1. DOUBLE VISION,
ACQUIRED, and
CONGENITAL STRABISMUS
Robert Cordero, M.D., F.A.C.S
Central Florida Eye Specialists, P.L.
October 30, 2010

2. • www.theeyespecialists.com
• www.aapos
• www.aao
• Google
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3. New, Updated, Revised, Better
• potions, purification, diet, lancets
• Hammurabi’s Code 1800 B.C.
• Egyptian Papyrus 1600 - 1300 B.C.
• Susruta father of Hindu surgery
• Hebrew Talmud 1300 B.C.- 70 A.D.
• Greece, Alexandria, and Rome
• Middle Ages (395-1492) and Renaissance
14-16th century
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4. Georg Bartisch (1535-1606)

5. Chevalier John Taylor 1739
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6. First Muscle Operations
• 1838 Stromeyer, an Orthopedic surgeon on a
cadaver Hanover, Germany
• 1839 J.F. Diffenbach in Berlin, by 1842 had
done 1,200 strabismus operations, which
consisted of tenotomy of the medial rectus
muscle
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8. Eye Massager 1890
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9. Double Vision=/=Diplopia
• Diplopia = Seeing one object as two. Must
rule out Vertigo, Syncope, Hysteria, etc.
• Double the Time
• Double the Effort
• Double the Cost
• Double the reward

10. Questions to Ask
• Does the DV go away by covering one eye
• Abnormal head posture seen in old photos
• Pain, facial numbness, circulatory issues
• Eyelid malposition and endocrine disease
• Fatigability, dysarthria, dysphagia, SOB
• FH, Meds, MH, SH, smoking, ETOH, etc
• Compliance and socioeconomic
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11. Work-up Diplopia
• History, History, Histroy
• Old Records and Studies
• Compare Measurements
• Impression(s)
• Plan: Short and Long Term
• Communication

12. Tools of the Trade
• Patience, Efficiency and Insight
• Lensometer readings
• Best Corrected Vision, Pinhole
• Stereopsis
• Prism Bars, Occluder, Pupil Light
• Clip-ons, Trial Set, Cycloplegia

14. Basic Review
• Anatomy
• Eye Movements
• Binocular Vision
• Strabismus
• Motor Evaluation
• Sensory Evaluation

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21. SENSORY
• Simultaneous perception- brains ability to perceive
images from OU at same time
• Suppression-brain shuts off information
• Fusion- cortical integration of separate retinal
images into single sensory perception
• Stereopsis- to perceive the relative distance of
objects
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22. Tests for stereopsis
Titmus TNO random dot test
• Polaroid spectacles • Red-green spectacles
• Figures seen in 3-D • ‘Hidden’ shapes seen
Frisby Lang
• No spectacles • No spectacles
• ‘Hidden’ circle seen • Shapes seen

23. Tests for sensory anomalies
Worth four-dot test Bagolini striated glasses
a - Prior to use of glasses a - Normal or ARC
b - Normal or ARC b- Diplopia
c - Left suppression c - Suppression
d - Right suppression d - Small suppression scotoma
e - Diplopia

24. Synoptophore
• Grading of binocular vision
• Detection of suppression and ARC
• Measurement of angle
• Measurement of fusional amplitudes

25. Hirschberg test
• Rough measure of deviation
• Note location of corneal light reflex
• 1 mm = 7 or 15
Reflex at border of pupil = 15 Reflex at limbus = 75

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29. Motility tests
• Tests versions and ductions
• Grades under/overaction
Left lateral rectus underaction
Left inferior oblique overaction

30. Cover tests
• Cover test detects heterotropia • Prism cover test measures tropia
• Alternate measures total tropia and phoria
• Uncover test detects heterophoria
• Alternate cover test detects total deviation

31. Amblyopia
• Strabismus
• Anisometropic (sph or cyl) > 1.5 D
• Deprivation (media opacity >1 mm in size
• or ptosis < 1 mm margin reflex distance)
• Cost Effectiveness Tx gain from $2053 to
• $2509 ($/ QALY) <20K especially good
• www:aao.org/ppp cost-utility analysis

