Non Surgical Treatment of Strabismus

Non - surgical treatment of squint i.e. all types of squint have some modalities of treatment [ optical treatment, orthoptic treatment, Prismo-therapy, and pharmacological treatment] except surgical treatment.
1. OPTICAL TREATMENT -
in optical treatment, it should be include correction of refractive error and prismotherapy.
SPECTACLES should be prescribed in every cases.
It may correct to squint partially or completely.
IN PRISMOTHERAPY, for correction of squint, This is light weight, and easy to apply on the back surface of glass.
It is useful in heterophoria, nystagmus, convergence insufficiency, managing diplopia and maintain binocular single vision.
IN PHARMACOLOGICAL TREATMENT, miotics, atropine and botulinum toxin are prescribed in some types of cases of strabismus.
IN ORTHOPTIC TREATMENT, means straight eyes.
It is used as a diagnostic purpose and therapeutic purposes.
- to increase fusion amplitude.
- anti suppression exercises.
- treatment of amblyopia.
- treatment of abnormal retinal correspondance.
- to control deviations.
ORDER OF ORHOPTIC TREATMENT -
. amblyopia is treated firstly.
. anti- suppression therapy.
- diplopia training.
- amplitude improvement.

1. NON-SURGICAL &
SURGICAL
MANAGEMENT OF
STRABISMUS

2. CONTENTS
NON SURGICAL TREATMENT
SURGICAL TREATMENT

3. NON –SURGICAL TREATMENT
AIMS OF TREATMENT OF STRABISMUS –
To restore good visual acuity in each eye.
To achieve satisfactory cosmetic appearance.
To restore, if possible, normal vision.

4. TREATMENT MODALITIES –
A.) OPTICAL TREATMENT
B.) PHARMACOLOGICAL TREATMENT
C.) ORTHOPTIC TREATMENT
D.) SURGICAL TREATMENT
Non surgical treatment is essential in almost all strabismus cases & in many cases
may be sufficient to successfully treat the strabismus without surgery.

5. OPTICAL TREATMENT
1.) CORRECTION OF REFRACTIVE ERROR :-
Spectacles for correction of Refractive error should be prescribed in every
case.
Refractive correction also provide a proper balance b/w accommodation
& convergence
This, at fimes may correct the squint partially or completely.

6. GENERAL PRINCIPLES –
•In general, full cycloplegic correction should be prescribed.
•In school going children, the refractive correction prescribed should be such that
would provide an optimal distant vision.
•An overcorrection of +1.00 DS to +3.00 DS of the amblyopia eye has been
advocated.

7. ROLE OF GLASSES IN ESOTROPIA –
Refractive accommodative ESOTROPIA with CYCLOPLEGIC CORRECTION.
Non –Refractive accommodative esotropia with high AC/A ratio needs to be
treated with BIFOCAL GLASSSES.
Esotropia patients having associated myopic should be prescribed minimum
MINUS (-VE) LENS.
Esotropia patients having associated myopia and high AC/A ratio also require
BIFOCAL GLASSSES.
Residual esotropia of small amount should be prescribed the maximum
HYPERMETROPIC (+VE) CORRECTION.
Consecutive esotropia of small amount persisting after 3 weeks of surgery for
intermittent exotropia can be treated.

8. ROLE OF GLASSES IN EXOTROPIA –
An undercorrection of hypermetropia eroor recommended to reduce the
degree of consecutive exotropia.
Overcorrection of myopia may sometimes help in controlling the
intermittent exotropia by stimulating accommodation & convergence.

9. 2.) PRISMOTHERAPY –
PRISMOTHERAPY for strabismus has become popular after the introduction of
fresnel press on prisms.
Light weight.
Cosmetically acceptable.
Easy to apply on the back of the patient’s glasses.
Availability in powers from 0.5∆ to 30∆.

10. INDICATIONS –
Role of prism to assess the effect of surgery.
Role of prism in managing diplopia and abnormal head posture.
Maintenance of binocular single vision by neutrilizing the deviation.
Management of convergence insufficiency.
Management of heterophoria.
Role of prisms in Nystagmus.

