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Strabismus Prof.Dr. Emel Başar İ.Ü. Cerrahpaşa Tıp Fakültesi, Göz Hastalıkları Anabilim Dalı.

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Presentation on theme: "Strabismus Prof.Dr. Emel Başar İ.Ü. Cerrahpaşa Tıp Fakültesi, Göz Hastalıkları Anabilim Dalı."— Presentation transcript:

1 Strabismus Prof.Dr. Emel Başar İ.Ü. Cerrahpaşa Tıp Fakültesi, Göz Hastalıkları Anabilim Dalı

2 SYNONYMS Squint Squint Cross-eyed Cross-eyed Wall-eyed Wall-eyed

3 DESCRIPTION Misalignment of the eyes, such that both eyes are not simultaneously directed at the same object Misalignment of the eyes, such that both eyes are not simultaneously directed at the same object Esotropia is a common type of strabismus characterized by inward deviation of one eye relative to the other Esotropia is a common type of strabismus characterized by inward deviation of one eye relative to the other Infantile esotropia is inward deviation of the eyes noted before the patient reaches age 6 months Infantile esotropia is inward deviation of the eyes noted before the patient reaches age 6 months Exotropia is a common type of strabismus characterized by outward deviation of one eye Exotropia is a common type of strabismus characterized by outward deviation of one eye relative to the other relative to the other

4 CONCOMITANT STRABISMUS

5 EPIDEMIOLOGY Incidence and prevalence PREVALENCE One of the most prevalent ocular problems among children, affecting 50 in every 1000 US citizens, or some 12 million people in a population of 245 million One of the most prevalent ocular problems among children, affecting 50 in every 1000 US citizens, or some 12 million people in a population of 245 million Estimated prevalence of strabismus in the general population is 20-60/1000 Estimated prevalence of strabismus in the general population is 20-60/1000 Of this, infantile esotropia is believed to affect about 1 % of full-term, healthy newborns and a much higher percentage of newborns with perinatal complications due to prematurity or hypoxic/ischemic encephalopathy Of this, infantile esotropia is believed to affect about 1 % of full-term, healthy newborns and a much higher percentage of newborns with perinatal complications due to prematurity or hypoxic/ischemic encephalopathy

6 EPIDEMIOLOGY DemographicsAGE Usually presents in patients aged 2-3 years Usually presents in patients aged 2-3 years By definition, infantile esotropia is seen in infants before age 6 months By definition, infantile esotropia is seen in infants before age 6 monthsGENDER No gender predilection exists. No gender predilection exists.RACE No racial predilection exists. No racial predilection exists.GENETICS It is strongly believed that a genetic component exists, but a solid basis for linkages among family members is still to be established It is strongly believed that a genetic component exists, but a solid basis for linkages among family members is still to be established Around 20-30% of children born to a strabismic parent will eventually develop strabismus Around 20-30% of children born to a strabismic parent will eventually develop strabismus

7 CAUSES OF STRABISMUS Common causes Exact cause of infantile esotropia remains unknown Exact cause of infantile esotropia remains unknown Results from paralysis of one or more ocular muscles; may be caused by a specific oculomotor nerve lesion (Paralytic Strabismus) Results from paralysis of one or more ocular muscles; may be caused by a specific oculomotor nerve lesion (Paralytic Strabismus) Disuse of an eye, as in cases of severe refractive error or impaired vision due to disease, may also result in strabismus Disuse of an eye, as in cases of severe refractive error or impaired vision due to disease, may also result in strabismus Ambiyopia or lazy eye (reduced visual acuity caused by an abnormal visual experience early in life) may occur in strabismus, usually due to cortical suppression of the image in the deviating eye to avoid confusion and diplopia Ambiyopia or lazy eye (reduced visual acuity caused by an abnormal visual experience early in life) may occur in strabismus, usually due to cortical suppression of the image in the deviating eye to avoid confusion and diplopia

8 CAUSES OF STRABISMUS Rare causes Patients with craniofaciai syndromes, ocular albinism, midline defects, and cerebral palsy may present with congenital exotropia. Patients with craniofaciai syndromes, ocular albinism, midline defects, and cerebral palsy may present with congenital exotropia.

9 CAUSES OF STRABISMUS Serious causes A specific oculomotor nerve lesion may cause paralysis of one or more ocular muscles A specific oculomotor nerve lesion may cause paralysis of one or more ocular muscles In children, such a nerve lesion may be caused by cerebral palsy, Down syndrome,hydrocephalus, or brain tumors In children, such a nerve lesion may be caused by cerebral palsy, Down syndrome,hydrocephalus, or brain tumors In adults, nerve lesion may be caused by stroke, diabetes, cardiovascular disease, tumors, or trauma In adults, nerve lesion may be caused by stroke, diabetes, cardiovascular disease, tumors, or trauma If there is a cranial nerve lesion the strabismus it is paralytic If there is a cranial nerve lesion the strabismus it is paralytic

10 CAUSES OF STRABISMUS Contributory or predisposing factors Infantile esotropia: perinatal complications (e.g. prematurity, birth injury, low birthweight). Infantile esotropia: perinatal complications (e.g. prematurity, birth injury, low birthweight).

