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Modern System of Ophthalmology [MSO] Series
Theory and Practice of
Squint and
Orthoptics
Fourth Edition
Modern System of Ophthalmology [MSO] Series
Theory and Practice of
Squint and
Orthoptics
AK Khurana MS, FAICO, CTO (London)
Fellow, Moorfields Eye Hospital, London
Director, Institute of Ophthalmology and Health Sciences, KEC, Rohtak
Former
Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
Professor and Head, Department of Ophthalmology
SGT Medical College, Hospital and Research Institute
Gurugram, Haryana, India
Former
Regional Institute of Ophthalmology
Senior Professor and Head
Fourth Edition
Assisted by
Aruj K Khurana DNB, FICO
Assistant Professor
Department of Ophthalmology
Vitreo-Retinal Services
SGT Medical College, Hospital and Research Institute
Gurugram, Haryana, India
Bhawna P Khurana MS, DNB, FICO
Associate Professor
Squint, Paediatric Ophthalmology
Orbit and Oculoplasty Services
Department of Ophthalmology
SGT Medical College, Hospital and Research Institute
Gurugram, Haryana, India
CBS Publishers & Distributors Pvt Ltd
New Delhi • Bengaluru • Chennai • Kochi • Kolkata • Lucknow • Mumbai
Gujarat • Hyderabad • Jharkhand • Nagpur • Patna • Pune • Uttarakhand
Disaimer
978-81-989-5381-0
Fourth 6
Branches
st
th
nd
Representatives
to
my parents and teachers for their blessings
and
the students and readers for their encouragement
Preface to the Fourth Edition
Modern System of Ophthalmology (MSO) series comprises separate volumes on different
subspecialties of ophthalmology. Each volume is planned with a very specific aim to cater to the
needs of postgraduate students in ophthalmology. Salient Features of MSO Series are:
• Each volume is edited by different editors, yet the layout and organization has been kept similar.
• Editors of different volumes are masters in their subspecialty with an uncanny knack of picking
up the right perspectives.
• Text matter is designed to meet the needs of residents in ophthalmology with a comprehensive
coverage in a concise manner. Text is complete and up-to-date with recent advances incorporated.
• Text is organized in such a way that the students can easily understand, retain and reproduce it.
Various levels of headings, subheadings, bold face and italics given in the text will be helpful for
a quick revision of the subject.
Theory and Practice of Squint and Orthoptics. The journey into the realm of strabismus
requires a multidisciplinary approach, combining insights from ophthalmology, optometry,
neurology, and orthoptics. This textbook is crafted to serve as a comprehensive guide,
providing a foundation for readers to explore the complexities of strabismus, from its basic
concepts to advanced diagnostic and therapeutic strategies. In its fourth edition this book
presents an updated and thoroughly revised text in a simplified form, so that the complex
and intricate physiology of neuromuscular co-ordination of extraocular muscles can be easily
understood. This flavour of the book makes the strabismus a fascinating and interesting entity.
The text has been organized into fifteen chapters. First four chapters have been devoted to
the anatomical and physiological aspects of extraocular muscles, faculty of vision, and binocular
vision. The remaining eleven chapters have been planned to provide a clear insight of the
various disorders of ocular motility. Each chapter is designed to offer a structured and indepth exploration of various aspects of strabismus, ensuring that readers can navigate the
content with clarity and confidence.
Salient Features of the Book
• Foundational concepts: This book provides a solid understanding of the basic principles of
strabismus, including anatomy, physiology, and the development of binocular vision.
• Diagnostic approaches: Delves into the various methods and technologies used to diagnose
and evaluate strabismus accurately. Includes how to interpret clinical findings and formulate
comprehensive treatment plans.
• In-depth exploration: Advanced concepts in strabismus go beyond the basics, offering a
thorough exploration of the intricate applied aspects relevant to strabismus.
• Pediatric and adult strabismus: Recognizes the unique challenges presented by strabismus
in different age groups. Provides insight into the developmental aspects of pediatric
strabismus and the complexities of managing adult cases.
• Clinical decision-making: Provides insights into the nuances of clinical decision-making in
strabismus management. Explores the intricacies of patient assessment, diagnostic dilemmas,
and the formulation of individualized treatment plans, equipping with the skills needed for
real-world clinical scenarios.
viii
Theory and Practice of Squint and Orthoptics
• Management strategies: Explores a spectrum of therapeutic interventions, ranging from
non-invasive approaches such as glasses, prisms and orthoptics to surgical techniques.
Understand the nuances of patient management and the importance of a personalized,
patient-centric approach.
• Surgical techniques: Delves into the latest surgical techniques and innovations in strabismus
correction. From traditional approaches to emerging minimally invasive procedures, this
textbook provides a comprehensive overview of surgical interventions, complemented by
lucid line diagrams.
AK Khurana
Contents
ix
Preface to the First Edition
trabismus, being an interesting subject, has always fascinated most of the ophthalmologists.
S
However, the extremely complex physiology and pathology of binocular vision and an
intricated neuromuscular co-ordination of the extrinsic ocular muscles have made strabismus
an untouchable entity for majority of the residents in ophthalmology as well as the practising
general ophthalmologists. Therefore, an attempt has been made in this book to present the
subject in a more easily understood form. In a bid to simplify the text, at places the description
looks more dogmatic than is warranted by the facts.
This book is intended to provide information on basic principles of squint and orthoptics to
the residents in ophthalmology and, students of orthoptics and optometry. It is hoped, the
book would be equally useful for the practising ophthalmologists and orthopticians as well.
To keep the book a basic text, advanced theories and many diverse opinions have not been
included. I hope, the experienced strabismologists and researchers in this field will bear this
with me.
First four chapters of this book have been picked up as such from the book, 'Anatomy and
Physiology of Eye'—a joint venture of mine with my wife. This would definitely extend some
relief to the students as this new text, comprising of fifteen chapters would practically get
down to eleven chapters. This becomes particularly relevant when the uncopable advances
in the field of ophthalmic technology has beset the present day residents in ophthalmology
with the voluminous texts on different aspects of the discipline. Some of the salient features of
this book are as follows:
The text has been organised in such a way that the students can easily understand, retain
and reproduce it. Various levels of headings, subheadings, boldface and italics given in the
text should be helpful for a quick revision of the text.
A brief list of the contents given in the beginning of each chapter provides a clear layout of
the text.
The text has been well illustrated with high quality clear line diagrams depicting vivid
and lucid details.
The text matter in chapters on 'Evaluation of Strabismus and Orthoptic Instruments' and
'Treatment Modalities and Outlines of Strabismus Management' has been discussed in length.
Operative steps of various surgical techniques have been illucidated in a self explanatory
manner.
Volumes like this are impossible without the contribution of several people. The significant
efforts put in by Dr Vinod Kumar Sharma are loudly acknowledged. He has rendered an
unprecedented help in completion of this book. I am thankful to Dr RC Nagpal, Prof and
Head, Deptt of Ophthalmology and Prof DS Dubey, Director, Pt BD Sharma PGIMS, Rohtak
for affording me a working atmosphere.
I am deeply indebted to my dear friend and old batchmate and a well known strabismologist,
Dr Kanwar Mohan, Assoc. Prof., Deptt. of Ophthalmology, PGI Chandigarh, for providing
the valuable photographs of patients with palsy of third and fourth cranial nerves (Figs 12.42
and 12.19) and Duane's retraction syndrome (Figs 12.43 to 12.45).