An Overview of the OrthoptistAn Overview of the Orthoptist

Practical DemonstrationPractical DemonstrationThe Cover TestThe Cover Test

Louise.C.CorpLouise.C.Corp

Senior OrthoptistSenior Orthoptist

The Role of the OrthoptistThe Role of the Orthoptist

Assess and Manage:Assess and Manage:

Vision Defects (Amblyopia)Vision Defects (Amblyopia)

Vision ScreeningVision Screening

Defects of Binocular Single Vision (Squint)Defects of Binocular Single Vision (Squint)

Ocular Motility DefectsOcular Motility Defects

Low Vision AssessmentLow Vision Assessment

Glaucoma ClinicsGlaucoma Clinics

Vision AssessmentVision Assessment

‘Hundreds and thousands’ sweet test

Preferential looking with Cardiff cards

Kay single picture Multiple pictures

Sheridan-Gardiner Sonksen-Silver

At age 3 years (matching tests)

At age 2 years (naming pictures)

Expectations of a baby Expectations of a baby

To be able to fix and follow small toys To be able to fix and follow small toys ( e.g. mobile whilst in their cot), lights.( e.g. mobile whilst in their cot), lights.

Respond to facial expression Respond to facial expression ( e.g. confirmed by baby smiling, laughing, following ( e.g. confirmed by baby smiling, laughing, following parents face on movement ). parents face on movement ).

Baby will attempt to grasp for small toys whilst fixating on them Baby will attempt to grasp for small toys whilst fixating on them (e.g play frame over the child whilst laying on their back on the (e.g play frame over the child whilst laying on their back on the floor)floor)

At birth - VA approx 6/240 - Improvement rapid in first 6mths At birth - VA approx 6/240 - Improvement rapid in first 6mths with a slower rate up until 12mthswith a slower rate up until 12mths

Managing Vision DefectsManaging Vision Defects

AMBLYOPIAAMBLYOPIA – “Lazy Eye” – Reduced vision in – “Lazy Eye” – Reduced vision in one or both eyesone or both eyes

Causes – refractive error, squint, stimulus Causes – refractive error, squint, stimulus deprivation (ptosis or cataract)deprivation (ptosis or cataract) Patches

Atropine Penalisation Glasses

Blenderm

Optical Penalisation

Vision ScreeningVision Screening Reception Class (4 - 5yrs)Reception Class (4 - 5yrs) Vision, Check for Squint, Assess BSV, Ocular MotilityVision, Check for Squint, Assess BSV, Ocular Motility Pass / Fail CriteriaPass / Fail Criteria Absentees offered appointment at Community Clinic or re-visit Absentees offered appointment at Community Clinic or re-visit

schoolschool Referred to: Referred to:

Orthoptic Clinic, Hospital Optician, Consultant, High street Orthoptic Clinic, Hospital Optician, Consultant, High street OpticianOptician

96% coverage 96% coverage 83% passed 83% passed 5.4% referred to optician 5.4% referred to optician 4.8% referred to CRH 4.8% referred to CRH 1% referred to community clinic as borderline results 1% referred to community clinic as borderline results 4% absent but offered test at community clinic close to 4% absent but offered test at community clinic close to homehome

Defects of Binocular Single Defects of Binocular Single VisionVision

SquintsSquints

There are two types of There are two types of StrabismusStrabismus

M A N IF E S T L A TE N T

S TR A B IS M U S

Manifest StrabismusManifest Strabismus Also known as HETEROTROPIAAlso known as HETEROTROPIA When one eye focuses on an object, one eye deviates away When one eye focuses on an object, one eye deviates away

from the objectfrom the object Squint is caused by failure of two eyes to look at objects in a Squint is caused by failure of two eyes to look at objects in a

coordinated manner. Depends on the normal functioning of coordinated manner. Depends on the normal functioning of brain, optic nerve and twelve muscles around our eyes brain, optic nerve and twelve muscles around our eyes enabling the two images to superimpose on each other and enabling the two images to superimpose on each other and to form a three dimensional image.to form a three dimensional image.

