Restrictive strabismus

restrictive strabismus simplified

1. RESTRICTIVE STRABISMUS Dr. Debarati Dasgupta

2. Characterised by limitation of movement which is out of proportion to the ocular deviation in primary position. Can be mechanical or innervational anomaly.

3. Medial Rectus – Adduction. Lateral Rectus – Abduction. Superior Rectus – Elevation , adduction , intortion . Inferior Rectus – Depression, adduction, extortion. Superior Oblique – Intortion , abduction, depression. Inferior oblique – Extortion , abduction, Elevation.

4. CLASSIFICATION CONGENITAL DRS Brown’s syndrome CFEOM Mobius syndrome ACQUIRED Thyroid ophthalmopathy Orbital injury Tumours Surgeries

5. DUANE’S RETRACTION SYNDROME Stilling –Turk-Duane syndrome. Congenital miswiring of medial and lateral rectus muscles.

6. Prevalence – 1/1000. F >M. 4 % of all strabismic cases. 80 % are U/L. 30 % of cases a/w congenital anomalies. 90 % sporadic, 10 % inherited. Syndromic forms: Goldenhar syndrome. Moebius syndrome. Morning glory syndrome.

7. Complete or partial abduction or adduction deficit. Retraction on adduction. Pseudotosis on adduction. Upshoot or downshoot on adduction. Abnormal head posture.

8. MANAGEMENT NON SURGICAL Retractive error correction. Treatment of amblyopia. Prism glasses. Botulinum toxin – decreases upshoot or downshoot of globe with adduction. SURGERY Marked deviation. Significant head posture. Upshoot or downshoot. Severe globe retraction.

9. Type 1 & 3 with head turn – Recession of medial rectus or horizontal transposition of vertical rectus muscle. Type 1 & 3 with upshoot or downshoot or severe globe retraction – Recession of both MR & LR with Y splitting of LR.

10. Type 2 with head turn & fixation with uninvolved eye : Recession of I/L LR. Type 2 with head turn & fixation with involved eye: Recession of C/L LR. Type 2 with upshoot or downshoot: Recession of LR with with Y splitting.

11. Congenital 6 th Nerve Palsy – Infantile esotropia Mobius Syndrome

12. BROWN SYNDROME Tight or short superior oblique tendon. Congenital or acquired.

13. Limited elevation in adduction. Unaffected elevation in primary position & abduction. Divergnce in upgaze . FDT + ve . Widening of palpebral fissure on adduction. Ortho or hypo in primary position. Head posture.

14. Indication of surgery: Hypotropia in primary position Anomalous head posture. Surgery : SO Tendon sheath dissection. Chicken suture technique. Silicone expander.

15. Inferior Oblique palsy – no divergence in upgaze , SO overaction. Congenital fibrosis of inferior rectus- limitation of elevation in abduction. Grave’s disease.

16. CFEOM Fibrosis of extraocular muscles and tenon. Inelastic conjunctiva. Ptosis. Absent elevation. Perverted convergence on attempted upgaze . Choroidal coloboma, pendular nystagmus, optic nerve hypoplasia.

17. supramaximal recession of I.R. Correction of S.O overaction. Correction of Exodeviations , Perverted convergence – Faden procedure .

18. CPEO – later onset with progression. Congenital ptosis Congenital myasthenia – fatigable ptosis.

19. MOBIUS SYNDROME 1.Orthotropia in primary position with marked deficits in abduction and adduction (40% of cases) 2. Esotropia with cross-fixation and sparing of convergence and adduction (50% of cases) 3. Large exotropia with absence of convergence (10% of cases)

20. Medial rectus muscle recession in large-angle esotropia. To improve abduction by performing vertical rectus muscle transposition procedures after medial rectus muscle restriction has been relieve

21. THYROID OPHTHALMOPATHY Lid retraction, proptosis. Limitation of EOM. Convergence insufficiency. GAG production & deposition. Increase orbital pressure. Correction by prism or occlusion. Steroid. Surgical decompression Ocular deviation by muscle recession. Adjustable suture.

22. ORBITAL INJURY Most commonly inferior wall is involved. Entrapment of orbital tissue. Limitation of EOM. Hypoesthesia

23. Observe . Follow up with vision and diplopia chart. Indication for surgery : Diplopia in primary position or downgaze. Severe enophthalmos. Ocular deviation can be dealt later. MRI Surgical exploration.

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