11 CARDINAL FEATURES General Deviation may be constant, or it may come and go Deviation may be constant, or it may come and go May be present at birth, become apparent at a later age, or occur following an illness or accident May be present at birth, become apparent at a later age, or occur following an illness or accident Horizontal deviations can be divided into two broad categories - esotropias and exotropias. Esotropia designates a convergent horizontal strabismus (one eye turns in) and exotropia designates a divergent horizontal strabismus (one eye turns out) Horizontal deviations can be divided into two broad categories - esotropias and exotropias. Esotropia designates a convergent horizontal strabismus (one eye turns in) and exotropia designates a divergent horizontal strabismus (one eye turns out) If angle of deviation remains same for all gaze directions this a CONCOMITANT STRABISMUS If angle of deviation remains same for all gaze directions this a CONCOMITANT STRABISMUS

12 CARDINAL FEATURES General Misalignment of the visual axes of the two eyes may interfere with patient's ability to fuse and to develop normal binocular vision, this may cause suppression in one eye (amblyopia or lazy eye) in children and diplopia (double vision) in teenagers and adults Misalignment of the visual axes of the two eyes may interfere with patient's ability to fuse and to develop normal binocular vision, this may cause suppression in one eye (amblyopia or lazy eye) in children and diplopia (double vision) in teenagers and adults Abnormal vertical head postures, e.g. head turning, may develop to place the eyes in position of minimal deviation to restore single binocular vision Abnormal vertical head postures, e.g. head turning, may develop to place the eyes in position of minimal deviation to restore single binocular vision

13 CARDINAL FEATURES Esotropia Accommodative esotropia (refractive accommodative esotropia) - an esodeviation due to normal accommodation in uncorrected hyperopia (far- sightedness) Accommodative esotropia (refractive accommodative esotropia) - an esodeviation due to normal accommodation in uncorrected hyperopia (far- sightedness) Uncorrected hyperope must exert accommodation to clear a blurred retinal image. Process of accommodation will stimulate convergence and strain fusional divergence. When fusional divergence is overcome, the eyes cross Uncorrected hyperope must exert accommodation to clear a blurred retinal image. Process of accommodation will stimulate convergence and strain fusional divergence. When fusional divergence is overcome, the eyes cross

14 CARDINAL FEATURES Esotropia Patient with uncorrected hyperopia can see either a single blurred image or a double image in which one image is clear and one is blurred Patient with uncorrected hyperopia can see either a single blurred image or a double image in which one image is clear and one is blurred Over time, the blurred image can be suppressed, fixation can alternate, or, more commonly, amblyopia (lazy eye) can occur Over time, the blurred image can be suppressed, fixation can alternate, or, more commonly, amblyopia (lazy eye) can occur

15 CARDINAL FEATURES Infantile esotropia Inward deviation of the eyes noted before the patient reaches age 6 months Inward deviation of the eyes noted before the patient reaches age 6 months Infantile esotropia is not believed to be connatal, but develops in the first few weeks or months after birth Infantile esotropia is not believed to be connatal, but develops in the first few weeks or months after birth Children who undergo surgical alignment at age 6 months have a higher prevalence of coarse stereopsis than those who are corrected surgically at age 7-15 months Children who undergo surgical alignment at age 6 months have a higher prevalence of coarse stereopsis than those who are corrected surgically at age 7-15 months

16 CARDINAL FEATURES Infantile esotropia Amblyopia is relatively common in patients with infantile esotropia Amblyopia should be suspected strongly in patients with esotropia and asymmetric inferior oblique activity, specifically in the eye with more inferior oblique overaction Amblyopia is relatively common in patients with infantile esotropia Amblyopia should be suspected strongly in patients with esotropia and asymmetric inferior oblique activity, specifically in the eye with more inferior oblique overaction Virtually all patients with infantile esotropia fail to develop normal binocular vision and stereopsis Virtually all patients with infantile esotropia fail to develop normal binocular vision and stereopsis

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18 CARDINAL FEATURES Exotropia As many as 60% of patients who have exotropia may develop oblique muscle dysfunction, dissociated vertical deviation, and amblyopia As many as 60% of patients who have exotropia may develop oblique muscle dysfunction, dissociated vertical deviation, and amblyopia Nystagmus is rare Nystagmus is rare

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20 CARDINAL FEATURES Adult strabismus When strabismus occurs in an adult for the first time, it leads to double vision, or diplopia When strabismus occurs in an adult for the first time, it leads to double vision, or diplopia Secondary to the inability of a person to use both eyes together (binocular vision) or other unknown causes Secondary to the inability of a person to use both eyes together (binocular vision) or other unknown causes Most often, the poor-seeing eyes drift outward Most often, the poor-seeing eyes drift outward

21 DIFFERENTIAL DIAGNOSIS Oculomotor nerve palsy Extraocuiar muscle paralysis resulting from destructive lesions in one or all of the cranial nerves results in failure of one or both eyes to rotate in concert with the other eye. Extraocuiar muscle paralysis resulting from destructive lesions in one or all of the cranial nerves results in failure of one or both eyes to rotate in concert with the other eye.