HORIZONTALHORIZONTAL VERTICALVERTICAL TORSIONALTORSIONAL

HorizontalHorizontal

Convergent - one eye deviates nasally Convergent - one eye deviates nasally (turns inwards) (turns inwards) ESOTROPIAESOTROPIA

Divergent - one eye deviates temporally Divergent - one eye deviates temporally (turns outwards) (turns outwards) EXOTROPIAEXOTROPIA

Reflex at border of pupil = 15 Reflex at limbus = 45

What type of squint do these patients have?

RIGHT CONVERGENT SQUINT LEFT DIVERGENT SQUINT

Pseudo-Strabismus

Pseudo-Esotropia

• Epicanthic folds• Short interpupillary distance

Pseudo-Exotropia

• Wide interpupillary distance

Essential Infantile Esotropia Presents within first 6 months

• Angle large and stable

• Cross fixation

• Normal refraction for age

• Nystagmus in some cases

• Poor potential for BSV

• Amblyopia in about 30%

Signs

Constant Exotropia

Congenital

• Presents at birth• Large angle

• Disruption of binocular reflexes by acquired lesions, such as cataract

Sensory

• Alternating fixation• Normal refraction for age

Consecutive - follows previous surgery for esotropia

The effect of glasses The effect of accommodation

Ocular Motility DefectsOcular Motility Defects

Abnormal Eye MovementsAbnormal Eye Movements

• Ptosis, mydriasis and cycloplegia

• Abduction in primary position

• Limited depression • Limited adduction

• Normal abduction

• Limited elevation

• Intorsion on attempted downgaze

Third Nerve Palsy

THE PATIENT WILL SUFFER DIPLOPIA

Straight in primary position due to partial recovery

Limitation of right abduction and horizontal diplopia

Normal right adduction

Sixth Nerve Palsy

NERVE PALSIES (III,IV,VI) NERVE PALSIES (III,IV,VI) Be aware in ChildrenBe aware in Children

Present with acute onset SquintPresent with acute onset Squint

Complaining of DiplopiaComplaining of Diplopia

Parents notice closing of one eyeParents notice closing of one eye

Urgent referralUrgent referral

Serious PathologySerious Pathology

More common 6th Nerve PalsyMore common 6th Nerve Palsy

Elevation defect - most common Abduction defect - less common

Depression defect - uncommon Adduction defect - rare

Thyroid Eye Disease

Right Brown`s Syndrome

Normal elevation in abduction

Straight in primary position Limited elevation in adduction

Defect to the Superior Oblique Muscle / Tendon

EYE MOVEMENTS

PLOTTED USING THE

LEES SCREEN

HESS CHART

DIPLOPIA DIPLOPIA HORIZONTALHORIZONTAL

VERTICALVERTICAL

MAY REQUIRE THE USE MAY REQUIRE THE USE OF FRESNEL PRISMSOF FRESNEL PRISMS

What to refer to an Orthoptist ??What to refer to an Orthoptist ??

YesYes Vision concerns – baby Vision concerns – baby

not fixing/following small not fixing/following small toy / lightstoy / lights

Squint Squint Ocular Movement Ocular Movement

concernsconcerns Poor cooperation of Poor cooperation of

patient to ensure no patient to ensure no defectsdefects

Parental Concern Parental Concern BE CAREFUL!!BE CAREFUL!!

NoNo Family History alone – Family History alone –

distant relativesdistant relatives

If ? A squint in a child If ? A squint in a child < 4 months old if < 4 months old if obvious squint seen then obvious squint seen then refer if not ask HV to refer if not ask HV to check at 6mths, if still check at 6mths, if still doubtful then referdoubtful then refer

Does anyone in the group Does anyone in the group have a squint?have a squint?

Let`s find out ???Let`s find out ???

The Cover TestThe Cover Test

““An objective dissociation test to elicit the An objective dissociation test to elicit the presence of a presence of a manifestmanifest or latent deviation. It or latent deviation. It relies upon the observation of the eyes whilst relies upon the observation of the eyes whilst fixation is maintained and each eye is covered fixation is maintained and each eye is covered and uncovered in turn”.and uncovered in turn”.

Firstly, check for a manifest squint before Firstly, check for a manifest squint before progressing to find a latent squint.progressing to find a latent squint.

