Strabismus & Amblyopia

Dr. Pandji A. Akbar, SpM(K)

Dept. of Ophthalmology
Faculty of Medicine UNPAD
 Strabismus
 Definition :
• Ocular misalignment, whether due to
abnormalities in binocular vision or
anomalies of neuromuscular control of
ocular motility
 When the eyes become dissociated
(not aligned)  Strabismus
 The Advantages of Binocular Vision :
• Better visual acuity
 Exp. : - One eye  0,8 -- Both eyes  1,0
- One eye  1,0 -- Both eyes  1,2
• Wider field of view
• Stereoscopic vision
 Normal condition of muscle balance
 Orthophoria  producing single
binocular vision
 Extra Ocular Muscles
A TEAM OF SIX MUSCLES CONTROLS THE MOVE-
MENT OF EACH EYE and BALANCING THE EYE
 THE RECTUS MUSCLE

- THE MEDIAL RECTUS  adduction

- THE LATERAL RECTUS  abduction
- THE SUPERIOR RECTUS  supraduction
- THE INFERIOR RECTUS  infraduction
 THE OBLIQUE MUSCLE

- THE SUPERIOR OBLIQUE  intorsion

- THE INFERIOR OBLIQUE  extorsion
 Single Binocular Vision
 Is a condition when retinal images
from two eyes integrating into a
single three-dimensional visual
perception
 Prerequisites for binocular vision :

• Visual acuity of the two eyes after

corrected are the same or slightly
different and anisokonia not present
• Good coordination of eye muscles on the
both eyes  same direction of viewing
• Fusion capabilities of the brain
 Nomenclature of Strabismus
 Prefixes :
• Eso- : rotated nasally
• Exo- : rotated temporally
• Hypo- : rotated inferiorly
• Hyper- : rotated superiorly
• Incyclo-: torted nasally
• Exyclo- : torted temporally
 Nomenclature (Cont.)
 Suffixes :
• -phoria : A latent deviation that is controlled
by the fusional mechanism so that under
normal binocular vision of the eyes remain
aligned
 Exp : Exophoria, Esophoria, etc
• -tropia : A manifest deviation that exceeds the
control of the fusional mechanism so that the
eyes are not aligned
 Exp. : Hypotropia, Esotropia, etc
 Classification of Strabismus
 According to fixation :
• Alternating : Spontaneous alternation of
fixation from one eye to the other
• Monocular : Definite preference for
fixation with one eye
 According to age of onset :
• Congenital  prior of 6 months of age
• Acquired  after 6 months of age
 Classification (Cont.)
 According to the type of deviation :
• Horizontal : Esodeviation or
Exodeviation
• Vertical : Hyperdeviation or
hypodeviation
• Torsional : Incyclodeviation or
excyclodeviation
• Combined : Horizontal, vertical, and/or
torsional
 Classification (Cont.)
 According to variation of the
deviation with fixating eye :
• Comitant (concomitant) :does not vary
with eye direction
• Incomitant : varies with eye direction
 Etiology of Strabismus
 Heterophoria :
• Muscle weakness :
 Congenital
 Acquired

• Muscle spasm
• Refraction anomalies
• Anomalies of anatomy of the eye muscle
 Etiology of Strabismus (Cont.)
 Heterotropia :
• Congenital :
 Eye muscle or neural anomalies
• Disturbances of accommodation
• Infection
• Trauma
• Head/brain neoplasm
• Specific eye disease that attack macula
 toxoplasmosis
 Clinical Symptom
 Subjective :
• Heterophoria :
 Blurred vision, especially when tired
 Headache after reading

• Heterotopia :
 Diplopia
 Eye ball’s range of movement  limited

 Changing the position of the head

 Assessment of Strabismus
 Patient’s eye ball appearance
(simplest methods)
 Corneal light reflex test :

• Hirschberg test
• Modified Krimsky’s method test
 Assessment (Cont.)
 Cover tests
• Cover-uncover test
• Alternate cover test
 Therapy of Strabismus
 Main goal of therapy  Single
binocular vision
 Other goal  cosmetic reason

 Treatment :

• Congenital  strabismus surgery as

soon as possible
• Refraction disturbances  correction
• Orthopic exercises
• Surgery
 Complication
 Amblyopia
 Cosmetic
 Head posture
disturbances
 Amblyopia
 Definition :
• Unilateral or bilateral reduction of visual
acuity (with best refractive correction)
that cannot be attributed directly to the
effect of any structural abnormality of
the eye or the posterior visual pathway
 Caused by abnormal visual
experience early in life
 Developmental Period of The Eye
 Period of development :
• Intra uterine development
• Period I : 0 – 6 months  critical
• Period II : 6 months – 2 years
• Period III : 2 years – 5 years
• Period IV : 5 years – 9 years
• Period V : 9 years – 12 years
 Good development  Macula lutea have
to well trained by rays that straight
focused onto macula, before 6 years old
 Types of Amblyopia
 Strabismic amblyopia
• Most common form
 Anisometropic amblyopia
 Isoametropic amblyopia

 Deprivation Amblyopia (amblyopia ex

anopsia)
 Severity of Amblyopia
 Mild Amblyopia :
• Visual acuity : 0,6 or better
 Moderate Amblyopia :
• Visual acuity : 0,2 – 0,6
 Severe Amblyopia
• Visual acuity : 0,1 – 0,2
 Therapy of Amblyopia
 Goal of therapy :
• Normal visual acuity of both eye
• Perfect eye ball position of both of eye
• Streoscopic eye
 Prognosis of the therapy is depend
on :
• Age onset of Amblyopia
• When the treatment begin
• Severity of amblyop
• Fixation type
• Patient’s compliance
 Therapy (Cont.)
 Principal of therapy  train the
amblyopic eyes with :
• Occlude fellow eyes (the health eyes)
• Cyclopegic on fellow eye (Penalization)
• CAM stimulator (still controversial)
 Recurrence  50%