squint examination & management- simplified !!

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CONCOMITANT SQUINT EXAMINATION & MANAGEMENT Dr. NITISH NARANG

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Page 1: Squint examination & management- simplified !!

CONCOMITANT SQUINT EXAMINATION & MANAGEMENT

Dr. NITISH NARANG

Page 2: Squint examination & management- simplified !!

MOTOR SYSTEM EXAMINATION• VISUAL ACUITY• HEAD POSTURE• INTER PUPILLARY DIAMETER• OCULAR DEVIATION • LIMITATION OF MOVEMENT / EXTENT OF VERSION• FUSIONAL VERGENCE

Page 3: Squint examination & management- simplified !!

VISUAL ACUITY

• INFANTS – OCCLUSION

OPTOKINETIC NYSTAGMUS

FORCED CHOICE PREFERENTIAL

LOOKING TEST

VISUALLY EVOKED POTENTIAL• PRE SCHOOL - ALLENS CARDS

SHERIDEN GARDINER TEST• SCHOOL GOING - VISUOSCOPE

Page 4: Squint examination & management- simplified !!

HEAD POSTURE• CHIN POSITION• FACE TURN• HEAD TILT CAUSES INCOMITANT SQUINT A OR V CONCOMITANT SQUINT NYSTAGMUS REFACTIVE CAUSES ONE EYED PERSON HOMONYMOUS HEMIANOPIA CONGENITAL SUP OBLIQUE PALSY

Page 5: Squint examination & management- simplified !!

INTERPUPILLARY DISTANCE• ORDINARY MILLIMETER SCALE• PULZONE HARDY RULE• SYNOPTOPHORE

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PSEUDOSTRABISMUS

• PSEUDOESOTROPIA

TELECANTHUS

EPICANTHUS

EURYBLEPHARON

• VERTICAL SQUINT

PTOSIS

LIDRETRACTION

• PSEUDOEXOTROPIA

HYPERTELORISM

CANTHOPLASTY

Page 7: Squint examination & management- simplified !!

ANGLE KAPPA• VISUAL AXIS - FOVEA TO TARGET• OPTICAL AXIS - CENTRE OF PUPIL• NORMAL - 5°EXOTROPIA• HIGHER - PSEUDOEXOTROPIA-

HYPERMETROPIA• NEGATIVE - PSEUDOESOTROPIA-

MYOPES

Page 8: Squint examination & management- simplified !!

OCULAR DEVAIATION *OBJECTIVE TESTS OF DEVIATION * COVER TEST UNCOVER TEST COVER UNCOVER TEST *PRISM BAR COVER TEST * SYNOPTOPHORE *CORNEAL REFLECTION TESTS HIRSCHBERG TEST KRIMSKY TEST

*SUBJECTIVE TESTS OF DEVIATION DIPLOPIA TEST HESS LEES SCREEN TEST *MEASUREMENT OF CYCLODEVIATION

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COVER - & UNCOVER TESTPREREQUISITES• FIXATION TARGET SIZE- 6/9 SNELLENS• FIXATION DISTANCE - 33CM & 6M• SPIELMANNS TRANSLUCENT OCCLUDER

Page 10: Squint examination & management- simplified !!

INTERPRETATION• COVER TEST - HETEROTROPIA• UNCOVER TEST - HETEROPHORIA SPEED OF RECOVERY DOMINANT EYE VISUAL ACUITY PSEUDOPTOSIS• COVER UNCOVER TEST - TRUE MANIFEST LATENT SQUINT DEVIATION DOMINANT EYE AMBLYOPIA

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PRISM BAR COVER TEST• APEX OF PRISM SHOULD POINT TOWARDS DEVIATION• LARGE DEVIATIONS - 30-40Δ FOR ONE EYE ADDITIONAL

PRISM TO OTHER EYE• PLASTIC PRISM – FRONTAL POSITION• GLASS PRISM – PRENTICE POSITION• RELAX DYNAMIC FACTORS –

ACCOMMODATION :REFRACTIVE CORRECTION

FUSION :OCCLUSION

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EFFECT OF GLASSES• HIGH PLUS – LESS DEVIATION • HIGH MINUS – MORE DEVIATION• MD/AD = 1- (0.025×D)

