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Strabismus For Medical Students & GP - PowerPoint PPT Presentation

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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

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Strabismus For Medical Students & GP

Samir Jamal




  • 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.

Anatomy & Physiology

Anatomy & Physiology

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

Non-Accommodative Esotropia

Non-Accommodative Esotropia

Alternating Esotropia


Alternating Esotropia

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)

Abnormal Head Posture

Role of GP

  • Confirm Diagnosis

  • Decide on urgency

  • Teach patients

  • Referral to Ophthalmologist

Management of Strabismus


4 most important questions:

  • Age of onset

  • Constant or intermittent

  • Unilateral or alternating

  • Diplopia or torticollis

Management of Strabismus


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.


  • 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

Partially Accommodative Squint

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

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