Grade two : is tested by presenting two similar images

Binocular single vision with a missing detail in each eg. two similar rabbits , one
lacking a tail and the other lacking a bunch of flowers.
The ability of the brain to perceive a single mental image,
with the added blessing of depth perception, by receiving
two retinal - two dimensional- images.

 BNV is an acquired function of the brain, that takes

an average of 6 years to be fully developed
 The first 6 months (critical period ) . Grade three : by presenting two images of the same
object but with a different angle.

Grades of BNV

1) Grade one = Simultaneous perception (6 mths) :

ability to perceive two flat clear images of the two
foveas.
2) Grade two = Fusion (6yrs) : ability to fuse two
similar images .

The difference in retinal image sizes (anisokonia) has a

limit for fusion to occur of about 10-15%
2) Worth's 4 dot test
3) Grade three = Stereopsis : ability to perceive depth
aided by the nasal disparity

Advantages of BNV

1. Larger field

2. Stereopsis (depth
perception)

3. Masking defects of the other eye

Testing of BNV

1) Synaptophore

a) normal binocular fusion {the white dot sows rivalry}

b) 2 red dots : eye under green suppressed ( left)
c) 3 green dots : eye under red suppressed (right)
d) 5 dots : diplopia

Grade one is tested by presenting two dissimilar images

such as a bird and a cage
 Latent squint
(heterophoria)
Tendency for the visual axes to deviate from the
orthophoric position when the binocular vision is
dissociated or fusion is disrupted eg. covering one eye
or presenting to dissimilar images to the brain or loss of
interest in using both eyes or fatigue
exophoria ( latent divergent ) squint
Etiology = Uncorrected error of refraction
NB: the alternate cover test is done if no deviation is revealed
Types during cover test by covering one eye for 2 sec and shifting
 Esophoria : tendency for an inward deviation in quickly to the other eye noting any corrective movements as it
hypermetropia due to increase in the assumes fixation.
accommodative / convergence ratio
 Exophoria : tendency for an outward deviation in 4) To measure the angle of squint
myopia
idea is to dissociate BNV by presenting dissimilar images
Symptoms to both eyes by using :

1) No symptoms : in compensated phoria a) Maddox rod for far

2) Decompensated phoria :
 Due to the effort to maintain binocular vision =
Muscular asthenopia (eye strain )
 Due to failure of binocular vision for intermittent
periods = Intermittent binocular diplopia and
blurring of print and running of letters while
reading

Signs
1) Retinoscopy : reveals ametropia
2) Corneal light reflex ( Hirshburg test ) : NO primary
angle of deviation
3) Cover – uncover test :

 The idea is to abolish the stimulus for

binocular single vision ( dissociate the eyes) by
covering one eye. b) Maddox wing for near
Result :
o any recovery movement after removing the
cover (secondary angle of deviation) indicates the
presence of latent squint or phoria
o The direction of movement indicates the type of
squint eg. From outwards inwards indicates
exophoria

orthophoria : no movemet with cover Treatment:

 Correction of ametropia
 +/- exercising weak muscles eg. by prisms
 Asthenopia (eye strain) Concomitant squint
Group of symptoms noticed with visual tasks chiefly after It's the manifest squint in which the angle of squint is
near work, esp by artificial illumination, such as eye ache, constant in all directions of gaze ie. the eyes move
frontal headache, blurring, lacrimation +/- hyperemia together freely with no limitation of movement (non-
paralytic ).
 Accommodative (ciliary muscle) eg. Hyperopia
Presbyopia [ NOT myopia } Etiology = Any obstacle that interferes with BNV
 Muscular (extra-ocular muscles ) eg. development ( before 6 years ).
Heterophoria
a) Uncorrected error of refraction
b) Uncorrected Anisometropia
a) Unilateral sensory obstacle affecting vision eg.

Anisometropia
o Central corneal scar
o Complete ptosis
o Congenital cataract
o Retinal pathology eg.retinoblastoma
Significant difference in the refractive power of both eyes
- more than 4 D in most people - which is beyond the Types
fusional capacity of the brain dt the big difference According to which eye deviates
between the size of retinal images ( anisokonia ) 1) Unilateral : one eye is always deviating while
the fellow eye is always fixing eg.
Anisometropia and Unilateral or bilateral
asymmetric organic disease (sensory obstacle
in one eye)
a) Alternating : the two eyes alternate deviation
and fixation eg. uncorrected error almost of the
same degree in both eyes.

According to the direction of deviation

a) Convergent = Esotropia … more common

b) Divergent = Exotropia

Clinical picture
Symptoms
1) If below 6 years and uncorrected = Amblyopia and i. Cosmetic ( crossed eyes)
ii. Of cause
concomitant squint iii. NO diplopia
2) if corrected by glasses eg. unilateral aphakia = Signs
Binocular diplopia . { as the spectacle 1) Visual acuity: Unequal VA usually accompanies
magnification factor of glasses is 33 % which is unilateral squint, & may point out to amblyopia.
beyond the fusional capacity of the brain } 2) External and slit lamp examination = cause eg.
Ptosis, corneal scar, cataract.
Treatment = Contact lens ( anisokonia < 10 %) 3) Cycloplegic Refraction = anisometropia or
uncorrected error of refraction
NB: In case of a planned cataract surgery = IOL 4) Fundus examination
implantation ( anioskonia of about 1-2%)
Any child with concomitant squint fundus examination is a
must to exclude sensory cause, the most serious of which
is retinoblastoma
5) Corneal light reflex : there is a primary angle of o If any residual angle is left = surgery
deviation which is constant in all gazes o Treatment of amblyopia = occlusion or patching
of the fixing eye to give a competitive advantage
If the light reflex falls on the pupillary edge = 15 for the squinting amblyopic eye
If the light reflex falls on the limbus = 45
o Rules of occlusion :
o Before 6
o After treating the cause
o Part-time occlusion = one week per each year of
life - 6 hours each day . It’s essential to follow up to
monitor your treatment and more importantly to
avoid inducing amblyopia of the sound eye.

