.

Dr. Sunita Kumawat,

Deptt. Of ophthalmology,
spmc bikaner.

Examination of
strabismus

Definition
Derived from greek word strabismos, to

suint, to look obliquely.

Strabismus : It is the condition where visual
axes of two eyes do not meet at point of
regard.
whether it is caused by abnormalities in
binocular vision or by anomalies of
neuromuscular control of ocular motility.
crooked eyes/misaligned eyes/ crossed eyes

Orthophoria is an ideal condition of normal

ocular alignment under binocular condition.

Some perfer the term orthotropia.
Heterophoria is a condition of ocular
deviation kept latent by fusional mechanism
(latent strabismus)
Heterotropia is condition of ocular deviation
that is manifest and not kept under control
by fusional mechanism (manifest strabismus)

Classification of
Heterophoria
Heterotropia
strabismus
(manifest squint) (latent suint)

Eso (convergent)
Exo (divergent)
Hyper (sursumvergent)
Hypo (deorsumvergent)
Cyclo (torsional)

Full description of the squint involves the use

of many different terms, although in practice
it is customary to apply any few of these to
any particular squint. These are usually:
1.first the eye which is affected, Rt. , Lt. or
alternating.
2.Secondly the presence of comitance or
incomitance
3.Thirdly the direction of deviationconvergent, divergent. Example:
Rt. Comitant convergent
strabismus
Alternating comitant divergent
strabismus

Additional terms which may be

used in connection with the

classification of strabismus:
1.Pseudostrabismus (apparent
squint): false appearance of squint
in absence of any deviation (broad
epicanthal fold, flat bridge of nose,
euryblepharon = false impression of
convergent squint),

(Marked narrowing of lateral canthi , hypertelorism

= false impression of divergent squint)

2.Fleeting squint
3.Purposive squint

Angle kappa;
The visual axis(line joining the fovea and
the target object) is not the same as the
optical or geometric axis(line passing
through the centre of pupil and cornea)
They differ normally by about +5 degrees
out (exotropic), known as angle kappa.

Negative angle kappa (myopia) pseudo-

esotropia.
Large positive angle kappa
(hypermetropia) leads to pseudoexotropia

Preliminary examination:
1. Presenting coplaints &History
2. Visual acuity assessment
3. Refraction
4. Examination of anterior and posterior

segment

During history taking examinar should

inspect the patient for:

-Size of both eyeballs and their position in
the orbits,
-Width of lid slits, lids motility and presence
of the
pathological synkineses,
-Ocular movements and presence or
absence of nystagmus,
-Head posture, facial torsion, and chin
position should also be inspected:

Visual acuity
Distance
Near
In adults and children more >5yrs
snellens chart, log MARcharts.
Visual acuity can be measured in children:
1 Observation.
2 Optokinetic nystagmus.
3 Visual evoked potentials.
4 Forced choice preferential looking.
5 Graded optotypes of special
construction.
6 Monocular fixation.

Visual acuity:
1.Detection Acuity test: assess the ability to

detect the smallest stimulus eg: catford

drum, STYCAR graded balls test,Boeck
candy beads, Dot visual acuity.
2.Recognition acuity tests: sjogrens hand test
landdolts C, snellens E, Arrows, beal
collins picture chart,allen picture chart,
cardiff acuity cards, OKNOVIS.
3.Resolution acuity test: Optokinetic
nystagmus,Visual evoked potentials,Forced
choice preferential looking,Graded
optotypes of special construction.

Visual acuity in preverbal children:

1.Observation technique:
Child in the first month of life reacts to the
faces being near and his pupillary light
reactions are normal. 2 to 5months of age
child blinks in response to the visual threat
and fixation are well developed.
If the visual acuity of one eye is poorer than
that of other eye, child will not allow to cover
better-sighted eye.

2. Optokinetic nystagmus
showing the child white-and-black strips

moved on the special cylinder.the higher

density of strips is producing nystagmus in
the child, better the visual acuity of the
examined eye.

3. Visual evoked potentials

They are useful in giving an objective record
of underlying visual pathway and do exclude
organic pathology.

