STRABISMUS

CLINICAL OPHTHALMOLOGY • MEDICAL STUDENT REFERENCE

Learning Objectives — The Student Should Be Able To:

1. Recognize the signs and symptoms of amblyopia and strabismus.

2. Perform the necessary tests to screen for these conditions.
3. Understand the basis of treatment of different types of strabismus.

1. ANATOMY OF EXTRAOCULAR MUSCLES

A team of six extraocular muscles (EOMs) controls the movements of each eye.

Origin
• 4 Recti Muscles: From the corresponding areas of the annulus of Zinn (tendinous ring) at the apex of the
orbit around the optic foramen and medial part of the superior orbital fissure (SOF).
• 2 Oblique Muscles:
◦ Superior Oblique Muscle: At the apex of the orbit, above and medial to the annulus of Zinn. (Trochlea
→ physiological origin).
◦ Inferior Oblique Muscle: Shallow depression in the floor of the orbit lateral to the opening of the
nasolacrimal duct.

Insertion
The six extraocular muscles are inserted into the sclera:

• 4 Recti: Inserted in the sclera anterior to the equator of the eyeball (by a flat tendon ~10 mm in breadth)
at a variable distance from the limbus:

MR IR LR SR

5.5 mm 6.5 mm 6.9 mm 7.7 mm

• Oblique Muscles: Inserted in the sclera behind the equator of the eyeball:
◦ Superior Oblique: In the upper postero-lateral part of the sclera.
◦ Inferior Oblique: In the lower postero-lateral part of the sclera (5 mm from the optic nerve, almost over
the macula).

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Nerve Supply
• Oculomotor (3rd) Nerve:
◦ Superior Division: SR
◦ Inferior Division: MR, IR, and IO

• Trochlear (4th) Nerve: SO

• Abducent (6th) Nerve: LR

NB — 3rd Nerve Supplies:

• EOMs: SR, MR, IR and IO (i.e., all except SO and LR).

• IOMs: Sphincter pupillae and ciliary muscle (i.e., all except dilator papillae).

Actions of Extraocular Muscles

Muscle Primary Action Subsidiary Actions

MR Adduction —

LR Abduction —

SR Elevation Adduction, Intorsion

IR Depression Adduction, Extorsion

SO Intorsion Depression, Abduction

IO Extorsion Elevation, Abduction

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 Key Points on Muscle Actions (Prof. Notes):

• SR is the ONLY elevator in abduction.

• IR is the ONLY depressor in abduction.
• IO is the ONLY elevator in adduction.
• SO is the ONLY depressor in adduction.
• Muscles attached at the 12 o’clock position → Intorsion.
• Muscles attached at the 6 o’clock position → Extorsion.
• Main action becomes the ONLY action when the visual axis coincides with the muscle axis.
• Main action becomes ZERO when the visual axis is perpendicular to the muscle axis.
• In the primary position, all 6 muscles work in balance.
• Nine directions of gaze = 6 cardinal directions + primary position + 2 others (Horizontal & Vertical).
• Reading position → SO active in each eye.
• Laws governing muscle action:
◦ Law of Equal Innervation (Hering's Law): Both eyes receive equal innervation so they move
together.
◦ Law of Reciprocal Innervation (Sherrington's Law): Antagonistic muscles receive opposing signals
(when a muscle contracts, its antagonist relaxes).

Ocular Movements
Each eye rotates on a fixed point (centre of rotation, near the equator). Movement is named by the direction
of the anterior part of the eye:

Axis of Rotation Direction Movement

Horizontal axis Up / Down Elevation / Depression

Vertical axis In / Out Adduction / Abduction

Anteroposterior axis 12 o’clock → nasal Intorsion (involuntary)

Anteroposterior axis 12 o’clock → temporal Extorsion (involuntary)

Note: Intorsion & Extorsion are involuntary movements — they prevent image tilting when the head tilts.

2. BINOCULAR VISION

Coordinated use of both eyes to produce a single visual mental impression.

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Development
• At 6 months: Maintained binocular fixation (fovea is fully developed).
• At 6 years: Binocular vision with fusion is fully developed. Training of fusion is usually NOT successful
after 6 years of age.

Importance
• Stereopsis (depth perception).
• Binocular visual field is larger than the uniocular field alone.
• Optical defects and field defects (e.g., scotoma) in one eye are masked by the other overlapping field.

