squint - dr. ajay dudani, mumbai retina centre. definition squint is a disorder in which one eye...

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SQUINT SQUINT - Dr. Ajay Dudani, Dr. Ajay Dudani, Mumbai Retina Centre Mumbai Retina Centre

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Page 1: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

SQUINTSQUINT

-Dr. Ajay Dudani,Dr. Ajay Dudani,

Mumbai Retina CentreMumbai Retina Centre

Page 2: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

DEFINITIONDEFINITION

Squint is a disorder in which one eye misaligns Squint is a disorder in which one eye misaligns with the other when focusing in a primary with the other when focusing in a primary direction of gaze. It is an imbalance in the direction of gaze. It is an imbalance in the normal tone or coordination of one or more normal tone or coordination of one or more extra ocular muscle which results in a manifest extra ocular muscle which results in a manifest deviation of the affected eye. deviation of the affected eye.

Page 3: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

EXTRAOCULAR MUSCLESEXTRAOCULAR MUSCLES

Page 4: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

CARDINAL GAZESCARDINAL GAZES

Page 5: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

CLASSIFICATIONCLASSIFICATION

1. Direction of deviation:1. Direction of deviation: - convergent (esotropia)- convergent (esotropia) - divergent (exotropia) - divergent (exotropia) - hypodeviation- hypodeviation - hyperdeviation- hyperdeviation

2. Comitancy:2. Comitancy: - comitant or non paralytic- comitant or non paralytic - incomitant or paralytic- incomitant or paralytic

Page 6: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

3. Constancy:3. Constancy: - intermittent- intermittent - constant- constant

4. Onset:4. Onset: - childhood (congenital)- childhood (congenital) - adult (acquired)- adult (acquired)

5. Unilateral or Alternating5. Unilateral or Alternating

Page 7: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

6. Apparent (psuedostrabismus)6. Apparent (psuedostrabismus)

Manifest (tropias)Manifest (tropias)

Latent (phorias)Latent (phorias)

Page 8: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

PSEUDOSTRABISMUSPSEUDOSTRABISMUS

Pseudoesotropia- in Pseudoesotropia- in prominent epicanthal prominent epicanthal folds, high myopiafolds, high myopia

Pseudoexotropia- in Pseudoexotropia- in hypertelorismhypertelorism

Page 9: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

ETIOLOGYETIOLOGY

1.1. High Refractive errors - High Refractive errors - High degree of High degree of uncorrected refractive uncorrected refractive error in children may error in children may cause deviation of the cause deviation of the most affected eye.most affected eye.

2.2. Ocular conditions- Ocular conditions- causing visual axis causing visual axis obstruction eg. cataract, obstruction eg. cataract, corneal opacities, corneal opacities, retinoblastoma, ROP, retinoblastoma, ROP, macular disease etc.macular disease etc.

Page 10: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

3. Trauma3. Trauma

4. Lesions affecting the 4. Lesions affecting the EOM’s or CN’s EOM’s or CN’s especially no. III especially no. III

5. Systemic dis- DM, 5. Systemic dis- DM, stroke, botulism stroke, botulism

Page 11: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

PREDISPOSING FACTORSPREDISPOSING FACTORS

General debility and lowered vitalityGeneral debility and lowered vitality Psychosis, neurosis and mental stressPsychosis, neurosis and mental stress Inadequacy of fusional reserveInadequacy of fusional reserve Precision of jobPrecision of job Advancing ageAdvancing age

Page 12: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

CAUSES OF CHILDHOOD CAUSES OF CHILDHOOD STRABISMUSSTRABISMUS

CataractCataract Corneal opacitiesCorneal opacities ROPROP RetinoblastomaRetinoblastoma Traumatic brain injuryTraumatic brain injury Hemangioma near the eye Hemangioma near the eye

during infancyduring infancy Trisomy 18Trisomy 18 Congenital rubellaCongenital rubella Cerebral palsy Cerebral palsy

Page 13: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

SYMPTOMSSYMPTOMS

Deviated eye Deviated eye Abnormal head postureAbnormal head posture Poor visionPoor vision Headache Headache DiplopiaDiplopia

Page 14: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

EXAMINATIONEXAMINATION

1.HISTORY1.HISTORY A. Deviation: Age of onsetA. Deviation: Age of onset

Description of deviationDescription of deviation Previous treatmentPrevious treatment B. Pre and post natal factorsB. Pre and post natal factors Growth and developmentGrowth and development Family history of strabismusFamily history of strabismus2.GENERAL OBSERVATION.2.GENERAL OBSERVATION. Abnormal head postureAbnormal head posture

Page 15: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

3. VISUAL ACUITY3. VISUAL ACUITY a. Without glasses and with glassesa. Without glasses and with glasses b. Near and distant visionb. Near and distant vision c. Amblyopia testingc. Amblyopia testing

4.MOTOR:4.MOTOR: a. Extra ocular movements.a. Extra ocular movements. b. Phorias or tropiasb. Phorias or tropias c. Near point of convergence and near point of accommodation.c. Near point of convergence and near point of accommodation.

Page 16: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

5. MEASUREMENT OF DEVIATION.5. MEASUREMENT OF DEVIATION.

Distance and nearDistance and near

Without glasses and with glasses( if worn)Without glasses and with glasses( if worn)

6. SENSORY TESTS6. SENSORY TESTS

Worth 4 dot test.Worth 4 dot test.