4. forced choice
preferential looking
This technique is based on

the childs eye reaction.

child prefers to look to the
pattern stimulus rather than
homogenous field.
Using calibrated squarewave gratings, teller and
keeler acuity cards and
cardiff acuity cards for the
test, visual acuity can be
assessed.

Visual acuity in children at 1 to 2 yrs of age

can be tested by boeck candy test, worth

ivory ball test & sheridans ball test.
2 to 3yrs: crowded Kay picture, and keeler
logMAR crowded test.

3 to 5 yrs: picture chart and

single picture cards, Lea
symbols, Tumbling E test,
Snellen test. Child recognizes
by naming or matching the
picture or letter.

Monocular fixation
Fixation of each eye separately

is evaluated with visuscope in

every child. Star of the device is
clearly seen by the examined
child & by the physician in the
fundus of eye
The child is asked to look
straight into the star. fixing
fovea on the mid-star, indicates
central fixation. Visual acuity is
good in such a case.
If the patient does not fix with
fovea, it indicates decreased
visual acuity

Refraction:
Grade of vision abnormality

is determined in each child

with the aid of automatic
keratorefractometer. In
newborns and young
children hand-held
autokeratorefractometer
(Retinomax) is used. (after
proper cycloplegia)

Anterior and posterior segment

Examination

Examination of a case of
squint
1.Motor status
Sensory status

2.

Examination of motor
status

1. Looking for head posture

2. Ocular deviation
3. Limitation of movements
4. Fusional vergence

Head posture:
1.Chin elevation or depression
2.Face turn to right or left side
3.Head tilt to right or left shoulder
Patient chooses a head posture

such that ocular deviation the least

and image can be fused.

Cover uncover tests

For distant fixation figure/ letter of 6/9 of

snellen, from 6 mt. distance.

Near fixation at 33 cm.

Cover-Uncover test:

Alternate cover test

Covering both eyes alternately one and then

the other eye,

Each eye should be covered atleast for 2
seconds.
fusion is broken, alternate cover test brings
out the total deviation- heterophoria and
heterotropia.

Prism -alternate cover

To measure the angle of strabismus, the
test
prism bar is moved before one eye. Then
cover test performed with increasing
strength of prism.
Strength of the prism at which fixation
movement stops is the value of the angle
of strabismus.
.

Prism base is always directed opposite the eye

deviation. The test is performed for both distant
vision of 6 m and near vision of 30 cm.
Esotropia: prism base- out.

Exotropia: prism base- in.

Hypertropia: prism base- down.
-Hypotropia: prism base-up
-The results are expressed in prism diopter

(PD).

The value of angle of strabismus can also

be assessed with Krimsky test or

examining eye fundus through the prism.

Angle of strabismus by fundus

examination
The patient asked to views distant point with
normal eye.
stronger prisms are placed before the deviating
eye.
examining fundus through the prism with the
visuscope straight ahead (Baranowska-George).
The prism corresponding with the angle of
strabismus is the one through which the examiner
sees fovea in line with the visuscope star

Light reflex tests

1. Hirschberg method
2. Krimsky method
3. Bruckners test

Hirschberg method
Amount of deviation: note location
of corneal light reflex
1 mm = 7 or 15
Reflex at border of pupil = 15

Reflex at limbus = 45

Used as an initial screen

for strabismus.

Krimsky method
This test is used to
centralize the corneal
reflection in squinting eye
as compared to the reflex
in fixing eye.

Results are expressed in

prism diopter (PD).
angle of strabismus =
prism required for
centralize the corneal
reflex.

It is Convenient test for

quick evaluation of the
angle of strabismus,
especially in the abnormal
fixation of the squint eye
and ambylopia.

Bruckner Test
Performed by using direct
ophthalmoscope to obtain a red
reflex simultaneously in both
eyes.
Deviated eye will have a
lighter and brighter reflex than
the fixing eye.

Eye movement and extent

of versions:
1. Observation of ocular ductions, which are

the actual monocular movements of the eye

2. Observation of binocular alignment(in all
gazes).

Monocular eye movements

A- elevation
d- adduction

B- depression
Eextortion

C- adbuction
F- intortion

Motility tests
Tests versions and ductions
Grades under/overaction

Left inferior oblique overaction Left lateral rectus underaction

Forced
duction test
A topical anesthetic eyedrops
are given to the conjunctival sac
of the patients eye. Then, the
conjunctiva in the limbus is
grasped with forceps and an
attempt to abduct the eyeball
toward weakened muscle.
Limitation or block of eyeball
rotation means the mechanical
restriction of movement

Hess screening:
is a gray screen covered with

the net of tangent lines.

