Extrinsic muscle

 The six tiny muscles that surround the

eye and control its movements are
known as the extraocular muscles
(EOMs). The primary function of the
four rectus muscles is to control the
eye's movements from left to right and
up and down. The two oblique muscles
rotate the eyes inward and outward.
 Allsix muscles work in unison to move the
eye. As one contracts, the opposing muscle
relaxes, creating smooth movements. In
addition to the muscles of one eye working
together in a coordinated effort, the
muscles of both eyes work in unison so that
the eyes are always aligned.
 binocular vision
 Both eyes gaze at the same object,
then the images obtained by them are
fused as a single integrated one with
three grade spaces called binocular
vision. It is necessary to produce
binocular vision with following three
factors.
 (1)Normal retinal corresponding
points.
 Production of binocular vision due to
that the macula foveas of both eyes have
common visual direction, there are many
paired points with common visual
directions on binocular retina around the
macula called retinal corresponding
points.
Retinal corresponding points
 (2)Extrinsic muscles

 Extrinsic muscles of both eyes must be in

balance and coordination and with
ability of binocular fixation. Six
extraocular muscles control the
movement of each eye: four rectus and
two oblique muscles.
The distance of the points of insertion
from the corneal limbers
 (3)The cortex center of brain

 The cortex center of brain has a complete

fusion mechanism.
 Strabismus
 Strabismus: Any deviation from
perfect ocular alignment is called
strabismus. One eye gaze at the object
,whereas the other one is deviate from
the object.
 Misalignment may be in any
direction—inward, outward, up, or
down. The amount of deviation is the
angle by which the deviating eye is
misaligned.
 Strabismus is a problem caused by one
or more improperly functioning
eye muscles, resulting in a
misalignment of the eyes. Normally,
each eye focuses on the same spot but
sends a slightly different message to
the brain. The brain superimposes the
two images, interprets them as a single
one.
 Here's an easy way to see how the
eyes work together: hold your finger
at arm's length. While looking at your
finger, close one eye, then the other.
Notice how your finger changes
position. Even though the images are
slightly different, the brain interprets
them as one.
 Each eye has six muscles that work in
unison to control movements. The
brain controls the eye muscles, which
keep the eyes properly aligned. It is
critical that the muscles function
together for the brain to interpret the
image from each eye as Strabismus
must be detected early in children
because they are so adaptable.
 Ifa child sees double, his or her brain quickly learns
to suppress or block out one of the images to
maintain single vision. In a very short time, the
brain permanently suppresses vision from the
turned eye, causing a weak or amblyopic eye.
Children may also develop a head tilt or turn to
compensate for the problem and eliminate the
double image. Unlike children, adults with a newly
acquired strabismus problem typically see double.
 There are many causes of
strabismus. It can be inherited, or
it may be caused by trauma,
certain diseases, and sometimes
eye surgery.
 Signs and Symptoms
Adults are much more likely to be
bothered by symptoms from strabismus
than young children. It is unusual for a
child to complain of double vision.
Children should undergo vision
screening exams to detect problems
early. The younger the child is when
strabismus is detected and treated, the
better the chance of normal vision.
The following are common signs
and symptoms:
Turned or crossed eye
Head tilt or turn
Squinting
Double vision (in some cases)
 Detection and Diagnosis

 Strabismus is detected with a

comprehensive eye exam and
special tests used to evaluate the
alignment of the eyes such as: the
Hirschberg test and prism testing.
 Corneal reflection of light point

 The patient fixates a light at a distance of

about 33cm(13 inches). Decentration of the
light reflection is noted on the cornea of the
deviating eye, then an estimate of the angle
of deviation can be made.
 Treatment

 The appropriate treatment for

strabismus is dependent on several
factors including the patient's age, the
cause of the problem, and the type and
degree of the eye turn. Treatment may
include patching, corrective glasses,
prisms, or surgery.
 Treatment