32. The Pediatric Eye Disease
Investigator Group (PEDIG)
• Randomized multicenter clinical study
• Patching regimens part vs full time
• 2 hr/day for moderate cases(20/40-80)
• Atropine 1% vs patching(6hr/day) ages 3- 7
• 24% recurrence < 8 years age within one
year cessation either method
• 27% improvement age 3-7 anisometropia Rx
• 50% >2 lines age 7 to 12 either method, age
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33. Types of Turns
• ESODEVIATION
• EXODEVIATION
• A and V Patterns
• Cyclovertical

34. Monocular Diplopia

35. Signs of chalazion (meibomian cyst)
Painless, roundish, firm lesion May rupture through conjunctiva
within tarsal plate and cause granuloma

36. Morphological classification of keratoconus
Nipple cone Oval cone Globus cone
Small and steep curvature Larger and ellipsoidal Largest

37. Progressive iris atrophy
Progressive stromal iris atrophy
Broad-based PAS Displacement of pupil
towards PAS

38. Isolated familial ectopia lentis
Autosomal recessive
Pupil may be normal Pupil may be displaced in opposite
direction (ectopia lentis et pupillae)

39. Classification according to maturity
Immature Mature
Hypermature Morgagnian

40. Implant displacement
Decentration Optic capture
• May occur if one haptic is inserted • Reposition may be necessary
into sulcus and other into bag
• Remove and replace if severe

41. Binocular Diplopia

42. No Misalignment

43. INCOMITANT

44. Mechanical (Restrictive)
Diplopia
• Grave’s Ophthalmopathy
• Brown’s Syndrome
• Orbital Pseudotumor
• Ocular Myositis
• Orbital Mass Lesions
• Orbital Trauma

45. Signs of eyelid retraction
Occurs in about 50%
• Bilateral lid retraction • Bilateral lid retraction
• No associated proptosis • Bilateral proptosis
• Unilateral lid retraction • Lid lag in downgaze
• Unilateral proptosis

46. Restrictive myopathy
• Occurs in about 40%
• Due to fibrotic contracture
Elevation defect - most common Abduction defect - less common
Depression defect - uncommon Adduction defect - rare

47. Optic neuropathy
• Occurs in about 5%
• Early defective colour vision
• Usually normal disc appearance
Caused by optic nerve compression
at Often occurs in absence of significant
orbital apex by enlarged recti proptosis

48. Brown syndrome (right)
Normal elevation in Straight in primary position Limited elevation in
abduction adduction

49. Idiopathic orbital non-infectious orbitaldisease (IOID)
• Non-neoplastic,
inflammatory lesion (pseudotumour)
• Involves any or all soft-tissue components
• Presentation - 20 to 50 years with abrupt painful onset
• Usually unilateral
• Periorbital swelling and chemosis
• Proptosis
• Ophthalmoplegia

50. Clinical course and treatment of IOID
1. Early spontaneous remission without sequelae
Treatment - nil
2. Prolonged intermittent activity with eventual remission
Treatment options - steroids, radiotherapy or cytotoxics
3. Severe prolonged activity causing a ‘frozen orbit’
Left involvement resulting in ophthalmoplegia and ptosis

51. Orbital myositis
• Subtype of IOID
• Involvement of one or more extraocular muscles
• Clinical course is usually short - treat with NSAIDs
• Presentation - sudden onset of pain on ocular movement
• Underaction of left lateral rectus • CT shows fusiform enlargement
of left lateral rectus
• Worsening of pain on attempted left gaze

52. Cavernous haemangioma
• Most common benign orbital tumour in adults
• Usually located just behind globe
• Female preponderance - 70%
• Presents - 4th to 5th decade
Slowly progressive axial proptosis May cause choroidal folds
Treatment - surgical excision

53. Pleomorphic Lacrimal Gland Adenoma
Presents - 4th to 5th decade
• Painless and very slow- • Posterior extension may • Smooth, encapsulated
growing, smooth mass in cause proptosis and outline
lacrimal fossa ophthalmoplegia • Excavation of lacrimal gland
• Inferonasal globe fossa without destruction
displacement

54. Lacrimal gland carcinoma
• Presents - 4th to 6th decades
• Very poor prognosis
• Posterior extension may cause proptosis,
• Painful, fast-growing mass in ophthalmoplegia and episcleral
lacrimal fossa congestion
• Infero-nasal globe displacement • Trigeminal hypoaesthesia in 25%
Management
• Biopsy
• Radical surgery and radiotherapy

