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476 Theory and Practice of Squint and Orthoptics
3. Treatment of V-pattern exotropia
i. If inferior oblique muscle overaction is
present, these muscles should be recessed
and either a bilateral lateral rectus muscle
recession or recess-resect procedure should
be performed for the horizontal deviation in
primary position.
ii. When inferior oblique overaction is not
present, the treatment of choice is either
bilateral lateral rectus muscle recession with
supraplacement of the insertion or combined
supraplacement of LR and infraplacement of
MR with a recess-resect procedure.
4. Treatment of A-pattern exotropia
i. If superior oblique overaction is present, its
bilateral tenotomies should be performed.
And keeping in mind the effect of superior
oblique tenotomies on the horizontal
deviation in primary position, either bilateral
lateral rectus recession or a recess-resect
procedure should be planned.
ii. When superior oblique overaction is not
present, the treatment of choice is either
bilateral lateral rectus muscle recession with
infraplacement of the insertion or combine
infraplacement of the LR and supraplacement of MR with a recess-resect
procedure.
5. Treatment of Y-pattern exotropia
i. No treatment is required, when the patient
fuses in primary position and downward
gaze, has a normal head posture, and does
not have double vision in upward gaze.
ii. When chin elevation is present and there is
associated overaction of the inferior oblique,
surgical weakening of both inferior oblique
muscles will close the Y-pattern.
iii. If the inferior obliques are not overacting,
supraplace the lateral recti without recessing
or infraplace the medial recti without
recessing.
6. Treatment of
-pattern exotropia
Despite fusion in primary position, patients with
-pattern exotropia may have considerable
difficulty with near work (i.e. in downgaze). No
horizontal surgery is indicated, but following
procedures may be performed:
i. If the superior oblique are overacting,
perform bilateral superior oblique tenotomies.
ii. If the superior obliques are not overacting,
supraplace the medial recti without recessing
or infraplace the lateral recti without
recessing.
Paralytic strabismus
• Investigate and treat the cause of paresis if
found.
• Conservative management for 6–8 months.
• Surgery, if indicated after 6–8 months
depending upon the muscle involved.
Special restrictive ocular motility defects
Duane's retraction syndrome
Surgery is performed only if there is significant
abnormal head posture and/or significant
deviation in the primary position. In general
surgical results are not very encouraging.
Brown's syndrome
Surgery to weaken the superior oblique should
be performed only in the presence of a significant
head tilt and/or a large vertical deviation.
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Index
Abducent nerve 17
Abnormal retinal correspondence (ARC) 213
and suppression 215
clinical phenomena associated with 216
development of 214
harmonious 213
management of 217
quality of binocular vision in 215
tests for 217
Accommodation 175
in age-related changes 175
anomalies 176
assessment 175
insufficiency 176
paralysis 177
spasm 177
Accommodative esotropias 237
infantile 246
non-refractive 241
partially 245
refractive 237
Acquired motor fusion deficiency 174
Acquired non-accommodative esotropias 246
Actions of extraocular muscles 6
Adjustable sutures in rectus muscle surgery 445
Agonist, synergists, antagonists and yoke
muscles 30
Amblyogenic factor and pathophysiological
mechanism involved 191
Amblyopia 190, 190-213
anisometropic 191
classification and terminology 190
clinical characteristics and laboratory 196
critical flicker frequency 198
electroretinography 198
evaluation and diagnosis 198
experimental strabismic 194
fixation behaviour test 198
in acupuncture 209
in problems 212
isoametropic 191
meridional 191
pathogenesis and pathophysiology 191
pathophysiological mechanisms 195
prevention and early detection 201
prognosis 213
recurrence of 213
treatment 202
Anaesthesia for squint surgery 432
Anatomy of
fourth cranial nerves 12
sixth cranial nerves 12
third cranial nerves 12
Anomalies of
accommodation 176
convergence 165
divergence 173
Apparent oblique muscle dysfunction 270
Applied anatomical aspects 11
ARC and suppression 215
Assessment for
accommodation and AC/A ratio 126
accommodative convergence/accommodation
(AC/A) ratio 127
extraocular muscle paresis 128
ocular movements 120
visual acuity from
1 to 3 years 46
3 to 6 months 44
6 to 12 months 45
birth to 3 months 42
Basic kinematics 20
Benedikt's syndrome 343
Binocular
fusion 68
movements 34
vision
aspects 62
definition and grades 61
of psychophysics and sensory
tests 89
Blind spot syndrome 217
Blind spot mechanism 218
Blood supply of extraocular muscles 5
Brown's syndrome 360
Bruckner pupillary red reflex test 112
480
Theory and Practice of Squint and Orthoptics
Cheiroscope 152
Clinical phenomena associated with ARC 216
Clinical types of ocular deviations 102
Clinical varieties of ocular palsies 317
Cogwheeling 392
Comitant vertical deviations 268
Common operative steps in squint surgery 435
Complications of extraocular muscle surgery 462
Components of
abnormal head posture 303
orthoptic vision therapy programs 153
visual acuity 39
Computer-based
combined diagnostic and therapeutic programs
159
diagnostic programs 153
orthoptic vision therapy programs and
instruments 153
therapeutic programs 154
vision therapy and neurovision therapy
