squint clinic hyderabad l. v. prasad eye institute

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Page 1: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 2: Squint Clinic Hyderabad L. V. Prasad Eye Institute

SquintClinicSquintClinic

HyderabadHyderabad

L. V. Prasad Eye InstituteL. V. Prasad Eye Institute

Page 3: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 4: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Formal Orthoptic Diagnostic Aid:

Formal Orthoptic Diagnostic Aid:

1

2

3

1

2

3

management is traditional rather than rational

Page 5: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Orthoptic ReportOrthoptic Report

Getting an orthoptic report

is like kissing your own sister

It doesn’t lead anywhere

Getting an orthoptic report

is like kissing your own sister

It doesn’t lead anywhere

Page 6: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Practical

Approach

To

Strabismus

Practical

Approach

To

Strabismus

Page 7: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 8: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Definition of StrabismusDefinition of Strabismus

• When the two visual

axes do not intersect at

the object of attention

• When the two visual

axes do not intersect at

the object of attention

Page 9: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Aim of ExaminationAim of Examination

• To determine the normality or

abnormality of :

• The sensory apparatus

• The motor apparatus

• In a valid & repeatable manner

• To determine the normality or

abnormality of :

• The sensory apparatus

• The motor apparatus

• In a valid & repeatable manner

Page 10: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Information Required From ExamInformation Required From Exam

• Bifoveal Fusion

• Nature and degree of Deviation

• Fusional Vergences

• Measurements

• If Tropia – characteristics of Suppression scotoma

• Bifoveal Fusion

• Nature and degree of Deviation

• Fusional Vergences

• Measurements

• If Tropia – characteristics of Suppression scotoma

Page 11: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Factors to Be ControlledFactors to Be Controlled

• Accommodation

• Fixation

• Fusional vergences

• Accommodation

• Fixation

• Fusional vergences

Page 12: Squint Clinic Hyderabad L. V. Prasad Eye Institute

All TestsAll Tests

• Cycloplegic

retinoscopy

• Refractive errors

corrected

• Accommodative

target for distance

and near

• Cycloplegic

retinoscopy

• Refractive errors

corrected

• Accommodative

target for distance

and near

Page 13: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 14: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 15: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 16: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Sequence of Clinical Tests Sequence of Clinical Tests

• Bi foveal fusion

• Fusional vergences

• Deviations & Measurements

• Rotations, A/V, Head tilt

• Limitation of movements • Restriction VS weakness

• Characteristics of suppression

• Bi foveal fusion

• Fusional vergences

• Deviations & Measurements

• Rotations, A/V, Head tilt

• Limitation of movements • Restriction VS weakness

• Characteristics of suppression

Page 17: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Doctor Must Do the Examination

Personally

Doctor Must Do the Examination

Personally

Page 18: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Cover TestCover Test

Page 19: Squint Clinic Hyderabad L. V. Prasad Eye Institute

ExotropiaExotropia

Page 20: Squint Clinic Hyderabad L. V. Prasad Eye Institute

EsotropiaEsotropia

Page 21: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 22: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Alternate Divergent SquintAlternate Divergent Squint

Page 23: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Un - Cover TestUn - Cover Test

Page 24: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Un - Cover TestUn - Cover Test

Page 25: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Exophoria – Fusional ReflexExophoria – Fusional Reflex

Page 26: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Exophoria – Fusion MovementExophoria – Fusion Movement

Page 27: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Intermittent Divergent SquintIntermittent Divergent Squint

Page 28: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Intermittent Divergent SquintIntermittent Divergent Squint

Page 29: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Prism Bar Cover TestPrism Bar Cover Test

Page 30: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 31: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 32: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 33: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Ocular MovementsOcular Movements

Page 34: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 35: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 36: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 37: Squint Clinic Hyderabad L. V. Prasad Eye Institute

every limitation of movement must be checked uniocularly

every limitation of movement must be checked uniocularly

Page 38: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 39: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 40: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 41: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Patterns : Rising EyePatterns : Rising Eye

Page 42: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Patterns : Falling EyePatterns : Falling Eye

Page 43: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Testing For A-V PatternTesting For A-V Pattern

Page 44: Squint Clinic Hyderabad L. V. Prasad Eye Institute

No A or VNo A or V

Page 45: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 46: Squint Clinic Hyderabad L. V. Prasad Eye Institute

V PatternV Pattern

Page 47: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 48: Squint Clinic Hyderabad L. V. Prasad Eye Institute

A PatternA Pattern

Page 49: Squint Clinic Hyderabad L. V. Prasad Eye Institute

10 ET10 ET10 ET10 ET

10 RXT10 RXT10 RXT10 RXT

40 XT40 XT40 XT40 XT

+4+4+4+4 +4+4+4+4

L/R L/R ++3030L/R L/R ++3030

- 3- 3- 3- 3- 3- 3- 3- 3

R/L R/L ++3030R/L R/L ++3030

Recording ResultsRecording Results

Page 50: Squint Clinic Hyderabad L. V. Prasad Eye Institute

10 ET10 ET10 ET10 ET

10 RXT10 RXT10 RXT10 RXT

40 XT40 XT40 XT40 XT

+4+4+4+4 +4+4+4+4

L/R L/R ++3030L/R L/R ++3030

{-3}{-3}{-3}{-3}- 3- 3- 3- 3

R/L =30R/L =30R/L =30R/L =30

Recording ResultsRecording Results

Page 51: Squint Clinic Hyderabad L. V. Prasad Eye Institute

EXEXEX

Mild Face Turn

+EN

Page 52: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 53: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Globe RetractionGlobe Retraction

