CONCOMITANT

SQUINT
NOOR ASMAH MD AZMI
OPTOMETRIST
HSAH

4/12/2016
 Concomitant Squint
A type of squint in which the amount of
deviation in the squinting eye remains
constant in all directions of gaze, and
there is no associated limitation of ocular
movements
 Etiology
Binocular vision and coordination of ocular
movements are not present since birth but
are acquired in the early childhood.

The process starts by the age of 3-6

months and is completed up to 5-6 years.
Therefore, any obstacle to the
development of these processes may
result in concomitant squint.
 ETIOLOGY

Sensory obstacles
Refractive errors
Central obstacles
Prolonged use of Motor obstacles
Deficient development
incorrect Congenital
abnormalities of the of fusion faculty
spectacles
shape and size of the Abnormalities of
Anisometropia
orbit cortical control
Corneal opacities
of ocular movements,
Lenticular opacities Abnormalities of and hyperexcitability of
Diseases of macula extraocular the
Optic atrophy muscles
CNS during teething
Obstruction in the
pupillary area Abnormalities of
due to congenital ptosis accommodation,
convergence and AC/A
ratio
CLINICAL FEATURES

In general
 1. OCULAR DEVIATION
Unilateral or alternating
Inward deviation or outward deviation or vertical deviation
Primary deviation is equal to secondary deviation
Ocular deviation is equal in all directions of gaze
2. OCULAR MOVEMENT
Not limited in any direction

3. REFRACTIVE ERROR
May or may not be associated

4. SUPPRESSION AND AMBLYOPIA

May be develop as sensory adaptation to strabismus
Amblyopia develops in monocular strabismus only and is
responsible for poor visual acuity

5. A-V PATTERNS
May be observed in horizontal strabismus.
When this patterns associated, the horizontal concomitant
strabismus becomes vertically incomitant
A and V pattern
 TYPES
Esotropia
(convergent squint)
Exotropia
(divergent squint)
Hypo/Hypertropia
(Vertical squint)
 Classification
of
esotropia

Congenital Primary Secondary

Consecutive Residual
esotropia (sensory)
Accommodative
Non-
accommodative
Congenital / Infantile esotropia
 Congenital / Infantile esotropia
Onset within first 6 months of life
Unknown aetiology, multifactorial
Family history is common
Large angle >30, stable
Normal refractive error for age
Alternating fixation in primary position
Amblyopia (mild to moderate)
Cross fixation in side gaze
Latent & manifest nystagmus
IO overaction and DVD is common
 Congenital / Infantile esotropia
Treatment
Amblyopia treatment by patching the normal
eye should always be done before performing
surgery
Recession of both medial recti is preferred
over unilateral recess-resect procedure
Surgery should be done between 6 months
2 years; preferably <1 year
 Accommodative esotropia
Onset between 6mo and 7 years; often
hereditary
Associated with the activation of accommodation
Usually intermittent at onset, constant later
More noticeable when tired or unwell
Usually deviated eye is suppressed, diplopia is
uncommon but amblyopia is common
Loss of BV
 Accommodative esotropia
3 types
Refractive accommodative esotropia
Associated with high hypermetropia (+4 to +7D)
Fully correctable by use of spectacles

Non-refractive accommodative esotropia

Caused by AC/A ratio
Esotropia is greater for near than that for distance
Fully corrected by bifocal glasses with add +3DS for near vision

Mixed accommodative esotropia

Caused by combination of hypermetropia and high AC/A ratio
Esotropia for distance is corrected by correction of hypermetropia;
and the residual esotropia for near is corrected by addition of +3DS
lens
 Non-Accommodative esotropia
Developed after age 6 month and not
associated with accommodative
component
Deviation at Near=Distance
Correcting any hypermetropia or
prescribing near addition will give no effect
on the size of esotropia
 Consecutive esotropia
Occurs after surgical overcorrection of an
exotropia
May result in amblyopia and loss of normal
BV in young children
May result in diplopia in adults
 Secondary (sensory) esotropia
Develop within first 5 years of life
Results from monocular lesions such as
cataract, corneal scarring or optic atrophy
in childhood
Creates an obstacle to fusion
 Residual esotropia
Remaining after surgery for a larger
primary esotropia
Planned RE no further treatment
required, providing cosmetically accepted
and pt is symptom-free
Unplanned RE further treatment needed,
>15 with poor binocular function and
deviation remains cosmetically
unacceptable
 Classification
of
exotropia
Congenital Consecutive
Secondary
Residual
exotropia (sensory)
Primary
Intermittent
Constant
Congenital / Infantile Exotropia
 Congenital / Infantile Exotropia
Rare
Onset at birth/6mo
Large deviation
Amblyopia common especially in unilateral
Poor prognosis for binocular function
Usually associated with neurological
syndromes or defect
 Primary exotropia
Commonly intermittent than constant
Intermittent Constant
1. Distant XT 1. Early Onset
(Divergence Excess) (Congenital XT)
2. Non-specific XT
(Basic)
3. Near XT
(Convergence
Insufficiency/Weakness)
 Intermittent Distant XT
(Divergence Excess)
XT worse at Distance, XP at near
PCT measurement D>N, at least 10 PD
The manifest phase of XT precipitated by
- Inattention
- Poor health
- Fatigue
- Alcohol
 Intermittent Distant XT
(Divergence Excess)

