by pd examination of a squint

DR.VARSHINI SHANKARMODERATOR

DR.PUSHKAR DHIRPRESENTOR

HISTORY

INSPECTION

VISUAL ACUITY

EVALUATION OF MOTOR STATUS

HBCT/KRIMSKY/CT

EVALUATION OF SENSORY STATUS (STEROPSIS/ SUPPRESSION /ARC OR RC)

MEASUREMENT OF DEVIATION

ANT.& POST.SEGMENT

SPECIAL TEST TO IDENTIFY PARESIS & RESTRICTION

HISTORY• Age of Patient

• Complaint & HOPC:-o Age of Squint onset (early onset/ long

duration / constant angle / previous photos)

o Is it Sudden Or Gradual ?

o Direction of deviation patient / parent noted

o Is it Constant? Or Sometimes (INTERMITTENT)

o Noticed in One Eye or Both?

(U/L OR ALTERNATE)

o Diplopia? Asthenopia? Abn.Head Posture

• Birth Historyo Regarding Pregnancy & Delivery

o Developmental Milestones(Delay)

• Family History o Squint/ Refractive Error / Lazy eye

• Personal History o DM /HTN / Thyroid

• Treatment Historyo Glasses /Occlusion Therapy /Orthoptic

Exercise / Prev. Surgery

.….Looks can b really Deceptive

• Lid Fissure:-• Ptosis

• Mongoloid/Anti mongoloid

• Exophthalmos / enophthalmos

• Nasal Bridge

• Closure of one eye in bright light

• Epicanthal folds

• Head Posture (AHP)• Face Turn (Right/Left)

• Head Tilt (Right/Left Shoulder)

• Chin (Elevation/Depression)

• Facial Asymmetry

• Fixation Preference

• Nystagmus

INSPECTION

PTOSIS

Meri Refraction kon karega

VISUAL ACUITY

Infants (Birth-14 months)

Pre-Verbal Children

Toddlers ( 14 months – 21/2

years)

Preschoolers (21/2 years – 5years)

School going children (5years- 15 years)

1.Fixation preference test.

•Does he have a central/steady & mantained fixation.?

•Does he follow target?

•Does he get upset when u close one eye?

2.Optokinetic Nystagmus (OKN)

3.Force Choice Preferential looking test (FCPL)

4.Visual Evoked Potential (VEP)

1.Hundred & thousand sweet test

2. The Cardiff acuity Test

3.Dott Visual Acuity Testing.

1.LEA Symbols

2.Allen Picture Card

3.Broken Wheel Test

4.Tumbling E chart

5.Landolt C chart

6.Sjogren hand test

7.HOTV test

1.Tumbling E chart

2.Landolt C chart

3.Sjogren hand chart

4.Snellen’s chart

5.LogMAR chart.

FIXATION PREFERENTIAL TEST (CSM METHOD)

There are 2 types fixations are present:-

1.Centric 2.Eccentric

Component of Fixation

C= location of Corneal Reflex (Central/Uncentral)

S= Steady

M= Ability to maintain alignment first with one eye then with other

If Nystagmoid movements , VA ACUITY IN PATIENTS WITH NYSTAGMUS IS BINOCULAR

UC= uncentral

US= unsteady

UM= unmantained

MOTOR EXAMINATION

Extra-Ocular Movements

EOM

MONOOCULAR BINOCULAR

VERSIONS

(Conjugate Movements)

VERGENCES ( DisconjugateMovements)

???? ANGRY ?????

OR

????B/L MR OVER-ACTION

???

Points to Remember for EOM

• To check if all eye muscles r working together.

• Patient and examiner positioned at same level

• Correct any anomalous head position

• Room should be properly illuminated.

• Sit in front of the patient so that BE eyes can be seen simultaneously.

• Remove any Spectacles.( to remove prismatic effect)

• USE A PENLIGHT.

• 40 CM DISTANCE,SHINE ON FOREHEAD

• Move in 6 diagnostic/H position.

When Test Marks come

DEXTRO-ELEVATION LEVO-ELEVATION

DEXTRO-DEPRESSION LEVO-DEPRESSION

• ADDUCTION:- is normal when NASAL 1/3RD CORNEA crosses nasal punctum

• ABDUCTION:- is normal when TEMPORAL LIMBUS touches lateral canthus.

• INFERIOR OBLIQUES:- on lateral version , upwards deviation from the

horizontal line passing through centre of pupil

• SUPERIOR OBLIQUES :- on lateral version, downwards deviation from

the horizontal line.

• ELEVATION :-

• DEPRESSION :-

.

VergenceMovement

NPC NPA

NPC = role of DOT CARDNPA= role of FLIPPERSFusional Convergence= = role of CAT CARD/SYNAPTOPHOREFusional Divergence= =

!!D FORGOTTEN REFLEX!!

Bruckner Reflex

• Done with DO

• Distance of 3fts

• Power of DO is 0

• Helps to Detect:-Squint

Anisometropia

Leukocoria

Anisocoria

BRUCKNER REFLEX

Hirschberg Corneal Reflex (HBCT)• 1mm shift = 7° or 15 *Uses 1st Purkinje Image

00ºº

1515ºº

4545ºº

2828ºº

SQUINT

Apperent squint

(Pseudo-squint)

Latent squint

(Hetro-phoria)

Comitant

Paralytic/Paresis Ristrictive Spastic

Incomitant

Manifest squint

(Hetro-tropia)

Squint

PRE-REQUISTE FOR CT/CUT/ALT

• Vision More than 6/60 in BE to see the target

• Central fixation in BE

• If Bifocals are worn, near deviation measured through reading segment

SQUINT

TERMINOLOGIES

• IDS-RXT

• IDS-AXT

• LET

• ICS-RET

• ACCOMODATIVE ESOTROPIA

!!!!! KYA LOCHA HAI YE!!!!