programs 155
Computerised orthoptic diagnostic programs and
instruments 154
Concomitant esotropias 230
Congenital (infantile) exotropia 252
Congenital cranial dysinnervation disorders 349
Consecutive esotropia 252, 261
Contrast sensitivity 53
measurement of 54
Conventional (non-computerised) orthoptic
instruments 143
Convergence of 162
amplitude 165
anomalies 165
insufficiency 164
insufficiency associated with accommodative
insufficiency 170
near point, far point, range and amplitude 165
types 162
angle 164
reflex 162
voluntary 162
paralysis 170
spasm 171
Cyclodeviations 285
Depth perception 77
Development of ARC 214
Development of binocular vision 80
Dichoptic stimulation 71
Differential diagnosis of incomitant squint 312
Diploscope 149
Dissociated
horizontal deviation 284
strabismus complex 277
vertical deviation 278
Divergence 172
acquired motor fusion 174
anomalies of 173
of fusional 172
insufficiency 173
paralysis 174
Duane's retraction syndrome 351
Etiology of strabismus 104
Euthyscope 149
Evaluation and diagnosis 197
of amblyopia 198
Evaluation for ocular deviation 109
Evaluation of a case of strabismus 106
Examination (evaluation) of a case of heterophoria 223
Extraocular muscles 1
orbital fascia 1
Donders' law 32
Faden operation 448
fundamental laws governing ocular motility 32
general considerations 38, 213
global and orbital layers 6
Hering's law 32
listing's law 32
pulleys of rectus 10
Sherrington's law 33
surgical technique 449
transverse compartmentalization sleeves
(fascial sheaths) of 9
Exotropia 253
Goals of orthoptic vision therapy 153
Haidinger's brushes method 201
Hirschberg corneal reflex test 112
Heterophoria 220, 469
Heterotropias 469
History vision evaluation and preliminary
examination 108
Horizontal conjugate gaze paralysis 388
Incomitant vertical deviations 269
Indications for squint surgery 426
Infantile esotropia 231
Inferior oblique weakening procedures 451
Insufficiency of accommodation 176
Internuclear ophthalmoplegia 349, 389
Investigations of incomitant squint 306
Index
481
Livingston binocular gauge 147
Maddox rod test 116
Maddox wing test 118
Maddox double rod test 287
Maddox double prism test 288
Management of ARC 217
Marginal myotomy 448
Measurement of
contrast sensitivity 54
visual acuity 39
for near 52
in infants 42
in preschool children (3-5 years) 47
in school children (above 5 years) and
adults 50
Mechanics of actions of extraocular muscles 22
Milestones in development of vision 40
Monocular eye movements (ductions) 34
Monofixation syndrome 189
Motor adaptations 217
Motor fusion 69
Motor evaluation 110
Muscle transposition procedures 458
Nerve supply of extraocular muscles 5
Nerve
abducent 17
oculomotor 12
trochlear 16
Non-surgical management 420
optical treatment 420
orthoptics 425
pharmacologic treatment 423
Nystagmus 393
classification 396
definition and features 393
pathological 397
early onset (childhood) 397
late onset or acquired 400
like ocular motor oscillations 416
pathophysiology of 396
physiological 397
Nystagmus blockage syndrome 416
for surgical techniques 416
Oblique muscles 3
Oblique axis 22
Ocular
dysmetria 392
dysmetria, ocular flutters and opsoclonus 392
flutter 392
motor apraxia 387
movements 34
Opsoclonus 392
Ophthalmoplegia
external 349
internuclear 349
total 349
Oculomotor nerve 12
One-and-a-half syndrome 390
Optimal time for squint surgery 427
Orbital fascia 8
Orthoptic instruments 143
Outlines of strabismus management 469
Paralysis of accommodation 177
Paralytic squint 292
Pathogenesis and pathophysiology of
amblyopia 191
Physiology of ocular motility 20
Postoperative care after strabismus surgery 468
Preliminary examination 109
Prevention and early detection of amblyopia 201
Primary exotropia 253
Psychological adaptation 218
Psychophysics and sensory aspects of binocular
vision 62
Quality of binocular vision in ARC 215
Reading bars 151
Recession of rectus muscles 439
Rectus muscles 1
Remy separator 151
Resection of rectus muscles 441
Restrictive ocular motility defects 349
Restrictive strabismus due to
mechanical restrictions 360
misdirected muscle forces 349
Sensory
adaptations 180
esotropia 251
evaluation assessment for binocular
co-operation and sensory anomalies 136
exotropia 264
fusion 69
Skew deviation 391
Stereopsis 73
Strabismus
definition classification and etiology 97
Structural adhesions 368
Structural characteristics of extraocular muscles 6
482
Theory and Practice of Squint and Orthoptics
Superior oblique
strengthening procedures 457
weakening procedures 453
Suppression 180
Supranuclear
control of eye movements 372
disorders of eye movements 386
eye movement systems 383
ocular motor neural pathway 372
Surgical management 426
Symbols used for phorias and tropias 103
Symptoms of heterophoria 222
Syndrome
adherence 368
adhesive 368
Brown's 360
Duane's retraction 476
fusion maldevelopment nystagmus 398
Möbius 359
one-and-a-half 390
pseduo-Duane's refraction 366
spasmus nutans 399
tight lateral rectus 368
Tests for ARC 217
Tests for visual acuity assessment 40
Tibb's binocular trainer 152
Tight extraocular muscles 360
Treatment of
amblyopia 202
heterophoria 224
nystagmus 411
Trochlear nerve 16
Types of
contrast sensitivity 53
heterophoria 220
surgical techniques for squint correction 428
Vertical conjugate gaze paralysis 390
Vertical strabismus 268
Vertically incomitant
horizontal heterotropias 293
Vision evaluation 108
Visual acuity 38
and contrast sensitivity 38
components of 39
measurement of 39
Visual angle 38
Visual direction and the horopter 63
Visuscope 148
