SQUINT

SQUINT
• Cover test
• - Appreciation of stereopsis
• - Ability to overcome a base out prism and on its
removal to take up bifoveal fixation again.
• - VA measurement
• - Demonstration of BSV subjectively
• -Cycloplegic refraction
• -Indirect ophrhalmoscopy
• - Facial asymmetry → poendosquint of any variety
• - Psendoconvergence
a. Epicanthus - commonest cause
b.ve angle alpha, gamma, or Kappa
c. narrowIPD and enophthalmos.
- Psendodivergence :
a. Exophthalmos
b. Wide IPD
c. Enlarged tre angle alpha
 ManifestSquint
• Majority of squints are horizontal with high proportion as
having bot horizontal and vertical elements.
• CLASSIFICATION:-
• - Age at onset , congenital, infantile or acquired
• - Intermitlency : Esophoria – Esotropia
• - Relationship to accommodation: Accommod. -
Nonaccommod.
• - Comparisonof up and down gaze -A, V patterns.
• - Distance - Near - relationship.
• - Size of the deviation
 :ETIOLOGICAL FACTORS
1. Hereditary
2. Hypermetropiaaverage+ 4.75 D
3. High AC/A ratio
4. Combination of hypermetropia and high AC/A ratio
- SENSORY TESTING :
• 1. Bagolini glasses
• 2. Synoptophore
-target of 3 sizes: paramacular, macular and foreial. to test grade I,II or III
fusion.
- objective angle
- subjective angle
- angle of anomaly
3. Worth four dot rest 1R, 1W, 2G
4. After image test
 TECHNIQUESOF EVALUATION
- History
-VA testing
The target must beproper for the child's age & ability.
- Complete eye examination
- Cycloplegic refraction
* Fundus examination
* Fixation
- Measurementof the deviation
- Proper spectacles should be worn
- Measurementin the primary position at both distance and near.
- Cover test :
* Monoacular cover -uncover test. to determine if the deviation is a phoria or a tropia
* Altrnate cover testing: to uncover the entire deviation
* Prism cover test: to measure the deviation
* A or V pattern
• AC/ A ration.
AC/A = PD in cm + ( Delta n – Delta o)
D
AC/A = ( Delta i – Delta o )
D
 CONGENITAL ESOTROPIA
Esotropia of early onset - prior to 6 months of age.
INFANTILEESOTROPIA
Esotropia prior to 1 year of age.
CHARACTERISTICS :
- The etiology thought to be due to an imbalance between
tonic convergence and tonic divergence.
- Present atbirth or of early onset
- Large deviation: 50° or more.
- The visual acuity in each eye
- Cross-fixation (weakness of abduction, or pseudopalsy of LiR) when
VIA is good in each eye.
- HereditaryNormal Ac/A ratio
-Nonaccommodative deviation.
- Insignificantrefractive error.
-Abscence of Bsv- Altrernative suppresion
• TREATMENT:
-Treat amblyopia.
- Surgery
 :SENSORY ADJUSTMENTS
• can be made in the child who is still visually immature
• - Visual confusion i.e. each fovea being directed at a different
object in space is eliminated by suppresion of the deviating
fovea→ amblyopia.
• - Diplopia i.e. The same object in space is seen twice
is eliminated by suppression of the peripheral retinal
area of the deviating eye.
- ARC when visual axes are no longer aligned, new
directional values are assumed by disparate retinal
area thus providing binocularity in the presence of
manifest deviation.
 MOTOR ADJUSTMENTS
• Development of nonaccommodative
esotropia especially with high AC/ A ratio.
 ACQUIRED ESOTROPIA
Manifest Squint
Concomitant squint
Constant Squints :
- Constant convergent Squint :
* C.S. with an accommodative element,
partially accommodative, unilat., amblyopia , fusion power
deterioration, ARC.
* C.S without an accommodative element : unilat. or alternating
with divergence weakness.
- Constant divergent squint:
IntermiNant squints:
- Intermi Hant Convergent Squint
* Fully accommodative convergent squint: amblyopia is mild, fusion is usually strong
* Accommodative c .s .
- with convergence excess:
BSV for distance
manifest c. s. = near
moderate amblyopia , reduced fusional reserve.
_
- IntermiHant divergent squint
- IntermiHant divergent squint with divergent
excess.
- IntermiHant divergent squint with
convergent weakness
A and V patterns in horizontal deviation
• - Basically 4 patterns
• - 20 %of all strabismic patients exhibit a significant A or V pattern.
• - Etiology: Anatomical, mechanical and neurogenic factors.
-? Dysfunction of the M.R and L.R.
-? Dysfunction of the vertical recti
-? Dysfunction of the of the oblique muscles.
- Diagnostic criteria
- V esodeviation - should have 15“
- A esodeviation - should have 10°
- Incidence : Veso, Aeso, Vexo, A exo
- A and V deviations are present at an early age
- Strabismus amblyopia is rare.
-Refractive errors are usually not significant
- AHP is over 10 %,
e.g. -A eso :Recess + up displacement of MR
: S.R. transplanted temporally
: IR . transplanted temporally