Grades of Binocular Vision

Grade Name Description & Example

Ability to see two dissimilar objects presented simultaneously to

I Simultaneous Perception each eye. (e.g., Bird seen by one eye, Cage seen by the other
eye → Bird inside Cage).

Ability to superimpose 2 incomplete but similar objects to form

II Fusion one complete picture. (e.g., Rabbit with no tail + Rabbit with no
ears → one complete Rabbit with ears and tail).

Ability to appreciate depth (3D) by superimposition of two slightly

III Stereoscopic Vision dissimilar objects. (e.g., 2 Buckets with slightly dissimilar features
→ perceived as 3D).

• Tested with a Synoptophore (2 tubes that can be moved separately).

• Without binocular vision → no stereoscopic (3D) vision.

3. STRABISMUS (SQUINT) — DEFINITION & CLASSIFICATION

• Definition: Misalignment of both visual axes.

• The visual axis: Line from object → through nodal point (at posterior pole of lens) → to fovea.
• No squint: Both visual axes meet the object simultaneously, image falls on the fovea of each eye.
• Squint: The deviated eye’s image does NOT fall on its fovea.

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Classification

Squint Classification Tree

Latent Heterophoria

Concomitant: Unilateral / Alternating (Non-paralytic,

True Squint full movement)
Manifest (Heterotropia)
Inconcomitant: Restrictive / Paralytic (Limitation of
movement)

False / Pseudo-squint (Visual axes straight, but

Apparent Squint
appearance looks misaligned)

4. APPARENT SQUINT (False / Pseudo-Squint)

Definition: Apparent lack of parallelism between two visual axes with normal parallel visual axes. No
recovery movement on cover test; corneal reflex is in the centre of the cornea.

Causes of Apparent Squint

1. Anatomical
• Epicanthus fold (most common): Convergent appearance
• Ankyloblepharon: Divergent appearance
• Blepharophimosis: Convergent appearance

2. Optical — Abnormal Angle Alpha (α)

• Large (+) angle α (e.g., Hypermetropia): Apparent Divergent + True Convergent squint tendency.
• Small (-) angle α (e.g., Myopia): Apparent Convergent + True Divergent squint tendency.

Diagnosis — Tests (Normal in Apparent Squint)

• Hirschberg (Corneal Reflex) Test: Light reflex appears in the centre of the cornea in both eyes.
• Cover Test: No recovery movement (eye is already straight).
• Ocular Motility Test: Eye moves normally in all 6 cardinal directions.

5. LATENT SQUINT (Heterophoria)

Definition: Tendency of the visual axes to deviate when binocular vision is dissociated. This tendency is
held in check by the brain for the sake of binocular vision.

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Types

Type Tendency Direction

Esophoria Inward tendency

Exophoria Outward tendency

Hypophoria Downward tendency

Hyperphoria Upward tendency

Cyclophoria Wheel rotation tendency

Etiology

Physiological:
• Prolonged close work
• General fatigue
• Age: Esophoria in young, Exophoria in elderly

Errors of Refraction:
• Esophoria → Hyperopia
• Exophoria → Myopia
• Cyclophoria → Astigmatism

Prof. Notes Extra Causes:

• Weakness of one or more extraocular muscles (increased impulses to the weak muscle, decreased
impulses to its antagonist).

Clinical Picture

Symptoms:
Usually Asymptomatic due to compensation by binocular vision. When compensation strains or fails, the
following occur:

• When maintaining binocular vision becomes difficult: Diplopia, difficulty changing focus, photophobia.
• When binocular vision completely fails (Intermittent Squint): Diplopia, blurring of print, difficult reading,
nausea, and dizziness.

Signs & Diagnosis:

• Cover test: Latent eye shows deviation under the cover, then returns to normal position after cover
removal.
• Alternate cover test: Latent eye shows corrective movement.
• Maddox wing: Detects latent squint for near vision (33 cm).

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 • Maddox rod: Detects latent squint for far vision (6 m). Uses a cylindrical lens — one eye sees a line, the
other sees a spot of light. Esophoria → uncrossed diplopia; Exophoria → crossed diplopia.

Management of Latent Squint

1. Correction of errors of refraction.
2. Nutrition — Iron & vitamins.
3. Orthoptic treatment using a synoptophore.
4. Exerting prisms / Relieving prisms.
5. Surgical treatment (if conservative methods fail and symptoms are severe).