22 DIFFERENTIAL DIAGNOSIS Oculomotor nerve palsy FEATURES Diplopia from misalignment of visual axes Diplopia from misalignment of visual axes With unilateral third cranial nerve palsy, the involved eye usually is deviated down and out (infraducted, abducted), and ptosis may be present, which may be severe enough to cover the pupil With unilateral third cranial nerve palsy, the involved eye usually is deviated down and out (infraducted, abducted), and ptosis may be present, which may be severe enough to cover the pupil Pupillary dilatation can cause symptomatic glare in bright light (if ptotic lid does not cover the pupil) Pupillary dilatation can cause symptomatic glare in bright light (if ptotic lid does not cover the pupil) Paralysis of accommodation causes blurred vision for near objects Paralysis of accommodation causes blurred vision for near objects Glare sensation and photoaversion in bright light Glare sensation and photoaversion in bright light

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24 DIFFERENTIAL DIAGNOSIS Abducens nerve palsy Cranial (abducens) nerve VI defect. Ipsilateral lateral rectus, which is solely innervated by the involved peripheral sixth cranial nerve, is affected. Cranial (abducens) nerve VI defect. Ipsilateral lateral rectus, which is solely innervated by the involved peripheral sixth cranial nerve, is affected.

25 DIFFERENTIAL DIAGNOSIS Abducens nerve palsy Abducens nerve palsyFEATURES Horizontal diplopia and an esotropia in primary gaze Horizontal diplopia and an esotropia in primary gaze Deviation greater when the patient fixates with the paretic eye Deviation greater when the patient fixates with the paretic eye Head-turn to maintain binocularity and binocular fusion, and to minimize diplopia Head-turn to maintain binocularity and binocular fusion, and to minimize diplopia

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27 DIFFERENTIAL DIAGNOSIS Duane syndrome Congenital ocular motiiity disorder characterized by limited abduction and/or limited adduction. Congenital ocular motiiity disorder characterized by limited abduction and/or limited adduction.

28 DIFFERENTIAL DIAGNOSIS Duane syndrome Duane syndromeFEATURES Upward or downward deviation may occur with attempted adduction due to a leash effect Upward or downward deviation may occur with attempted adduction due to a leash effect Face-turn with strabismus in primary position Face-turn with strabismus in primary position Upshoot or downshoot during adduction Upshoot or downshoot during adduction Vertical deviation in primary position Vertical deviation in primary position Retraction during adduction Retraction during adduction Enophthalmos Enophthalmos

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30 MANAGEMENT ISSUES Goals Preserve vision Preserve vision Straighten the eyes Straighten the eyes Restore binocular (two-eyed) vision Restore binocular (two-eyed) vision Prevent amblyopia Prevent amblyopia Prevent diplopia in adults Prevent diplopia in adults Obtain normal visual acuity in each eye Obtain normal visual acuity in each eye Obtain and/or improve fusion Obtain and/or improve fusion

31 MANAGEMENT ISSUES Goals Obtain favorable functional appearance of alignment of eyes Obtain favorable functional appearance of alignment of eyes The best optical correction that allows a clear retinal image to be formed in each eye is generally the starting point for all treatments The best optical correction that allows a clear retinal image to be formed in each eye is generally the starting point for all treatments

32 SUMMARY OF THERAPEUTIC OPTIONS Choices First choice is corrective lenses and prisms. The eye caregiver will determine whether or not a trial of spectacles can treat the strabismus First choice is corrective lenses and prisms. The eye caregiver will determine whether or not a trial of spectacles can treat the strabismus Second choice is patching. In cases of amblyopia, early treatment with patching the normal eye is the mainstay of treatment, often associated with use of spectacles Second choice is patching. In cases of amblyopia, early treatment with patching the normal eye is the mainstay of treatment, often associated with use of spectacles Third choice is surgery. The eye caregiver may determine that surgery is needed to correct the strabismus Third choice is surgery. The eye caregiver may determine that surgery is needed to correct the strabismus

33 SUMMARY OF THERAPEUTIC OPTIONS Choices Fourth choice is botulinum toxin. Chemodenervation using botulinum toxin as an alternative to conventional incisional surgery is used in selected strabismic patients (those with small-to-moderate degrees of horizontal ocular misalignment, postoperative residual strabismus, acute paralytic strabismus) Fourth choice is botulinum toxin. Chemodenervation using botulinum toxin as an alternative to conventional incisional surgery is used in selected strabismic patients (those with small-to-moderate degrees of horizontal ocular misalignment, postoperative residual strabismus, acute paralytic strabismus) Fifth choice is anticholinesterase miotics. These can serve as temporary alternatives to corrective glasses and bifocal lenses for children with accommodative esotropia Fifth choice is anticholinesterase miotics. These can serve as temporary alternatives to corrective glasses and bifocal lenses for children with accommodative esotropia

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