Sign & Symptoms

Photophobia
Closure of one eye in bright light
Panoramic vision
Aware of squint
Blurred vision when manifest
Diplopia is uncommon
 Intermittent Non-specific XT
(Basic)
No significant near and distance deviation
Difference <10PD
 Intermittent Near XT
(Convergence Insufficiency/Weakness)

Near XT, distant XP

Near at least 10PD greater than distant
Poor convergence
Mainly in older children and adult
Equal VA
c/o asthenopia and headache with near
work
 Constant Exotropia
XT present at distant and near fixation
Happen at any age, after 1 years old
h/o intermitten deviation decompensated
Unilateral XT strabismic amblyopia
Alternating equal VA
Early onset suppression and no diplopia
No BSV
 Consecutive Exotropia
After squint surgery of ET
Pre-op ET
Post-op XT
Reduced potential for normal BV and
stereopsis
Diplopia
 Secondary/Sensory XT
Associated with monocular blindness or
dense amblyopia
Possible causes:
- Trauma
- Corneal opacities
- Congenital/Traumatic unilateral cataract
- Optic atrophy
- Untreated anisometropia/amblyopia
- RD
 Residual Exotropia
XT remaining after surgery for larger XT
May be planned (surgery carried out in 2
stages) or unplanned (most cases)

Tx indicated if:
- XT cannot be controlled bt motor fusion
reserves
- XT >15-20 PD with poor binocular
function
 Vertical deviation
When the visual axis of the squinting eye
deviates in the vertical plane
 Investigations
History
VA
Refraction
Cover test
EOM
Convergence
Binocular function
Suppression
Krimsky/Prism cover test
 History
Observation AHP/squint/eye
abnormalities
Complaints sign,symptom,which eye
History onset/duration/frequency,
past ocular history, birth history, family
history, other medical history, OLDER
PICTURE
 VA
Using appropriate method suitable for age
and intelligence
Monocular
 Refraction
Retinoscopy (objective)
Subjective RA
Cycloplegic RA
EOM
 Cover test
An objective method of evaluating of the
presence, direction and magnitude of the
phoria/tropia
Fixation targets
33cm (spotlight/detailed target/small
picture)
- 6m (spotlight/small toy/Snellen letter)
 Cover test
To determine:
- Phoria/tropia
- Unilateral/alternating
- Intermittent/constant
- Eye dominancy
- Direction/type
- Magnitude estimation
- Nystagmus
- DVD
Cover test
simulator
 Krimsky Test
To centralized the corneal
reflex in squinting eye to
that in fixating eye
Ideal for poor vision, poor
cooperation/baby
Place prism in fixating eye
until the reflex similarly
positioned
Esotropia BO
Exotropia BI
Direct reading of the squint
angle
 Prism cover test
Measure squint/misalignment
Single prism/prism bar
Primary position or all position of gaze
For near and distance
Prism cover test
1. Patient fixate on the target at
appropriate distance (30cm and
6m)
2. Perform cover test to determine
deviation (presence/type/which
eye/size)
3. Place prism in correct direction
before deviating eye (eso-BO,
exo-BI, hyper-BD, hypo-BU)
4. With prism in front of the eye,
perform alternate cover test-
ensure patient can see target at all
times. Increase strength of prism
until reversal of movement noted
5. Decrease the strength until no
movement noted.
6. Repeat for other
distance/positions of
gaze/with/without glasses.
 Parks Three Step Test
For patient with vertical deviation
Applicable for single vertical muscle palsy/paresis

Procedure
1. Ask patient to fixate at distance target
2. Perform CT/PCT at primary position-note the
size of vertical deviation
3. Perform CT/PCT with face turn at right and left-
note the size of vertical deviation
4. Perform CT/PCT with head tilt to right and left-
note the size of vertical deviation
Parks Three Step Test

PARKS THREE STEP TEST

 Management

Strabismus management

Non-surgical
- Optical (lens/prism)
- Medical/pharmacological Surgical management
- Orthoptic/exercise
 Management
Non surgical goals:
- restoration of VA
- restoration of comfortable BSV
 Optical management
Refractive correction
- cycloplegic RA
- proper glasses is the first basic step of
any form of treatment
Plus lens
- Fully accommodative ET
 Optical management
Bifocals
- relaxation of accommodation
- control ET at near
Minus lens
- stimulate accommodation & convergence
- control distance XT
 Optical management
Prism
In small angle strabismus with
diplopia/incomitant deviations
Eg: TED, post traumatic
Goals: to relieve diplopia, correct
significant AHP
Types : prism incorporated into glasses,
fresnel
 Medical/pharmacological
Miotic drugs pilocarpine, phospholine
iodide (rarely)
Cycloplegic, atropine prevent
accommodation
Botox rarely used
 Orthoptic/exercise
Examiner must certain that normal
sensory & motor fusion can be achieved
(has normal BV)
Patient must well motivated regular f/up,
home exercise
Aim eliminate suppression/sensory
adaptation, gain bsv, strengthen bsv
 Surgical management
Any deviation > 20 prism diopter will
almost certainly require surgery
Aim: straighten the eye for
functional/cosmetic, restore or maintain
concomitance, relieve symptoms