 With patching, the better eye is

covered, forcing the child to use the
weaker eye. Over time, the brain
adjusts to using the weaker eye and
vision gradually improves. For this
treatment to be effective, it must be
done at a young age before the child
can develop amblyopia.
 Treatment
 Surgery is sometimes performed for both adults
and children to straighten a crossed eye. The
procedure may be done with local or general
anesthesia. There are several different surgical
techniques used to correct strabismus. The
appropriate one is dependent on the muscle
involved and the degree of the eye turn.
 Strabismus may be divided into two
types: concomitant and non-concomitant.
 Concomitant strabismus
 The axes of both eyes are not parallel and eyes
aren’t able to gaze at the same object
simultaneously which can’t be controlled by the
subject, leading to that one eye is orthophoria,
another is deviated, but the deviating angles in
all fixed direction are without obvious
difference, called concomitant strabismus.May
be divided into esotropia and exotropia.
 ‹1› .Concomitant esotropia
《 Etiology 》
 May be divided into accommodative and
nonaccommodative. Accommodative one is due to
over accommodation aroused strong force of
convergence. The cause of nonaccommodative
esotropia is quite more, has relation with anatomic
abnormality of extrinsic muscles, too strong
convergence or too weak divergence,complicated
with bad fusional function and etc.
 《 Clinical findings 》

 1›.One eye deviates to nasal side.

 Hering’law
 For movements of both eyes in the same
direction, the corresponding agonist
muscles receive equal innervation.
 《 Clinical findings 》

 2›.Eye movements is basically normal

when healthy eye is covered,the deviating
angles are equal in any direction of
fixation.
 3›.Without diplopia.
 ‹2›.Concomitant exotropia

 It is less common than esotropia and with

chronic onset. Most exotropia are
intermittent at beginning, the change of
deviating angle is quite large; in the
morning, binocular position may be
normal and strabismus appears after
tired in the evening.
 《 Etiology 》
 1›.Due to bad fusional function,there is over
divergence or insufficient convergence.
 2›.Accommodation and convergence are not in
balance.
 3›.Due to anisometropia, the patient often sees far with
one eye （ emmotropia ） , sees near with another
（ myopia ） ,convergence isn’t needed in daily
work,with the time going, exotropia may be occurred.
 《 Etiology 》
 4›.Due to developing abnormality of
extrinsic muscles.
 5›.One eye lost vision due to organic
lesion, exotropia is commonly seen after
puberty.
 《 Clinical findings 》
 1›.The
position of one eye is deviated to
temporal side.
 《 Clinical findings 》

 2›.Deviating angles are the same in any

directions.
 3›.Without diplopia
 ‹3›.Treatment of concomitant
strabismus
 1›.To correct ametropia
 2›.To treat amblyopia
 3›.To do orthopedic training
 4›.Surgical treatment
 （ 3 ） Paralytic strabismus

《 Etiology 》
 It may be divided into congenital and
acquired, the cause of the former is
congenital development abnormality,the
cause of the acquired one is:
 1›.Inflammation or toxication peripheral
neuritis, cerebritis, meningitis ect.
 2›.Metabolic,vascular,degenerative
lesions,diabetes, thrombosis ect.
 3›.Tumor intraorbital tumor presses the
3rd,4th,6th nerve.
 4›.Injury Orbital as well as craniocere-
bral injury the 6th;the fracture of the
superior orbital fissure 3rd cranial nerve.
 《 Clinical findings 》

 1›.Restriction
of eye movement
 2›.Compensatory head position
 《 Clinical findings 》

 It is one of the characters of paralytic

strabismus, in order to avoid the interference
of diplopia, the patient doesn’t use the paretic
muscle as possible, so the head tilts to the
direction the paretic muscle acts on ,if one eye
is covered, the compensatory head position
disappears at once.
 《 Clinical findings 》

 3›.Diplopia
 4›.Ocular vertigo and staggering gait
caused by diplopia.
 《 Diagnosis 》

 1›.Primary position （ rested position ）

 2›.Second position
 3›.Third position The globe rotates from
the first position to oblique direction.
 《 Treament 》

