History
The most common presenting signs of V-pattern strabismus are as follows:
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Inward or outward deviation of the eyes
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Abnormal eye movements in different gazes
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Asthenopia (eyestrain)
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Abnormal head posture, chin down in V-pattern exotropia and chin up in V-pattern esotropia
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Diplopia in older children and adults
Physical
The physical examination includes a general eye examination combined with a detailed ocular motility examination. The ocular motility examination, performed with the refractive error corrected, consists of the following:
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Note any abnormal head position.
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Perform cover tests with prisms in the primary position, 30° upgaze and 30° downgaze at near and at distance.
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With ocular rotations, look for associated underaction or overaction of oblique muscles.
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Perform a head tilt test if V-pattern strabismus is noted in patients with suspected bilateral superior oblique palsy.
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Measure torsion in patients with suspected inferior oblique muscle overaction to check for excyclotorsion.
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When required, perform sensory testing, including distance and near stereoacuity, and other tests.
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V-pattern exotropia.
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V-pattern esotropia.
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Esotropia and exotropia, V-pattern. In Image 3a, lateral rectus muscle insertion moved toward the open end of V. In Image 3b, medial rectus muscle insertion moved toward the closed end of V.
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Esotropia and exotropia, V-pattern. In Image 4a, half tendon width vertical shift of muscle insertion. In Image 4b, full tendon width vertical shift of muscle insertion.
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Esotropia and exotropia, V-pattern. In Image 5a, slanting of rectus muscle insertion. In Image 5b, recession and slanting of rectus muscle insertion.
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Esotropia and exotropia, V-pattern. Recess-resect procedure in same eye.
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Patient with V-pattern exotropia and inferior oblique muscle overaction.
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Patient with V-pattern esotropia and inferior oblique muscle overaction.