Page 54: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Exotropia with HypertropiaExotropia with Hypertropia

R.E. Fixing

R.E. Fixing

Page 55: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 56: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Suspect StrabismusSuspect Strabismus

• If abnormal head posture

• If closing one eye

• If abnormal head posture

• If closing one eye

Page 57: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Head Tilt TestHead Tilt Test

Page 58: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Head Tilt Test : OthersHead Tilt Test : Others

Page 59: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Head Tilt Test : OthersHead Tilt Test : Others

Page 60: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 61: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 62: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Head Tilt Test : OthersHead Tilt Test : Others

Page 63: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Head Tilt Test : OthersHead Tilt Test : Others

Page 64: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Sixth Nerve Paralysis & SaccadesSixth Nerve Paralysis & Saccades

Page 65: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 66: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Floating SaccadesFloating Saccades

Page 67: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Primary Versus Secondary Deviation

Primary Versus Secondary Deviation

Page 68: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Forced Duction TestForced Duction Test

Page 69: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Forced Duction TestForced Duction Test

Page 70: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Force Generation TestForce Generation Test

Page 71: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Force Generation TestForce Generation Test

Page 72: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Sensory System / TestsSensory System / Tests

The sensory system is of inestimable importance in the management

Valid inferences :

• Age of patient

• Type of squint

• Refraction correction H/O

• Motor examination

The sensory system is of inestimable importance in the management

Valid inferences :

• Age of patient

• Type of squint

• Refraction correction H/O

• Motor examination

Page 73: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Sensory / Suppression - InferenceSensory / Suppression - Inference

Early onset tropia Binocular suppression scotoma

Early onset exotropia Temporal hemiretinal suppression scotoma

Early onset esotropia Regional nasal hemiretinal suppression

Early onset tropia Binocular suppression scotoma

Early onset exotropia Temporal hemiretinal suppression scotoma

Early onset esotropia Regional nasal hemiretinal suppression

Page 74: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Visual AcuityVisual Acuity

Page 75: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Even in a Baby It Is Possible ToEven in a Baby It Is Possible To

• Test the quality of vision

• Refract and examination fundi

(with help of atropine)

• Test the quality of vision

• Refract and examination fundi

(with help of atropine)

Page 76: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Qualitative VisionQualitative Vision

Page 77: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Don’t Forget The FundusDon’t Forget The Fundus

Page 78: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Prism RE: LE moves outAnd comes back to refixatePrism RE: LE moves outAnd comes back to refixate

4 Prism Test : Normal4 Prism Test : Normal

Page 79: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Prism RE: LE moves outAnd stays outPrism RE: LE moves outAnd stays out

4 Prism Test : Abnormal4 Prism Test : Abnormal

After removal of prismAfter removal of prism

Page 80: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Prism LE : No movementsPrism LE : No movements

4 Prism Test: Abnormal4 Prism Test: Abnormal

Page 81: Squint Clinic Hyderabad L. V. Prasad Eye Institute

4 Prism Test : Positive4 Prism Test : Positive

Page 82: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Sophisticated Tests Sophisticated Tests

Page 83: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 84: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 85: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 86: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 87: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 88: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Audience InteractionAudience InteractionAudience InteractionAudience Interaction

Page 89: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Aim of Strabismus ManagementAim of Strabismus Management

• Good vision in each eye

• Binocular vision

• Preferably stereopsis

• Normalise :

• Deviations

• Rotations

• Head position

• Good vision in each eye

• Binocular vision

• Preferably stereopsis

• Normalise :

• Deviations

• Rotations

• Head position

Page 90: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Rx of StrabismusRx of Strabismus

• Glasses

• Occlusion

• Prisms

• (Exercises)

• Surgery : minimum number of interventions

• Glasses

• Occlusion

• Prisms

• (Exercises)

• Surgery : minimum number of interventions

Page 91: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Pseudo StrabismusPseudo Strabismus

Page 92: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 93: Squint Clinic Hyderabad L. V. Prasad Eye Institute

GlassesGlasses

Page 94: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 95: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 96: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 97: Squint Clinic Hyderabad L. V. Prasad Eye Institute

OcclusionOcclusion

Page 98: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 99: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Cosmetic SurgeryCosmetic Surgery

Page 100: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Adjustable SuturesAdjustable Sutures

Page 101: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Superior Oblique ParalysisSuperior Oblique Paralysis

Page 102: Squint Clinic Hyderabad L. V. Prasad Eye Institute
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Page 106: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 107: Squint Clinic Hyderabad L. V. Prasad Eye Institute

Key to StrabismusKey to Strabismus

If you master the physical examination and

disregard the mystique of orthoptics then

strabismus is no longer such a difficult subject

Even I can handle it ?

If you master the physical examination and

disregard the mystique of orthoptics then

strabismus is no longer such a difficult subject

Even I can handle it ?

Page 108: Squint Clinic Hyderabad L. V. Prasad Eye Institute
Page 109: Squint Clinic Hyderabad L. V. Prasad Eye Institute

If you are interested in doing things mechanically

Fix holes in the retina / do cataracts If you want to exercise those grey cells

Do squints

If you are interested in doing things mechanically

Fix holes in the retina / do cataracts If you want to exercise those grey cells

Do squints

Page 110: Squint Clinic Hyderabad L. V. Prasad Eye Institute