 1﹥ Causative treatment
 2﹥ For those with unclear cause,
corticosteroid and antibiotic may be
administered to eliminate inflammation as a
therapeutic test.
 3﹥ Vitamine B group by oral or injection
 4﹥ Acupuncture or physical treatment.
 《 Treament 》
 5﹥ After conservative treatment for 6-8
months, the etiology has been eliminated,
but there isn’t any possibility to restore
the function of the paretic muscle,
surgery should be considered.
 3).Amblyopia

 All that without any intraocular or

extraocular organic lesion, but their
corrected vision is less than normal are
called amblyopia.
 Amblyopia is a term used to
describe an uncorrectable loss of
vision in an eye that appears to be
normal. It’s commonly referred to
as “lazy eye” and can occur for a
variety of reasons.

A child’s visual system is fully
developed between approximately the
ages of 9-11. Until then, children
readily adapt to visual problems by
suppressing or blocking out the image.
If caught early, the problem can often
be corrected and the vision preserved.
However, after about age 11, it is
difficult if not impossible to train the
brain to use the eye normally.
 etiology
 Some causes of amblyopia include: strabismus
(crossed or turned eye), congenital cataracts,
cloudy cornea, droopy eyelid, unequal vision and
uncorrected nearsightedness, farsightedness or
astigmatism. Amblyopia may occur in various
degrees depending on the severity of the
underlying problem. Some patients just
experience a partial loss; others are only able to
recognize motion.
 Patients with amblyopia lack
binocular vision or stereopsis , the
ability to blend the images of both
eyes together. Stereopsis is what
allows us to appreciate depth.
Without it, the ability to judge
distance is impaired. Turning or
tilting the head when looking at an
object
 Note: Children rarely complain of poor
vision. They are able to adapt very
easily to most visual impairments.
Parents must be very observant of
young children and should have a
routine eye exam performed by the age
of 2-3 to detect potential problems.
 Strabismic amblyopia
 Due to deviation of eye position, diplopia
happened, in order to eliminate the
diplopia and visual disturbance caused by
strabismus the visual center of the cerebral
cortex suppressed the visual impulses
transmitted by crossed eye,its macular
function has been suppressed for a long
time to form amblyopia.
 Anisometropic amblyopia

 If the difference of refractive power in

both eyes is more than 2.5D, the
difference size of binocular retinal
images is so large that images diffcult to
be fused by visual center, the eye with
sever ametropia may form amblyopia.
Amblyopia by visual deprivation

 Congenital disorders such as congenital

cataract, corneal opacity, long-term
hinder stimulation of outside things to
visual sensation, so that the development
of visual function has been suppressed,
gradually to form strabismus and ambly-
opia.
 Ametropic amblyopia

 For example in hyperopia, myopia,

and astigmatism, commonly seen in
astigmatism
 Congenital amblyopia

 Organic amblyopia—retinal or
macular disorder,hemorrhage in new
born;congenital total color blindness.
 《 Clinical findings 》
 Poor vision in one or both eyes
 Squinting or closing one eye while reading
or watching television
 Deviation of the eye position (xeotropia)
 Abnormal fixation (eccentric fix-ation)
 Detection and Diagnosis

 When amblyopia is suspected, the

doctor will evaluate the following:
vision, eye alignment, eye
movements, and fusion (the
brain’s ability to blend two images
into a single image).
 Problems that impair vision such as
cataracts or droopy eyelids often
require surgery. Regardless of the
treatment required, it is quite
important that intervention is
implemented as early as possible
before the child’s brain learns to
permanently suppress or ignore the
eye.
 《 Treatment 》

 The treatment is to eliminate

suppression,to train macular fixation and
fusional function, to correct strabismus,
to improve vision so that restore
binocular vision.
 The treatment for amblyopia depends
on the underlying problem. In some
cases, the strong eye is temporarily
patched so the child is forced to use the
weaker eye. For children with
problems relating to a refractive error,
glasses may be necessary to correct
vision.