concomitant and incomitant, ahp and hess chart
TRANSCRIPT
Presented By:Tehseen JavaidMuhammad Amin
1. CONCOMITANCE / INCOMITANCE
2. ABNORMAL HEAD POSTURE
3. HESS CHART
DEFINITIONS
CONCOMITANT DEVIATION:
Angle of deviation remain same in all directions of gaze and there is no limitation of ocular movements.
INCOMITANT DEVIATION:
Angle of deviation varies in different position of gazes and there is limitation of ocular movements.
Secondary angle of deviation is greater than primary deviation
DIFFERENCIAL CRITERIA COMITANT DEVIATION INCOMITANT DEVIATION
OCCURANCE More common Less common
ONSET Usually congenital Usually acquired
DEVIATION Primary angle is equal to secondary angle
Secondary greater than primary angle
MOVEMENT No limitation Limitation
AHP None Present
DIPLOPIA None Amblyopia
CAUSE Hereditary
Uncorrected refractive error
Usually injuryVascular diseases
DEPTH PERSCEPTION None due to suppression
Present when do AHP
INCOMITANT DEVIATION
NEUROGENIC MYOGENICMECHANICAL
3RD NERVE PALSY6TH NERVE PALSY4TH NERVE PALSYDOUBLE ELEVATOR PALSY DOUBLE DEPRESSIVE PALSY
Myasthenia gravis Chronic
Progressive External Ophthalmoplegia
Orbital myositis
Brown syndromeDuane syndromeOrbital injuryThyroid eye disease
INVESTIGATION CONGENITAL ACQUIRED
PRESENTATION Unacceptablecosmetic appearance symptoms of decompensation,Unaware of AHP.
Diplopia and occasionally pain
OCULAR MOTILITY Often full muscle sequlae
Muscle sequlae not fully developed
DURATION Longstanding Recent
BINOCULARFUNCTION
Extended vertical fusion range
Normal fusion range
ABNORMAL HEAD POSTURE:
AHP is a motor adaptation and it is adapted in the
interest of comfortable vision
COMPONENTS OF AHP:
Face turn towards right or left side
Chin up or down
Head tilt towards right or left shoulder
ASSESMENT OF AHP:
Compare ear is more visible
Check whether eyes are level
Observe chin from side
CAUSES OF AHP:
OCULAR CAUSES•Obtain BSV•Maintain BSV•Overcome symptoms•Improve visual acuity•Protect eyes•Separate diplopia in paralytic strabismus•Nystagmus
NON OCULAR CAUSES:•Shyness•Habit•Deafness•Mental developmental delay•Arthritic condition•Non ocular torticollis(Contracture of
Sterno- mastoid muscle.
How to confirm either AHP is ocular or non ocular?
EXAMINATION OF COMPONENTS OF AHP
FACE TURN:
CHIN ELEVATION OR DEPRESSION
HEAD TILT
AHP IN PARALYTIC CONDITIONS:NEUROGENIC PALSIES:
3rd nerve palsy
Complete
Incomplete(divisional or isolated)
4th nerve palsy
6th nerve palsy
MECHANICAL PALSIES:
Brown syndrome
Duane’s syndrome
AV PATTERNS:
A eso or V exo
A exo or V eso
NYSTAGMUS:
1:Dissociation of the eyes by either :
• Red and green goggles in case of hess
• The mirror in case of lees screen
2:Foveal projection inn the presence of normal retinal correspondence :
3:Herring’s law and sherrington’s law:
• Explain the development of muscle sequlae.
1:Diagnosis of:
U/a or o/a of eom.
Mechanical or neurogenic palsy
Congenital/long standing
Acquired/recent palsy
2:planning of surgery and post-op effects of surgery
3:Monitoring of surgery
Full muscle sequlae will include :
E.g :sr u/a = io o/a
:Ir o/a = so u/a
What is the direction of the deviation eg: Eso, exo, hyper, hypo?
What is the size of the deviation?
Is the deviation concomitant or incomitant ?
Is there a smaller field ?
Which is the affected muscle(s) or nerve(s) ?
Has the muscle sequelae spread to produce concomitance ?
Is the aetiology mechanical or neurogenic ?
Is there an a or v pattern ?