If it caused by refractive error
Non- Refractive If its not by refractive error
D)Eye movement
Convergent or esotropia if the eye movement is inwards
Divergent or exotropia if the eye movement is outwards
hypertropia if the turn is upwards
hypotropia if the turn is downwards
E)When eye muscles are involved

incomitant if the squint changes when looking
in different directions
Concomitant if the squint is the same when looking
in every directions
Symptoms
• Headaches
• Misalignment of the eyes or deviation
• Eyestrain
• Fatigue
• Vision loss
• Amblyopia
• Psychologically affect (embarrassment,awkwardness)
SIGNS
• Primary sign is visible misalignment of the eyes one eye turns in,out,up,down or oblique angle.
• The angle of deviation (small &large)
• Abnormalities or faulty insertion of extraocular muscles.
• Epicanthal folds.
• Nystagmus.
• Routine eye examinations are the best way to detect the strabismus.
• Without treatment the child may develops double vision ,amblyopia or visual symptoms that
could interfere with reading and learning.
Diagnosis
• A squint may be noticed by parents, relatives , friends or health care professionals.
• The government recommends that child’s vision should be screened b/w their 4th and 5th
birthdays around the time they start school to ensure that their eyes work together.
• Testing for strabismus may include,
a)patient history
b)visual acuity
c)refraction
d)alignment and focusing testing
e)examination of eye health
a)Patient history
• To ask the parents about any symptoms.
• Will note general health problems, medications or environmental factors that may be
contributing to the symptoms.
b)Visual acuity
• To measure V/A to assess how much vision is affected.
• For the test child will be asked to read letters on reading charts that are near and distance.
• Visual acuity is written as a fraction such as 20/40.
• A person with 20/40 visual acuity would have to get within 20 feet of a letter that should be
seen clearly at 40 feet.
• Normal distance visual acuity 20/20.
c)Refraction
• Refraction to determine the appropriate lens power you need to compensate for any refractive
error(myopia,hypermetropia,astigmatism)
• Using the instrument phoropter,retinoscope,AR, that evaluates the refractive power of the eye
without cooperation of the patient.
• Then will prescribe the best glasses.
d)Alignment & focusingtesting
• Hirschberg test-corneal reflex is used toassess whether the child has squint.
• A child with well aligned eyes , the light goes to center of both corneas.
• if it does not the examiner can determine whether patient has
exotropia,esotropia,hypertropia,hypotropia.
Treatment or management
• Glasses
• Occlusion therapy
• Exercises
• Surgery
• Injections
a) Glasses
• Child to have properly prescribed glasses to give them clear vision in both eyes.
• Most children with a squint may be prescribed with a prescribed with a pair of glasses that they
will need to wear all the time.
• It may notice when the child wears their glasses that their squint becomes less noticeable or
disappears completely, this type of squint is known as ACCOMODATIVE SQUINT.
b) Occlusion therapy
• Occlusion therapy is used to improve the vn in lazy eye
• Parent maybe asked to cover their good eye with a patch , the child then using their weaker eye to
see and buildup the pathway b/w eye and brain.
• Sometimes eye drops are used as an alternative to a patch.
• Atropine drops blur the vision in the child good eye enough so that thry will start to use other eye ,
just like when wearing patch.
c) Exercises
• In some cases exercises can be useful to strengthen the ability of the eyes to work together.
• This type of treatment is usually helpful in older children and is commonly used together with
glasses and surgery.
d) Botulinum toxin injection(botox)

• Some children may be offered treatment with a botox injection.
• This injection weakens the muscles that pull the eyes towards each other and in children is
carried out under general anaesthetic.
• The effect is temporary but may be effective for some squints.
e) Surgery
• A number of children may require an operation on the eye muscles to straighten the squint, and
it is not improved by the proper correction of the glasses.
• Sugery usually performed under general anaesthetic.
• Squint sugery is not uncommon for more than one operation to be necessary.
• The operation usually weakens or strengthens the muscles of the eye so that eyes are aligned.
(recession or resection).
• There is no age limited on surgery, age of 1year also on those age 16 years and above
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Congenital Strabismus

C) Cataract or eye surgery

Common types are,

most common forms are

1.CROSS FIXATION ESOTROPIA

B)When squint noticed in life

C)When squint by visual disturbance

E)When eye muscles are involved

d)Alignment & focusingtesting

d) Botulinum toxin injection(botox)

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