LEARNING OBJECTIVES

 CLASSIFY DIFFERERNT TYPES OF SQUINT

 LIST THE CLINICAL TESTS FOR THE ASSESSMENT
OF SQUINT
 DESCRIBE THE IMPORTANCE OF REFRACTIVE
ERROR AND FUNDOSCOPY IN SQUINT
Squint
 To look with the eyes partly closed
 It is often used an alternative to strabismus
 Squint/strabismus is the term used when the two
eyes are not pointing in the same direction
WHAT IS STRABISMUS ?

Non Alignment of the two visual axes to such an extent

that when one eye is looking at any target ; the other eye
deviates away
HIRSCHBERG TEST
Gross classification of strabismus

 Tropia  Phoria
The strabismus which is The strabismus which is
evident on gross evident upon breaking
inspection the binocular single
vision
This Misalignment Can
Take Several Forms:
Eso (crossed eyes)
Exo (out-turned eyes)
Hyper Or
Hypo (vertical
misalignment)
ORTHOPHORIA

 Visual axis of eyes are directed simultaneously

to the same point of fixation at both near and
distance when fusion is suspended.
 HETEROTROPIA
 HETROPHORIA
Classification
Etiology
 Runs in families
 Premature babies
 Illness at an early age, especially if there has been damage
to the brain
 Abnormal development or damage to the nerves or
muscles that control movement of the eye.
 Hypermetropia (or less commonly myopia) in both eyes
 Something may be wrong with the eye itself such as a
cataract (cloudy lens), or a scar on the front of the retina
Why is the diagnosis important?
 It can be simple disease like a refractive error
 It May Be Necessary To Treat The Underlying
Cause before treating strabismus
 It may be a presenting sign of a serious disease
either ocular , neurological or systemic
Types of squint
•NON PARALYTIC
•PARALYTIC
NON PARALYTIC SQUINT
(CONCOMITANT)

 Deviation of eyes , where deviation remains the same

in all directions of gaze
 ESOTROPIA

ACCOMODATIVE

NON MIXED
REFRACTIVE
REFARCTIVE ACCOMODATIVE

ACCOMODATION REFLEX = ACCOMODATION +

CONVERGENCE + PUPILLARY CONSTRICTION
ESOTROPIA
REFRACTIVE ESOTROPIA
-UNCORRECTED

REFRACTIVE ESOTROPIA
-CORRECTED WITH
GLASSES
EXOTROPIA
EXOTROPIA

CONSTANT INTERMITTENT

CONGENITAL CONVERGENCE DIVERGENCE

SENSORY BASIC
WEAKNESS EXCESS
Left Exotropia due to Cataract (Left) Eye
DIVERGENCE
EXCESS EXOTROPIA

Straight for
Near Fixation

Left Exotropia for

distance Fixation
PARALYTIC SQUINT
(NON CONCOMITANT)

 Deviation of eyes , where deviation is irregular and

varies in different directions of gaze
OCULAR MOTILITY

 Restriction in action of paralysed muscle

 Overaction of contra lateral yolk muscle
 Primary deviation in affected eye
 Secondary deviation in unaffected eye
EVALUATION
Clinical tests to be done in a patient with
strabismus
 HEAD POSTURE
 VA
 PUPIL REFLEXES
 EXTRAOCULAR MUSCLES
 VERSIONS
 DUCTIONS
 HIRSCHBERG TEST
 KRIMSKY TEST
 COVER/ UNCOVER TEST
 PRISM COVER TEST
 REFRACTION
 FUNDOSCOPY
ABNORMAL HEAD POSTURE
 FACE TURN:
Always in the direction of action of paralyzed muscle in Horizontal deviation
 CHIN ELE/DEP:

Always in Vertical deviation.

 Depression..in paralysis of one of the eye depressors
 Elevation … in paralysis of one of the eye elevators

 HEAD TILT:

Always in Tortional deviation.

 tilt towards R shoulder in LEFT superior Oblique
 tilt towards L shoulder in RIGHT Superior oblique
VISUAL ACUITY
 IN PRE-VERBAL CHILDREN (<2years)
• Occlusion of one eye
__Normal behavior
__Abnormal behavior
• Fixation Test -------- Prism
• Hundreds & Thousands sweets test
• Rotation Test ( Doll Eye test)
• Preferential looking __ Teller acuity cards
---Cardiff acuity cards
• Visually Evoked Potential
• Opto-kinetic Nystagmus
MEASUREMENT OF DEVIATION

 HIRSCHBERG TEST--------------( With torch)

 KRIMSKY TEST---------------------(With prism bars)
 COVER TESTS
(A) COVER – UNCOVER-(To see type of manifest squint)
(B) UNCOVER---------------(To see type of latent squint)
(C)ALTERNATE COVER-(To see type of both manifest &
latent )
(D)PRISM COVER---------(To assess exact degree of squint)
HIRSCHBERG TEST
HOW TO INVESTIGATE
PARALYTIC SQUINT
 DRAW DIPLOPIA CHART / PHOTOGRAPH
 CHECK OCULAR MOTILITY
 FIND OUT EXTENT OF PARALYSIS OF
EXTRA OCULAR/MUSCLE BY:
(a) HESS TEST.
(b) LEES SCREEN
(c) LANCASTER R/G
 FIND OUT THE CAUSE OF PARALYSIS
COVER TEST
(near, dist, all gaze with & without
glasses)
HESS TEST

 Hess screen
 Lees screen
 Lancaster red/green test
HESS TEST IN ® LR PALSY
Krimsky test
Cover uncover test
Exotropia, Constant
May be visible with or without
alternate cover
May or may not have constant
diplopia

G.Vicente,MD
Cover – Uncover test
Esophoria, abnormal, common
Only seen when eye is covered
Often asymptomatic, no complaints
Note OS does not move.
G.Vicente,MD
Alternate Cover test
Exotropia, intermittent
May be visible with or without
alternate cover
May have intermittent diplopia,
especially when tired or sick
Mom sees misalignment every
now and then.

G.Vicente,MD
Cover – Uncover test
Exophoria, abnormal, common
Only seen when eye is covered
Note OS does not move
Often asymptomatic, no complaints.
G.Vicente,MD
Cover – Uncover test
Orthophoria, normal
No complaints, asymptomatic

G.Vicente,MD
Label …
IMPORTANCE OF
REFRACTIVE ERRORS

• Hypermetropia- refractive esotropia

• Myopia- Exotropia

• Astigmatism

• Anisometropia
Cycloplegic refraction (to
neutralize accommodation)

•Cyclopentolate 0.5-1%- I drop every 5

min leads to maximal cycloplegia in 30
min.
•Atropine 0.5-1%- 1 drop tds for 3 days
FUNDOSCOPY

To rule-out any other cause of

decreased vision and subsequent
strabismus e.g. macular scarring, optic
nerve hypoplasia or retinoblastoma
CONCLUSION
 SQUINT IS NON ALIGNMENT OF VISUAL AXES
 TYPES NON PARALYTIC AND PARALYTIC
 HERSCHBERG AND COVER/UNCOVER TESTS PROVIDE QUICK
ASSESSMENT OF SQUINT
 PRISM COVER TEST TELLS US ABOUT THE DEVIATION OF
SQUINT
 HYPERMETROPIA CAN CAUSE SQUINT AND AMBLYOPIA
 REFRACTION AND FUNDISCOPY SHOULD BE PERFORMED IN
ALL THE CASES
THANK YOU