Strabismus

Strabismus is a misalignment of the eyes, such that the visual axes of each eye are
not simultaneously directed at the object of regard. The misalignment may be present in
particular direction of gaze or in all directions of gaze. Strabismus implies an impairment
of binocular vision. The close interrelationship between sensory and motor system
development means that strabismus may arise from a disturbance of either sensory or
motor development, particularly in the younger patient where the visual functions are
more vulnerable.
Studies show that almost 5% of children are born with some degree of strabismus.
It is recommended that the condition must be diagnosed as early as possible and the
treatment should not be delayed. This is very important, as a delay in treatment may
eventually lead to vision loss.

Types of Strabismus

 Some types are characterized by inward

turning of the eye (esotropia) and some by outward
turning of the eye (exotropia).

 Others are characterized by upward turning

of the eye (hypertropia) or downward turning of the
eye (hypotropia).
Pathophysiology

Strabismus can be an indication that a cranial nerve has a lesion, particularly cranial
nerve III (oculomotor), IV (trochlear) or VI (abducens). A strabismus caused by a lesion
in either of these nerves results in the lack of innervation to eye muscles and results in a
change of eye position. A strabismus may be a sign of increased intracranial pressure, as
CN VI is particularly vulnerable to damage from brain swelling, as it runs between the
clivus and brain stem.

More commonly however, squints are termed concominant (i.e. non paralytic). This
means the squint is not caused by a lesion reducing innervation. The squint in this
example is caused by a refractive error in one or both eyes. This refractive error causes
poor vision in one eye and so stops the brain from being able to use both eyes together.

How is strabismus diagnosed?

During eye examinations, orthoptists, ophthalmologists and optometrists typically

use a cover test to aid in the diagnosis of strabismus. If the eye being tested is the
strabismic eye, then it will fixate on the object after the "straight" eye is covered, as long
as the vision in this eye is good enough. If the "straight" eye is being tested, there will be
no change in fixation, as it is already fixated. Depending on the direction that the
strabismic eye deviates, the direction of deviation may be assessed. Exotropic is outwards
(away from the midline) and esotropic is inwards (towards the nose); these are types of
horizontal strabismus. "Hypertropia" is upward, and "Hypotropia" is downward; these are
types of vertical strabismus, which are less common.

A simple screening test for strabismus is the Hirschberg test. A flashlight is shone in the
patient's eye. When the patient is looking at the light, a reflection can be seen on the front
surface of the pupil. If the eyes are properly aligned with one another, then the reflection
will be in the same spot of each eye. Therefore, if the reflection is not in the same place
in each eye, then the eyes aren't properly aligned.
Treatment of Strabismus

Glasses and Drugs

In mild cases of strabismus, wherein the eyes are misaligned slightly, glasses are
prescribed as treatment. Wearing such glasses and using special eye drops can correct the
condition. Some of the affected children may need bifocals special lenses called prisms as
a part of strabismus treatment. As far as drugs are concerned, mostly medications are
prescribed in the form of eye drops. Usually, atropine and miotics are used to treat the
muscles that control the focusing ability of the eye. Miotics are used when inability to
focus is the cause of strabismus. Atropine is mainly used in case of poor vision in one
eye. This medicine is used for achieving a blurred vision in the good eye, so that the
affected person is forced to use the weaker eye, so that the power of the latter improves.

Drug Patches and Eye Exercises

Another strabismus treatment option is eye patches, which is primarily used as a

treatment for ambylopia (poor or indistinct vision of an eye), which is otherwise called
lazy eye. This condition can either be caused by strabismus or can be the cause of
strabismus. This treatment method uses a patch to cover the stronger eye, so that the
weaker eye is used more. While using eye patches, follow the instructions of the doctor
very carefully. It should be used for the recommended period only and its use after the
stipulated period may lead to amblyopia in the stronger eye too. Eye exercises are also
found to be beneficial in the treatment of strabismus. However, eye exercises alone may
not be sufficient to treat the condition. So, it is combined with other strabismus
treatments, like surgery.
Botulinum Toxin and Surgery

Botulinum toxin is a drug that can temporarily restrain a muscle from contraction for a
long period. These results in the relaxation of the muscle, which in turn makes the
opposing muscle to change the position of the eye. These drugs, which are given through
injections, may cause side effects like vision problems. It is not given as a single
treatment for strabismus, but is used after surgery which fails to completely correct the
misalignment of eyes. If all other treatment modes, like glasses, patches, etc., fail, surgery
is recommended by doctors. However, a botulinum injection remains to be one of the
controversial methods as far as strabismus treatment is concerned. It can be said that
strabismus eye surgery is one of the effective methods to align the eyes and to restore
vision. It is one of the commonly used as a treatment for strabismus in children. The
strabismus surgery is performed to loosen or tighten the muscles that control the
alignment of the eye, by altering the length or position of these muscles. It may also
happen that more than one surgery is required to correct the eye problem. Surgery is not a
common strabismus treatment in adults, as compared to strabismus treatment in children.
In adults, a strabismus treatment is given as per the cause.
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College of Nursing