StereopsisStereopsis

7. FIXATION: monocular , alternating, binocular7. FIXATION: monocular , alternating, binocular

8. SLIT LAMP EXAMINATION.8. SLIT LAMP EXAMINATION.

Page 17: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

9 . FUNDUS EXAMINATION.9 . FUNDUS EXAMINATION.

10 . CYCLOPLEGIC REFRACTION.10 . CYCLOPLEGIC REFRACTION.

Page 18: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

VISION TESTSVISION TESTS

In infants:In infants:

- fixation and following - fixation and following lightlight

- Catford drum test- Catford drum test

- preferential looking - preferential looking testtest

- Cardiff acuity test- Cardiff acuity test

- VER- VER

- reflex responses - reflex responses

Page 19: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

In 1 to 2 yr old:In 1 to 2 yr old:

- Boeck candy test- Boeck candy test

- Worth’s ivory ball test- Worth’s ivory ball test In 2 to 3 yr old:In 2 to 3 yr old:

- coin test - coin test

- miniature toys test- miniature toys test

- dot visual acquity test- dot visual acquity test

Page 20: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

In 3 to 5 yr old:In 3 to 5 yr old:

- tumbling E test- tumbling E test

- Landolt’s C test- Landolt’s C test

- Sheridan letter test - Sheridan letter test

Page 21: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

SENSORY TESTSSENSORY TESTS

Worth’s 4 dot testWorth’s 4 dot test Bielchowsky’s after Bielchowsky’s after

image testimage test Striated glasses of Striated glasses of

BagoliniBagolini 4 diopter prism base out 4 diopter prism base out

testtest SynaptophoreSynaptophore

Page 22: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

STEREOPSIS TESTSSTEREOPSIS TESTS

Titmus stereo testTitmus stereo test Random dot stereogram testRandom dot stereogram test Random dot e testRandom dot e test TNO testTNO test Lang testLang test Frisby testFrisby test 2 pencil test2 pencil test

Page 23: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

Titmus fly testTitmus fly test

Page 24: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

TNO testTNO test

Page 25: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

Lang testLang test

Page 26: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

HEAD POSTUREHEAD POSTURE

Incomitant squint Position of head in which

the eyes are in a position of no deviation or very small deviation so that fusion is possible.

3 components:

-Chin

-Face turn

-Head tilt

Page 27: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

TESTS TO MEASURE TESTS TO MEASURE DEVIATION ANGLEDEVIATION ANGLE

Hirschberg corneal Hirschberg corneal reflex testreflex test

Krimsky’s testKrimsky’s test Cover test Cover test Alternate cover uncover Alternate cover uncover

testtest Prism bar cover testPrism bar cover test Maddox wing testMaddox wing test Maddox rod testMaddox rod test

Page 28: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

MOTILITY TESTSMOTILITY TESTS

Ocular movementsOcular movements

- versions- versions

- ductions- ductions Near point of convergence- RAF ruleNear point of convergence- RAF rule Near point of accomodation- RAF ruleNear point of accomodation- RAF rule Fusional amplitudes- with prism bar or Fusional amplitudes- with prism bar or

synaptophoresynaptophore

Page 29: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

DIPLOPIA TESTSDIPLOPIA TESTS

Hess test Hess test Lees screenLees screen

Page 30: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

AMBLYOPIAAMBLYOPIA Unilateral or bilateral DOV Unilateral or bilateral DOV

due to form deprivation due to form deprivation &/or abnormal binocular &/or abnormal binocular interaction for which there interaction for which there is no ocular or visual is no ocular or visual pathway pathologypathway pathology

Most commonly due to Most commonly due to squint, large uncorrected squint, large uncorrected refractive errors etc.refractive errors etc.

Treatment: Treatment: - occlusion- occlusion - penalisation- penalisation

Page 31: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

MANAGEMENTMANAGEMENT

Refractive error Refractive error correction by spectacle correction by spectacle lenses, prisms, orthoptic lenses, prisms, orthoptic exercises. exercises.

Patching, reducing the Patching, reducing the VA or occluding the VA or occluding the good eye so as to good eye so as to activate the deviated activate the deviated eye. This is only done in eye. This is only done in children with unilateral children with unilateral deviation. deviation.

Page 32: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

Medical :Medical :

- miotics in - miotics in accomodative esotropiaaccomodative esotropia

- cycloplegics in - cycloplegics in accomodative esotropiaaccomodative esotropia

- levodopa, carbidopa in - levodopa, carbidopa in amblyopiaamblyopia

- botulinum toxin A - botulinum toxin A (botox) (botox)

Page 33: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

Surgery:Surgery:

- weakening procedures eg. - weakening procedures eg. recession, marginal recession, marginal myotomy, myectomy.myotomy, myectomy.

- strengthening procedures - strengthening procedures eg. resection, tucking, eg. resection, tucking, advancement.advancement.

Page 34: SQUINT - Dr. Ajay Dudani, Mumbai Retina Centre. DEFINITION Squint is a disorder in which one eye misaligns with the other when focusing in a primary direction

THANK YOUTHANK YOU