Cover Test / Cover-Uncover/

Alternate Cover Test

• Helps to establish Ortho-tropic or not.

• Is Squint Latent= Phoria

• Is Squint Manifested = Tropia

• Direction of Deviation

• Fixation Behavior

• Check for Distance & Near

Cover test in all gazes for distance and near

Cover Test

• Done for distance & near

• Covering one eye of patient with normal binocular vision interrupts fusion.

• See for the movement OF OTHER EYE

• When eye is uncovered ,it will reestablish binocular fixation

• Imp. of Test:- Detects & Confirms

Tropias

Cover- Uncover Test

• Examiner OBSERVE THE COVERED EYE AS COVER IS REMOVED.

• In Hetrophoria,covered eye will deviate toward hetrophoricposition.

• When eye uncovered Reestablish Binocular Vision.

• Imp.of Test:- used to find out

PHORIAS

Alternate Cover Test

• Identify (Tropia + Phoria)

• Hold occluder over one eye for

several seconds

o Dissociates binocular vision

• Rapidly move occluder to other

eye

• Observe Refixation shift of

unoccluded eye

Objective Test

• Hirshberg Test

• Prism Alt.Cover Test(PACT)

• Krimsky Test

• Synaptophore Test

Subjective Test

• Maddox Rod

• Hess Screen Test

• Synaptophore Test

Krimsky Test /Modified HBCT

• Angle of strabismus is evaluated,

when the light is projected straight

ahead, and subsequent prisms

(prism bar) are placed

• Based on HERRING LAW of

equal innervation

BEFORE THE FIXING EYE

until symmetrical light reflexes are

seen on the cornea of both eyes.

Prism Alt.Cover Test

1.Maximum Deviation of eyes to be achieved to bring out full amt. of deviation ( can be done by patching one eye for 45/60mins)

2.Place Neutralizing prism over one eye.

3.Repeat Alternate testing

4.Cover should be placed alternatively over each other for some time.

5.NEVER NEVER NEVER allow patient to regain Fusion while cover is transferred.

6. Check for Distant & Near Vision

SENORY

EXAMINATION

STEREOPSIS

SUPPRESSION & DIPLOPIA

RETINAL CORRESPONDANCE

TO BE DONE WITH FULL OPTICAL

CORRECTION

TO BE DONE PRIOR TO ANY

DISSOCIATION

STEREOPSIS

TITMUS FLY TEST

(Based on Vectographic Principle)

RANDOM DOT TESTS

• RANDOM DOT E TEST

• TNO TEST (Based on Anaglph mehtod)

LANG TEST

(L-sterotest1 & 2)

LANG 2 Pencil Test

SYNAPTOPHORE

(Based on Haploscopic Principle)

SUPPRESSION

WORTH 4 DOT TEST

4D/20D BASE OUT TEST

BAGOLINIS FILTER TEST

MADDOX ROD TEST

AFTER IMAGE TE4ST

Gross Stereoacuity

Top of Upper Wings:2000seconds

Bottom of Lower Wings:1150 sec

Tip of Abdomen:700 sec

Fine Stereoacuity

Circles

1-3:800-200sec

4-6:140-80 sec

7-9:60-40 sec

Animals

A row:400sec

B row:200sec

C row:100sec

• Graded from 15-480 arc sec

• 8 plates; 480/240/120/60/30/15

• 1ST 3 plates to check for presence of stereopsis

• 4 is SUPPRESSION TEST PLATE

• If a child see 2 circle ask for larger circle

• 5,6,7for degree of steropsis

• Special Glasses Required

• Kept at distance of approx 30 cms

• Cost around 20,000!!!!!!!!!

• Checks NEAR STEROPSIS ONLY

FRISBY DAVIS DISTANCE TEST(FD2)

• Red / Green glasses

(Red over right eye)

• Dark Room

• Illuminated Target

• VARY TESTING DISTANCE TO IDENTIFY

SIZE OF SUPPRESSION SCOTOMA.

• White light is only binocular fusion target

• Done with a Projector/Chart

(6m)

• Test for Macular Scotoma

• Done with a Flashlight

• At Near (1/3m)-subtends 6

degree arc

• Tests for Extramacular

Suppression

W4dt interpretations• Distant W4DT means fusion occurs at macular

level

• Near W4DT means fusion occur at extramacular/peripheral retina.

• Narrow striation running in

one principal meridian.

• Lenses oriented at 45o and

135o

• Evaluation of DISTANCE

AND NEAR retinal

correspondence with minimal

dissociations.

R L

F

FL FR

BG LBG R

Multiple cylindrical high plus lenses stacked ontop of eachother.

Converts point source to streak Streak is perpendicular to cylinders!

Dissociative Blocks fusion (measures phoria) No control of

accommodative convergence Less useful for horizontal deviations

Uncrossed : Rt EsoCrossed : Rt Exo

STIMULATOR

• DEMONSTARTE

Patient is asked to comment on

–Position

–Brightness

–Separation between images

Diplopia Test