PARALYTIC SQUINT –
INVESTIGATIONS AND MANAGEMENT
INVESTIGATIONS
ADDITIONAL
EVALUATION OF
TESTS REQUIRED
A CASE OF
FOR PARALYTIC
STRABISMUS
SQUINT
INVESTIGATIONS
ADDITIONAL
EVALUATION OF
TESTS REQUIRED
A CASE OF
FOR PARALYTIC
STRABISMUS
SQUINT
EVALUATION OF A CASE OF STRABISMUS
HISTORY EXAMINATION
HISTORY
Age of onset
Duration
Mode of onset
Any preceding illnesses
Intermittent/Constant
Unilateral/Alternating
Diplopia?
Family History
History of head tilt/turn
EXAMINATION
Inspection
Ocular Movements
Pupillary Reactions
Media + Fundus Exam.
EXAMINATION
Testing of Vision and Refractive Error
Cover Tests
Estimation of Angle of Deviation
Tests for Grade of Binocular Vision and Sensory Functions
EXAMINATION
INSPECTION Large degree of squint (convergent or divergent) will be obvious
OCULAR Unilocular and binocular
MOVEMENTS In all the cardinal positions of gaze
PUPILLARY Abnormal in patients with sensory exotropia (due to diseases of the retina and optic nerve)
REACTIONS
MEDIA AND FUNDUS Associated disease of ocular media, retina or optic nerve will be found
EXAMINATION
TESTING OF VISION May be the cause of symptoms or the deviation itself
AND REFRACTIVE Performed under full cycloplegia (especially in children)
ERROR
EXAMINATION – COVER TESTS
Alternate Cover
Direct Cover Test Cover-uncover Test
Test
Confirms presence of manifest The eye undercover Reveals if squint is
squint deviates unilateral/alternate
Uncovered eye will move in Fusion is interrupted by
Differentiates concomitant
opposite direction to take occlude, thus unmasking
squint from paralytic
fixation latent squint
Type of heterophoria:
Near and distant fixation moves inwards in exophoria
and outwards in esophoria
EXAMINATION – ESTIMATION OF ANGLE OF
DEVIATION
Hirschberg Modified Measurement of
Prism and Cover
Corneal Reflex Krimsky Corneal Deviation with
Test
Test Reflex Test Synaptophore
Estimation of Prisms with increasing All types of
angle of Prisms of
deviation with apex heterophorias
manifest squint increasing
towards deviation and
power placed in
front of normal heterotropias
Cover-uncover eye till corneal measured
Deviation of test performed light reflex is accurately
corneal light till no recovery centred in
reflex from movement seen squinting eye
centre of pupil is
noted in
Amount of deviation Power of prism
squinting eye
told in prism dioptres required equals
amount of squint
Heterophoria in prism dioptres
and heterotropia
measured
EXAMINATION – TESTS FOR GRADE OF
BINOCULAR VISION AND
SENSORY FUNCTION
Looking for
Disturbances of binocular vision
Eccentric fixation
Suppression
Amblyopia
Abnormal retinal correspondence
Diplopia
Sensory Function
Worth’s Four Dot Neutral Density
Tests for Fixation After-Image Test Tests with
Test Filter Test
Synoptophore
EXAMINATION – TESTS FOR GRADE OF
BINOCULAR VISION AND
SENSORY FUNCTION
Worth’s Four Dot Test
Normal binocular vision : all 4 lights (in absence of manifest squint)
Abnormal Retinal Correspondence (ARC) : all 4 lights (in presence
of manifest squint)
Left Suppression : only 2 red lights
Right Suppression : only 3 green lights
Alternating Suppression : alternates between 2 red and 3 green lights
Diplopia : 5 lights – 2 red and 3 green
EXAMINATION – TESTS FOR GRADE OF
BINOCULAR VISION AND
SENSORY FUNCTION
Tests for Fixation
Central fixation
Eccentric fixation
Parafoveal
Visuoscope or fixation star of the ophthalmoscope
Macular
One eye covered and the other fixes the star
Paramacular
Peripheral
EXAMINATION – TESTS FOR GRADE OF
BINOCULAR VISION AND
SENSORY FUNCTION
After-Image Test
Right fovea is stimulated with a vertical bright
light and left with a horizontal bright light.
Patient is asked to draw the position of after-
images.
Normal Esotropia Exotropia
EXAMINATION – TESTS FOR GRADE OF
BINOCULAR VISION AND
SENSORY FUNCTION
Sensory Function Tests with
Synoptophore
1. Estimation of Grades of Binocular Vision
2. Detection of normal/ abnormal retinal correspondence
Done by determining the subjective and objective angles of squint;
Normal retinal correspondence: angles are equal
Abnormal retinal correspondence:
Objective angle > subjective angles
Difference between angles = angle of anomaly
• Harmonious: objective angle = angle of anomaly
• Unharmonious: objective angle > angle of anomaly
EXAMINATION – TESTS FOR GRADE OF
BINOCULAR VISION AND
SENSORY FUNCTION
Neutral Density Filter
Visual acuity measured without and with Neutral Density Filter;
Functional Amblyopia: visual acuity is slightly improved
Organic Amblyopia: visual acuity is markedly reduced
INVESTIGATIONS
ADDITIONAL
EVALUATION OF
TESTS REQUIRED
A CASE OF
FOR PARALYTIC
STRABISMUS
SQUINT
INVESTIGATIONS
ADDITIONAL
EVALUATION OF
TESTS REQUIRED
A CASE OF
FOR PARALYTIC
STRABISMUS
SQUINT
ADDITIONAL TESTS FOR PARALYTIC SQUINT
Evaluation for Find out
strabismus underlying cause
Determine the muscles/nerves involved
ADDITIONAL TESTS FOR PARALYTIC SQUINT
Evaluation for
Strabismus
Diplopia Hess Screen Field of Forced duction
Charting Test Binocular Vision test (FDT)
EVALUATION FOR STRABISMUS
Diplopia Charting
Indicated in patients with confusion/ double vision
Shown a fine linear light from a distance of 1m in semi-dark room
Patient tells position and separation of the 2 images in different
fields (primary position and other positions of gaze)
EVALUATION FOR STRABISMUS
Hess Screen Test
Test tells about paralysed muscles and the pathological sequalae
Compare charts of right and left eye;
• Smaller chart belongs to eye with paretic muscle and larger to
the eye with overacting muscle
Right Lateral Rectus Palsy
EVALUATION FOR STRABISMUS
Field of Binocular
Fixation
Indicated in patients with
some field of single vision
Performed on the perimeter
using central chin rest
EVALUATION FOR STRABISMUS
Forced Duction Test
(FDT)
Differentiates between incomitant squint due to paralysis of
extraocular muscle and that due to mechanical restriction of the
ocular movements;
• Positive : due to mechanical restriction
• Negative : due to extraocular muscle palsy
ADDITIONAL TESTS FOR PARALYTIC SQUINT
Investigations to find
Underlying Cause of
Paralysis
Neurological
Orbital USG Orbital and Skull CT
Investigations
MANAGEMENT
Treatment of Treatment of Surgical
the Cause Diplopia Treatment
Conservative Chemo-
Measures denervation
MANAGEMENT
SURGICAL TREATMENT
Indicated when recovery doesn’t occur in 6 months
Aim: provide a comfortable field of binocular fixation
Principles:
1. Strengthening of paralysed muscle – RESECTION
2. Weakening of overacting muscle – RECESSION
3. Transplantation of normal muscle tendon at or near insertion of paralysed muscle