55. Optic nerve glioma
• Typically affects young girls
• Associated neurofibromatosis -1 is common
• Presents - end of first decade with gradual visual loss
Gradually progressive proptosis Optic atrophy
Treatment
• Observation - no growth, good vision and good cosmesis
• Excision - poor vision and poor cosmesis
• Radiotherapy - intracranial extension

56. Sphenoidal ridge meningioma
Presents with gradual visual loss and reactive hyperostosis
Proptosis Fullness in temporal fossa Hyperostosis on plain x-ray

57. Lymphoma
Presents - 6th to 8th decades
Affects any part of orbit and Anterior lesions are rubbery May be confined to
may be bilateral on palpitation lacrimal glands
Treatment
• Radiotherapy - localized lesions
• Chemotherapy - disseminated disease

58. Direct carotid-cavernous fistula
• Defect in intracavernous part of internal carotid
• Rapid flow shunt
Causes
• Head trauma - most common
• Spontaneous rupture - in hypertensive females
• Ptosis, chemosis and conjunctival injection
• Ophthalmoplegia
• Raised intraocular pressure

59. Direct carotid-cavernous fistula
• Pulsatile proptosis with bruit • Retinal venous congestion and haemorrhages
and thrill
• Abolished by ipsilateral
carotid compression

60. Indirect carotid-cavernous fistula (dural shunt)
• Indirect communication between meningeal branches of internal
or external carotids and cavernous sinus
• Slow flow shunt
Causes
• Congenital malformations
• Spontaneous rupture
• Dilated episcleral vessels • Occasional ophthalmoplegia
• Raised intraocular pressure with and mild proptosis
wide pulsation

61. Incomitant Misalignment

62. Tensilon Test
• Tensilon (Edrophonium HCL) 10 mg/ml fast
acting anti-cholinesterase
• Neostigmine (Prostigmin) IM (0.02mg/kg)
alternative
• Have injectable Atropine Sulfate ready

63. Ophthalmic Signs of Myasthenia
Gravis
• Ptosis
• EOM Palsies
• Pseudogaze Palsies
• Pseudointernuclear Ophthalmoplegia
• Pseudoconvergence Paresis
• Lid Twitch
• Quiver Movements
• Orbicularis Weakness

64. Myasthenia Gravis
1. Clinical features
• Uncommon, typically affects young women
• Weakness and fatiguability of voluntary musculature
• Types: Neonatal, Congenital, Ocular, System
2. Investigations
•ICE Test
•Tensilon test (edrophonium) or Prostigmine
• Antibodies to acetylcholine receptors 3 types, MuSK
(muscle-specific receptor tyrosine kinase)
• CT or MRI for presence of thymoma
3. Treatment options
• Medical - AChE inhibitor, steroids, immunomodulators
• Thymectomy, prisms, strabismus surgery

65. Ocular myasthenia
Ptosis Diplopia
• Insidious, bilateral but asymmetrical • Intermittent and usually vertical
• Worse with fatigue and in upgaze
• Ptotic lid may show ‘twitch’ and
‘hop’ signs

66. Edrophonium test
Before injection Positive result
• Measure amount of ptosis or • Inject i.v. test dose of edrophonium
diplopia before injection (0.2 ml-2 mg)
• Inject remaining (0.8 ml-8 mg) if no
• Inject i.v. atropine 0.3 mg hypersensitivity

67. Cranial Neuropathy
• Oculomotor (3rd) Cranial Nerve
• Trochlear (4th) Cranial Nerve
• Abducen (6th) Cranial Nerve
• Adult, Child, TITS

68. Anatomy of third nerve
Oculomotor nucleus
Pituitary gland
Red nucleus
Carotid artery
Cavernous sinus
Pons
III nerve
Post cerebral artery Clivus
Basilar artery

69. Applied anatomy of pupillomotor nerve fibres
Blood vessels on pia mater supply surface
of the nerve including pupillary
fibres ( damaged by
compressive lesions )
Vasa nervorum supply part
of nerve but not pupillary
fibres ( damaged by medical
lesions )
Pupillary fibres lie dorsal and peripheral

