SquintClinicSquintClinic

HyderabadHyderabad

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

Formal Orthoptic Diagnostic Aid:

Formal Orthoptic Diagnostic Aid:

1

2

3

1

2

3

management is traditional rather than rational

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

Practical

Approach

To

Strabismus

Practical

Approach

To

Strabismus

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

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

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

Factors to Be ControlledFactors to Be Controlled

• Accommodation

• Fixation

• Fusional vergences

• Accommodation

• Fixation

• Fusional vergences

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

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

Doctor Must Do the Examination

Personally

Doctor Must Do the Examination

Personally

Cover TestCover Test

ExotropiaExotropia

EsotropiaEsotropia

Alternate Divergent SquintAlternate Divergent Squint

Un - Cover TestUn - Cover Test

Un - Cover TestUn - Cover Test

Exophoria – Fusional ReflexExophoria – Fusional Reflex

Exophoria – Fusion MovementExophoria – Fusion Movement

Intermittent Divergent SquintIntermittent Divergent Squint

Intermittent Divergent SquintIntermittent Divergent Squint

Prism Bar Cover TestPrism Bar Cover Test

Ocular MovementsOcular Movements

every limitation of movement must be checked uniocularly

every limitation of movement must be checked uniocularly

Patterns : Rising EyePatterns : Rising Eye

Patterns : Falling EyePatterns : Falling Eye

Testing For A-V PatternTesting For A-V Pattern

No A or VNo A or V

V PatternV Pattern

A PatternA Pattern

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

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

EXEXEX

Mild Face Turn

+EN

Globe RetractionGlobe Retraction

Exotropia with HypertropiaExotropia with Hypertropia

R.E. Fixing

R.E. Fixing

Suspect StrabismusSuspect Strabismus

• If abnormal head posture

• If closing one eye

• If abnormal head posture

• If closing one eye

Head Tilt TestHead Tilt Test

Head Tilt Test : OthersHead Tilt Test : Others

Head Tilt Test : OthersHead Tilt Test : Others

Head Tilt Test : OthersHead Tilt Test : Others

Head Tilt Test : OthersHead Tilt Test : Others

Sixth Nerve Paralysis & SaccadesSixth Nerve Paralysis & Saccades

Floating SaccadesFloating Saccades

Primary Versus Secondary Deviation

Primary Versus Secondary Deviation

Forced Duction TestForced Duction Test

Forced Duction TestForced Duction Test

Force Generation TestForce Generation Test

Force Generation TestForce Generation Test

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

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

Visual AcuityVisual Acuity

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)

Qualitative VisionQualitative Vision

Don’t Forget The FundusDon’t Forget The Fundus

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

4 Prism Test : Normal4 Prism Test : Normal

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

Prism LE : No movementsPrism LE : No movements

4 Prism Test: Abnormal4 Prism Test: Abnormal

4 Prism Test : Positive4 Prism Test : Positive

Sophisticated Tests Sophisticated Tests

Audience InteractionAudience InteractionAudience InteractionAudience Interaction

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

Rx of StrabismusRx of Strabismus

• Glasses

• Occlusion

• Prisms

• (Exercises)

• Surgery : minimum number of interventions

• Glasses

• Occlusion

• Prisms

• (Exercises)

• Surgery : minimum number of interventions

Pseudo StrabismusPseudo Strabismus

GlassesGlasses

OcclusionOcclusion

Cosmetic SurgeryCosmetic Surgery

Adjustable SuturesAdjustable Sutures

Superior Oblique ParalysisSuperior Oblique Paralysis

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 ?

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