11. METHODS OF USING PRISMS –
As fresnel prism
In spectacle frames.
As clip on prism.

12. PHARMACOLOGICAL TREATMENT
1.) MIOTICS-
Mechanism of action-
It includes miosis and spasm of accommodation, their utility in strabismus is
through their effect on accommodation.
It includes –long acting cholinesterase inhibitors such as echothiophate,
Demacarium bromide.
2.) ATROPINE –call mmon use of atropine
Cycloplegic refraction
Therapy of accommodative esotropia
Amblyopia

13. 3.) BOTULINUM TOXIN –
Mechanism of action –
When injected into an extraocular muscles blocks release of acetylcholine and thus
cause chemical denervation and thus paralysis of muscle for several weeks.
INDICATIONS-useful in short term treatment of –
Infertile ESOTROPIA
Paralytic strabismus
Surgical overcorrection
Graves ophthalmopathy and nystagmus
COMPLICATIONS –
Diplopia
Blepharoptosis
Vertical deviations
Perforation of globe

14. ORTHOPTIC TREATMENT
Literally, the word ORTHOPTIC means STRAIGHT EYES.
Practically, ORTHOPTIC training is used to treat
convergence insufficiency, to combat suppression,
amblyopia, & abnormal Retinal correspondence
and to improve fusional amplitude and stereopsis.

15. GOALS OF ORTHOPTIC TREATMENT –
Visual acuity levels in each eye should be best possible.
Eyes should be straight with/ without Surgical help.
Binocular single vision.
Fusion with good amplitude & reservers.
Reduction of Refractive glasses.

16. INDICATIONS-
1.) Diagnostic indications
2.) Therapeutic indications
Elimination of convergence insufficiency.
Fusion training, to increase fusion amplitude.
Anti suppression exercise
Treatment of abnormal Retinal correspondence.
Treatment of amblyopia
Control of deviations.

17. ORDER OF ORTHOPTIC TREATMENT –
Amblyopia is treated first.
Anti suppression therapy
Diplopia training.
Amplitude improvement.

18. DELIVERY OF ORTHOPTIC TREATMENT –
1.) TREATMENT OF CONVERGENCE INSUFFICIENCY –
Pencil convergence exercise
Physiological diplopia exercise.
Training for increasing fusional convergence with base
out prisms or synoptophore.
2.) EXERCISES FOR INCREASING FUSIONAL AMPLITUDE –
Both convergence and divergence.
Prisms
Major amblyoscope/ synoptophore.

19. 3.) ORTHOPTIC TREATMENT OF SUPPRESSION –
Diplopia exercises.
Vergence control in heterophoria.
Surgical alignment of eyes in large tropias.
Differential stimulation.
Macular massage.
Occlusion therapy.

20. SUGICAL TREATMENT
Extra ocular muscles is only a part of the therapeutic management of a
strabismus patients.
The squint surgery is aimed to procedure and maintain a condition in
which the visual axes of the two eyes are directed, without consious effort
to the object of fixation whatever it’s position.

21. INDICATIONS –
To correct squint cosmetically as well as functionally.
To correct the squint only cosmetically.
Marked asthenopic.
To correct abnormal head posture.
To relieve mechanical restrictions or to improve appearance.

22. OPTIMAL TIME FOR SQUINT SURGERY –
1.) CONCOMITANT SQUINT –
Children too young for orthoptic treatment .
a)For constant squint
b)For intermittent squint
Children old enough for orthoptic treatment.

23. 2.) PARALYTIC SQUINT –
Common surgical techniques for squint corrections –
A.) MUSCLE WEAKENING PROCEDURE –
Recession
Marginal myotomy
Myectomy
Free tenotomy
Posterior fixation suture.
Recession of conjunctiva and tenons capsule.
Muscle lengthening by insertion of a silicon expander /non
absorbable suture material.

24. B.) MUSCLE STRENGTHENING PROCEDURE –
Resection
Advancement.
Tucking.
C.) PROCEDURE THAT CHANGE DIRECTION OF MUSCLE ACTION –
Vertical transpositioning of the horizontal rectus muscles.
Horizontal transpositioning of vertical rectus muscles .
Slanting of the rectus muscle insertion.
Transplantation of muscle in paralytic squint.

25. THANKING YOU…….