6. CONCOMITANT SQUINT (Manifest Non-Paralytic)

Definition: Manifest non-paralytic squint in which the eye moves without limitation and the angle of
deviation remains the same in all directions of gaze.

Causes
• Defective vision in one eye (Anisometropia): Anisometropia > 4.0 diopters → Diplopia → Amblyopia /
Suppression Squint.
• Abnormal relation between Accommodation & Convergence (Ametropia): As in severe Hyperopia &
Myopia.
• Central causes: Primary absence of binocular vision / fusion faculty.

Types
• According to eye: Unilateral or Alternating
• According to direction: Vertical or Horizontal (Esotropia / Exotropia)

Management
1. Treatment of the underlying cause.
2. Correct Accommodation / Convergence relation using Glasses, contact lenses, or drugs (Miotics /
Cycloplegics).
3. Surgery: Weakening (recession) or strengthening (resection) of muscles to restore alignment.

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7. PARALYTIC SQUINT (Inconcomitant)

Definition: Manifested squint in which there is limitation of eye movement due to paralysis of an
extraocular muscle. The angle of deviation is NOT constant (varies with the direction of gaze).

Lower Motor Neuron Lesion (LMNL).

Causes

Category Examples / Detail

1. Traumatic Head trauma, orbital fractures

2. Metabolic Diabetes Mellitus (diabetic mononeuropathy)

3. Vascular Embolism, microvascular ischemia, aneurysm

4. Myogenic Myopathy, ocular myositis

5. Neuromuscular Myasthenia Gravis

6. Neurogenic Nerve compression, intracranial pressure

7. Tumour Brain stem tumor, orbital tumor

Clinical Picture

Symptoms:
• Binocular diplopia:
◦ Homonymous (uncrossed): Associated with Esotropia (Inward deviation)
◦ Crossed: Associated with Exotropia (Outward deviation)

• Diplopia increases in the direction of action of the paralyzed muscle.

• Vertigo: Leading to nausea and vomiting.

Signs:
• Ocular deviation: Against the direction of action of the paralyzed muscle. Variable angle depending on
direction of gaze — angle increases in the direction of action of the paralyzed muscle.
• Limitation of movement: Toward the action of the affected muscle.
• Face turn & Head tilt: Compensatory head position (Ocular Torticollis) — occurs in the direction of action
of the paralyzed muscle to avoid diplopia.
• Secondary angle of deviation > Primary angle of deviation: Because the brain sends increased
impulses to the paralyzed muscle, which by Hering's Law are also sent to the contralateral synergetic
muscle, causing overaction.

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 • Past-pointing (False projection).

Patient compensates for diplopia by:

1. Covering one eye (occlusion)
2. Suppression (by the brain over time)
3. Compensatory head position (face turn / head tilt)

Diagnostic Tests for Paralytic Squint

• Ocular Deviation Test: Covers & reveals each eye; if the paralyzed eye is covered → no movement. If
the normal eye is covered → more impulses sent to the paralyzed muscle → severe secondary deviation
in the sound eye.
• Ocular Motility Test: Prominent limitation of movement in the direction of action of the paralyzed muscle.
• Diplopia Chart / Hess Screen Test: Maps fields of maximum separation to identify the paralyzed muscle
and false projection.

Treatment of Paralytic Squint

I. Pre-operative (Conservative):
1. Treatment of the primary cause (e.g., control of Diabetes Mellitus).
2. Alternate covering (occlusion) to avoid diplopia and Amblyopia.
3. Relieving prisms.

II. Operative (After 6 months of stability):

1. Weakening procedure (Recession of the overacting antagonist).
2. Strengthening procedure (Resection — cutting and advancing part of the paralyzed or weak muscle).
3. Muscle transplantation / transposition: Used in severe or complete muscle weakness (e.g., partial
transposition of SR/IR to LR in 6th nerve palsy).

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QUICK REVISION — Comparison of Squint Types

Feature Apparent Squint Concomitant Squint Paralytic Squint

True deviation None Yes Yes

Eye movement Full, normal Full, normal Limited

Angle of deviation N/A Constant Variable

Hirschberg test Normal (Central) Abnormal Abnormal

Cover test No recovery movement Recovery movement Recovery movement

Diplopia None None (suppressed) Yes (binocular)

Head tilt None None Present

2° angle vs 1° N/A Equal 2° > 1°

Nerve involved None None CN III, IV, or VI

Clinical Ophthalmology — Strabismus Reference • For Medical Students

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