In the semi dark room the
patient wearing red-green
spectacles projects green light
to super impose red points lit
on the screen by the examiner.
All the points are plotted in
turn.
Result should be mapped in all
gaze positions.

In orthophoria two lights are super imposed in all

nine position of gaze.

Goggle then reversed and procedure is repeated.
The relative positions are marked by

examinar on hess chart and connected with

straight lines.

Two chart of both eyes are

compared
Smaller chart indicates the
eye with paretic muscle (Rt.)
Larger chart indicates eye
with Over acting yolk
muscle(Lt. eye).
Greatest restriction is in
main direction of action of
muscle (Rt. Lateral rectus).
Greatest expansion in the
main direction of action of
the yolk muscle(Lt. medial
rectus).

Showing changes

with rt. Superior

rectus palsy

Lees screen

Sensory status:
1. Test for stereopsis
2. Test for binocularity & Diplopia

Qualitative tests for Stereopsis:

Langs 2 pencil test
Synoptophore

Quantitative tests for Stereopsis:

Random Dot test
Titmus Fly Test
TNO Test
Frisby stereo test
Langs Stereo Test
Stereoscope (holmes, key stone, asher law)

Stereopsis:
Can be detected by Using targets which lie in two planes, but

are so constructed that they stimulate disparate retinal elements

and give a three dimensional effect, for example:

Tests for stereopsis

Titmus

Polaroid spectacles
Figures seen in 3-D

TNO random dot test

Lang

Frisby

No spectacles
Hidden circle seen

Red-green spectacles
Hidden shapes seen

No spectacles
Shapes seen

Synoptophore

It is a versatile instrument &

has special sets of slides for

testing : simultaneous
perception, fusion,
stereopsis.
Presence of stereopsis
indicates good binocular
single vision.
Can measure: objective
angle
subjective angle of
deviation &
angle of anomaly.

Test for diplopia:

Maddox rod:
Test is performed 5 m
before Maddox cross.
One eye covered with
maddox rod, Fellow eye
fixes the white light on the
scale.
Patient with ortophoria
sees the red line running
through the light point.
If the red line is on another
side of the light (crossed
position), there is
exophoria.

 If the red line is on the

same side (uncrossed

position), esophoria is
present.
The red line may rotate
downward
(hyperphoria), upward
(hypophoria), outside
(incyclophoria) , inside
(excyclophoria).
Deviation of the eye is
read on the Maddox
scale in prism diopters

White spot converted into red streak

Cannot differentiate tropia from phoria

Double maddox rod:

Maddox wing
Rt. Eye sees only a white

Dissociates eyes for near

fixation (1/3 m)
Measures heterophoria

vertical & red horizontal

arrow.
Lt. eye sees only horizontal
and vertical rows of numbers
the no. where white arrow
points= Hz. Deviation
the no. where red arrow
points= Vt. Deviation.
Cyclophoria measured by
asking the pt. to move the
red arrow to put it parallel
with Hz. Row of numbers

Red green goggle:

Image will be

farthest in the
direction of
paralysed
muscle

Worth four dot test

Bagolini lens
Each lens has fine

striation which convert

a point sorce of light in
into line.
Two lenses are placed
45 & 135 degree in
front of each eye.

a) normal person

perceives Two streaks

intersect at their
centres, form an
oblique cross.
b) If Pt. sees two line but
they do not form a
cross.
c) If Only one streak is
seen.
d) If Pt. sees a small gap
in one of the streak.

Ocular deviation:

References:
1. Practical orthoptics in the treatment of
2.
3.
4.
5.
6.

squint; T.Keith Lyle.

Strabismus simplified; Pradeep sharm.
Paediatric ophthalmology & strabismus; AAO
Parsons diseases of eye.
Kanski Brad Bowling; clinical ophthalmology.
Internet resources.