70. Signs of right third nerve palsy
• Ptosis, mydriasis and cycloplegia • Normal abduction
• Abduction in primary position • Intorsion on attempted
downgaze
• Limited adduction • Limited elevation • Limited depression

71. Important causes of isolated third nerve palsy
Idiopathic - about 25%
Vascular disease - hypertension, diabetes
Trauma Posterior communicating aneurysm
Extradural Aneurysm
haematoma
Chiasm
Midbrain
pushed
across
Edge of
tentorium Prolapsing
temporal Posterior cerebral
artery
lobe
Third nerve

72. Anatomy of fourth nerve
Internal carotid artery
Postr. communicating
artery
III
VI
Postr.cerebral artery
Supr.cerebellar artery
Basilar artery
IV
• Only cranial nerve to emerge dorsally
• Crossed cranial nerve
• Very long and slender

73. Signs of right fourth nerve palsy
• Right hyperdeviation in primary • Right underaction on depression
position when left eye fixating in adduction
• Excyclotorsion • Vertical diplopia
• Right overaction on left gaze

74. Positive Bielschowsky test in right fourth nerve pal
Increase in right Absence of right
hyperdeviation on ipsilateral hyperdeviation on
head tilt contralateral head tilt

75. Anatomy of sixth nerve
Basilar artery
Medial Pituitary gland
lemniscus Carotid artery
4th ventricle Cavernous sinus
Petroclinoid
ligament
Vestibular Clivus
VI nerve
nucleus
Pyramidal tract

76. Old right sixth nerve palsy
Straight in primary position due to partial
recovery
Limitation of right abduction and Normal right adduction
horizontal diplopia

77. Important causes of isolated sixth nerve palsy
Vascular - hypertension, diabetes
Raised intracranial pressure Acoustic neuroma
Dilated
ventricles
Petrous
tip
Brainstem pushed downwards

78. SUPRANUCLEAR DISORDERS OF
EYE MOVEMENT
1. Horizontal gaze palsies
• Internuclear ophthalmoplegia
• Combined internuclear and PPRF
(‘one-and-a-half syndrome’)
MLF
2. Vertical gaze palsies
• Parinaud dorsal midbrain syndrome
• Progressive supranuclear palsy

79. 79

80. Internuclear ophthalmoplegia
Lesion involving left MLF
Defective left adduction and ataxic Normal left gaze
nystagmus of right eye
Convergence intact if lesion discrete
Important causes
• Demylination - usually bilateral
• Vascular disease
• Tumours of brainstem

81. ‘One-and-a-half syndrome ’
Combined lesion of left MLF and PPRF
Paralytic Pontine Exotropia
• Ipsilateral (left) gaze palsy • Defective left adduction
• Normal right abduction with ataxic
nystagmus

82. Parinaud dorsal midbrain syndrome
• Supranuclear upgaze palsy • Normal downgaze
• Large pupils with light-near dissociation • Convergence weakness
• Lid retracton (Collier sign) • Convergence-retraction nystagmus
Important causes
• In children: aqueduct stenosis, meningitis and pinealoma
• In young adults: demylination, trauma and a-v malformations
• In elderly: vascular accidents and posterior fossa aneurysms

83. Progressive supranuclear palsy
( Steele-Richardson-Olszewski syndrome )
• Affects elderly
• Pseudobulbar palsy
Initially involves downgaze
• Extrapyramidal rigidity
• Gait ataxia
• Dementia
Subsequent defective up and
horizontal gaze

84. Medial wall blow-out fracture
Signs
Ophthalmoplegia - adduction and abduction
Periorbital subcutaneous emphysema if medial rectus muscle is entrapped
Treatment
• Release of entrapped tissue
• Repair of bony defect

85. COMITANT
• Review History
• Decompensated Phoria
• Accomodative Esotropia
• Acute Esotropia of Childhood
• Vergence Paresis
• Skew Deviation
• Foveal Displacement Syndrome
• Central Disruption of Fusion

86. Decompensated Phoria
• latent ocular misalignment due to lose of
single binocular fusion
• associated with febrile illness, head trauma,
changing refractive needs, asthenopia
• presence of adaptive head posture and large
fusional amplitudes
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87. Refractive accommodative esotropia
• Presents between 18 months - 3years
• Initially intermittent
• Normal AC/A ratio
• Excessive hypermetropia
Fully accommodative Partially accommodative
Esotropia greater for near Straight for distance
Straight for distance and near Esotropia for near