Detection of a manifest squintDetection of a manifest squint

Ensure patient is looking straight aheadEnsure patient is looking straight ahead A A light is used initiallylight is used initially as the position of as the position of

corneal reflections may indicate a manifest corneal reflections may indicate a manifest squint squint should be central / symmetrical or should be central / symmetrical or both displaced slightly nasalboth displaced slightly nasal

Hold fixation target Hold fixation target on a levelon a level with patients with patients eyes at a eyes at a 1/3m1/3m and ask them to look at it and ask them to look at it

Introduce occluder in front of one eye and Introduce occluder in front of one eye and watch for any watch for any movement of the other eyemovement of the other eye

Continued……………..Continued……………..

If there is no movement, repeat with the If there is no movement, repeat with the occluder in front of the other eyeoccluder in front of the other eye

If no movement visible then the patient If no movement visible then the patient DOES NOTDOES NOT have a manifest squint at that have a manifest squint at that fixation distancefixation distance

Repeat CT at 6m and far distance if Repeat CT at 6m and far distance if necessarynecessary

Possible findings for Possible findings for Manifest SquintManifest Squint

E X O TR O P IA

U n covered eyem oves in

In d ica tes it wasD IV E R G E N T

E S O TR O P IA

U n covered eyem oves ou t

In d ica tes it wasC O N V E R G E N T

D E V IA TIO N M A YA L TE R N A TE

IN D IC A TIN G E Q U A LV IS IO N IN E A C H E Y E

C O M B IN A TIO N O FH O R IZ O N TA L A N D

V E R TIC A L

H Y P E R TR O P IA

U n covered eyem oves d own

In d ica tes it wasE L E V A TE D

H Y P O TR O P IA

U n covered eyem oves u p

In d ica tes it wasD E P R E S S E D

P oss ib le F in d in g s :

Continued…………Continued…………

Performed at 1/3m, 6m and far distancePerformed at 1/3m, 6m and far distanceUsing accommodative/non-Using accommodative/non-

accommodative fixation targetsaccommodative fixation targetsWith and without glassesWith and without glassesWith or without any With or without any AAbnormal bnormal HHead ead

PPostureosture In 9 positions of gaze if requiredIn 9 positions of gaze if required

Detection of a latent squintDetection of a latent squint

Use appropriate accommodative/non-Use appropriate accommodative/non-accommodative targets on a level with the accommodative targets on a level with the patients eyes at 1/3mpatients eyes at 1/3m

Introduce occluder in front of one eyeIntroduce occluder in front of one eye Observe for any movement of the eye Observe for any movement of the eye

behind the occluder once it is removedbehind the occluder once it is removed Repeat with other eyeRepeat with other eye If no movement seen, alternate the occluder If no movement seen, alternate the occluder

from eye to eye (make sure binocularity is from eye to eye (make sure binocularity is avoided)avoided)

Continued………...Continued………...

A movement maybe A movement maybe more obvious as more obvious as alternate eyes are occludedalternate eyes are occluded

Size and direction of movement of the Size and direction of movement of the occluded eye as it is moved over to the other occluded eye as it is moved over to the other eye should be notedeye should be noted

Speed at which the eye moves back to the Speed at which the eye moves back to the normal position as the occluder is completely normal position as the occluder is completely removed should be noted (rate of recovery) – removed should be noted (rate of recovery) – indicates strength of BSV or vision levelindicates strength of BSV or vision level

Repeat at 6mRepeat at 6m

Remember…………….Remember…………….

Position of eyes on appearancePosition of eyes on appearance Check corneal reflections firstCheck corneal reflections first Ensure no manifest deviation Ensure no manifest deviation

present firstpresent first Estimate size of deviation Estimate size of deviation

(minimal,slight,mod,mkd) and (minimal,slight,mod,mkd) and direction of deviationdirection of deviation

Fixation targets-light,small picture Fixation targets-light,small picture or toy, 6m picture/objector toy, 6m picture/object

Can the manifest deviation Can the manifest deviation alternate or hold fixationalternate or hold fixation

Thank youThank you

Louise.C.CorpLouise.C.CorpOrthoptic DeptOrthoptic Dept

Calderdale Royal HospitalCalderdale Royal Hospital

01422 22221801422 222218