6) Cover test :
 secondary angle of deviation = primary angle of
deviation
 Diagnose the type of squint after cover removal
 Alternating : remains fixing with the squinting eye

Squint surgeries

1) Weakening eg. Recession ( moving muscle

insertion backwards)

a) Unilateral : previously deviating eye will

deviate again indicating amblyopia

2) Strengthening eg. Resection by excising part of its

belly or moving insertion forwards

Treatment

 If >6 years = surgery for cosmetic reasons

 If < 6years = treat the cause
o Organic lesion eg. . Ptosis surgery,
keratoplasty, cataract extraction and IOL
o Anisometropia = contact lens {not glasses}
o Myopia or astigmatism : full correction of the
error
o Hypermetropic (accommodative convergent
squint ) = full correction of the total error by
glasses

NB: total error is the one revealed after

cycloplegia
 Signs
Paralytic squint 1) Corneal light reflex : Manifest squint to the
opposite direction of affected
Its is the manifest squint dt paresis or paralysis of one or muscle.
more of the extraocular muscles.

Etiology = Lower motor neuron lesion of the 3rd +/- 4th +/-
6th nerves.  Esotropia in 6th nerve palsy

 Vascular eg. DM, BP, atherosclerosis

 Inflammatory eg. neuritis - meningitis
 Trauma eg. fracture base  Exotropia with hypotropia in
 Aneurysm eg. Posterior communicating artery 3rd nerve palsy
aneurysm in 3rd nerve
 Demylinating diseases ( MS - DS )
 Raised intracranial pressure ( esp 6th )
 Neoplastic eg. brain gliomas
 Congenital  Hypertropia in 4th nerve
 Cavernous sinus lesions palsy
 Orbital lesions
 Neuro-muscular junction eg. myasthenia gravis

Symptoms = Binocular diplopia as the image falls on The diplopia and primary angle of deviation is maximum towards the
non-corresponding points direction of the affected muscle eg.
o In abduction in 6th nerve palsy,
o On looking down eg. reading or going downstairs in 4th nerve
palsy

2) Cover-uncover test : secondary angle of deviation

larger than primary angle of deviation

dt Hering's law: were in the attempt of the brain to give

extra impulses to the paralysed muscle & extra impulses
are given simulataneously to the yoke muscle in the other
diplopia is the simultaneous perception of two images for
eye producing larger deviation.
the same object
binocular diplopia is the diplopia that appears only under
3) Motility : limitation of movement towards the
binocular conditions ie. disappears by covering either eye.
direction of affected muscle.

Types :
 Uncrossed ( homonymous) : paralytic esotropia or in
lateral rectus palsy or 6th nerve palsy

 Limited depression in adduction in 4th nerve

palsy.
 Limited abduction in 6th nerve
palsy
 Crossed ( heteronymous) : in paralytic exotropia or
medial rectus palsy
 Vertical : in paralytic hypertropia or superior oblique
4th nerve palsy
  Limited depression, elevation, and adduction in 5) In 3rd nerve palsy
3rd nerve palsy.
o Ptosis: if complete there will be no diplopia unless
the lid is elevated . That’s why, if surgery is to be
done (not before 6 months), squint surgery must
precede ptosis surgery
o Pupil : dilated and fixed ( efferent defect) with
paralysis of accommodation

NB: In medical causes eg. DM, atherosclerosis : the

pupil is usually spared dt affection of the vasa
nervosa while In surgical causes eg. Aneurysm,
hematoma : it is usually affected dt early affection of
the pupillary fibers

4) Compensatory posture = towards the direction of

action affected muscle to minimize diplopia :
 in 6th np = ipsilateral face turn
 in 4th np = conralateral head tilt & chin depression

Treatment
 Of the cause : Refer to neurologist , MRI brain eg.
Aneurysm, neoplasm
 To avoid diplopia : Alternate occlusion or relieving
prisms

 surgical correction : wait for spontaneous nerve

regeneration {6 months)
 Botilinium toxin (botox ) could be injected in the
antagonist to avoid its contracture.
 Apparent (pseudo) strabismus Amblyopia
 Apparent convergent ( pseudo-esotropia) eg.
epicanthus – blepharophimosis - high axial myopia : Types :
dt small angle kappa ( < 5° )
1) Stimulus or pattern deprivation (amblopia
exanopsia): media opacities will degrade the image
from the affected eye. in cases of a unilateral or
bilateral asymmetric sensory obstacle eg. congenital
cataract or ptosis covering the pupil .
2) Anisometropic or optical defocus amblyopia: the
patient will suppress the more blurred image.
 Apparent divergent ( pseudo –exotropia) eg. high 3) Strabismic amblyopia : in order to avoid diplopia ,
axial hypermetropia : dt large angle kappa { > 5°) the patient will suppress the deviating eye.

Treatment :

part time occlusion occlusion (patching) of the fixing

eye to give a competitive advantage for the amblyopic
eye. But only after treating the cause and before the
critical or sensitive period during which it could be
reversed { <6 years }