88. Non-refractive accommodative esotropia
• Presents between 18 months to 3years
• High AC/A ratio
- due to increased AC (convergence excess)
- due to decreased A (hypoaccommodative)
• No significant refractive error
Signs
Straight for distance Esotropia for near

89. Recent right sixth nerve palsy
Right esotropia in primary position due to Marked limitation of right abduction due t
unopposed action of right medial rectus right lateral rectus weakness

90. Skew Deviation
• vertical misalignment of visual axes due to
imbalance of prenuclear inputs
• vertical diplobia cannot be isolated to a
single EOM(s)
• Hypertropia varies with gaze associated with
downbeat nystagmus
• brainstem and cerebellar disease, MS, INO,
increased ICP
90

91. Assessment after photocoagulation
Poor involution Good involution
• Persistent neovascularization • Regression of neovascularization
• Haemorrhage • Residual ‘ghost’ vessels or
fibrous tissue
• Re-treatment required • Disc pallor

92. Choroidal neovascularization (CNV)
• Less common than atrophic AMD but more serious
• Metamorphopsia is initial symptom
• Most lesions are not visible clinically
Suspicious clinical signs
Pinkish-yellow subretinal lesion Subretinal blood or lipid
with fluid

93. Idiopathic premacular fibrosis
Cellophane maculopathy Macular pucker
• Translucent epiretinal • Severe retinal wrinkling and • Opaque epiretinal membrane
membrane vascular distortion
• Fine retinal striae and mild • Pucker emanating from
• May be associated with
vascular distortion macular pseudo-hole
epicenter

94. Recession Resection

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96. Summary
• What is patient’s real complaint ?
• Disease process, work up, time frame
• Trial of prisms
• Is surgery an option?
• Are other referrals or treatments necessary?
• Communication between all parties
• Evidence-Based Medicine

97. Evidence-based Medicine
• “ the conscientious, judicious,explicit use of
the best available evidence from clinical
care research in making health care
decisions”
• Harvard Health Policy Review 2007: 8:145-155 Montori
and Guyatt: Corruption of the evidence as threat and
opportunity for evidence-based medicine
97

98. VISION THERAPY
• 1) Orthoptic VT helpful for convergence
insufficiency and binocular function
• 2) Behavioral-Perception VT unproven for
visual processing and perception
• 3) Prevention or correction of Myopia
unproven
• * Eye excercises do not treat learning
disabilities
98

99. Learning Disabilities
• 15-20% of the population affected with
reading, math, foreign langauge problems,
organizing written and spoken language
• reading disorder different from dyslexia
• 85% have dyslexia, whereby, loosing place
reading due to difficulty decoding letter(s)
or word combinations and/or lack of
comprehension, not because of a “tracking
abnormality” 99

100. References:
• Burde RM, Savino PJ, Trobe JD. Cliinical Decisions in Neuro-
Ophthalmology, 2nd ed. St. Louis: Mosby-Year Book Inc., 1992.
• Gorin G, History of Ophthalmology. Delaware:Publish or Perish, 1982
• Miller KM, Capo H, Mallette RA, Guyton DL. Ocular Motility and
Binocular Vision. St. Louis: C.V. Mosby Co., 1989.
• Pediatric Ophthalmology and Strabismus, Section 6, Basic and Clinical
Course. San Francisco: American Academy of Ophthalmology,1990-1.
• Taylor D. Pediatric Ophthalmology. Cambridge: Blackwell Scientific
Publications, Inc, 1990.
• Wright KW. Text Book of Ophthalmology. Baltimore: Williams P.
Wilkins, 1997.
• Kanski JJ, Bolton A. Illustrated Tutorials in Clinical Ophthalmology.
• Butterworth-Heinemann, 2001.
• American Orthoptic Journal, Volume 60, 2010
• FocalPoints Advances in the Management of Amblyopia, Kerr,NC 2010
• FocalPoints Practical Management of Amblyopia, Keech,RV Mar 2000
• FocalPoints Diplobia:Diagnosis and Management, Lee,MS Dec 2007

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