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DIFFERENT ASPECTS OF MEASUREMENT• DISTANT & NEAR FIXATION - BASIC, EXCESS OR

INSUFFICIENCY• WITH & WITHOUT GLASSES – ACCOMMODATIVE

ELEMENT• CARDINAL POSITIONS OF GAZE – INCOMITANCE• UPGAZE 25 DOWN GAZE 35 – A V PATTERN• EYE FIXATING ALTERNATIVELY – PRIMARY OR

SECONDARY DEVIATION• SUBJECTIVE & OBJECTIVE METHOD – RETINAL

CORRESPONDENCE• AFTER PROLONGED COVER – TRUE / SIMULATED

DIVERGENCE EXCESS, FULLY DISSOCIATED DEVIATION

Page 14: Squint examination & management- simplified !!

SYNOPTOPHORE

• ORTHOPTIC INSTRUMENT WITH HAPLOSCOPIC PRINCIPLE• INTERPUPILLARY DISTANCE• TORSION• ACCOMMODATIVE CONVERGENCE

RELATIONSHIP• ORTHOPTIC EXERCISES• SYNOPTISCOPE CUPRAX MAJOR• SYNOPTISCOPE OCULUS

Page 15: Squint examination & management- simplified !!

HIRSCHBERG TEST• FIRST CATOPTRIC IMAGE OF PURKINJE SANSON• NOT EXACTLY CENTERED; SYMMETRICAL• 1MM SHIFT = 5°DEVIATION• LIMBUS = 30° = 60Δ

Page 16: Squint examination & management- simplified !!

KRMSKYS TEST• PRISM REFLEX TEST• PRISM PLACED ON FIXATING EYE , NEUTRALISATION DONE BY

OBSERVING CORNEAL REFLEX IN DEVIATING EYE

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SUBJECTIVE TESTS • DIPLOPIA PRINCIPLE – 1 PHYSICAL LOCATION

PERCEIVED AS 2 PERCEPTUAL LOCALISATIONS

RED GREEN GOGGLES

MADOX TANGENT SCALE• HAPLOSCOPIC PRINCIPLE – 2 PHYSICAL LOCATIONS

USED TO HAVE 1 PERCEPTUAL LOCALISATION

SYNOPTOPHORE

HESS/LEES SCREEN

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RED – GREEN GLASS TESTING

• ESO – UNCROSSED – HOMONYMOUS• EXO – CROSSED – HETERONYMOUS • ILLUMINATED SLIT TARGET • 33CM & 6 M • 9 DIAGNOSTIC GAZE POSITIONS• INCOMITANT; DIAGNOSIS & FOLLOW UP

Page 19: Squint examination & management- simplified !!

HESS / LEES SCREEN• GRID PATTERN EACH SQUARE = 5° EXCURSION FOR

FIXATING EYE• INNER SQUARE TESTS 15° EYE MOVEMENT FROM

PRIMARY POSITION• OUTER SQUARE TESTS 3O° EXCURSION FOR FIXING

EYE• HESS – RED GREEN GLASSES• LEES – MIRROR SEPTUM• POLAROID DISSOCIATION , LANCESTER RED GREEN TEST WITH 2 FOSTER

TORCHES WITH FILTERS

Page 20: Squint examination & management- simplified !!

CYCLODEVIATION MEASUREMENT• DOUBLE MADDOX ROD TEST• SYNOPTOPHORE• INDIRECT OPHTHALMOSCOPY & FUNDUS EVALUATION

Page 21: Squint examination & management- simplified !!

LIMITATION OF MOVEMENTS• LIMBUS TEST OF MOTILITY OF KESTENBAUM• GRADING OF EOM

SCALE OF 7 OR 9• GRADING OBLIQUE OVERACTION

1= UPTO 15 ANGLE WITH HORIZONTAL

2 = UPTO 30

3 = UPTO 60

4 = UPTO 90

Page 22: Squint examination & management- simplified !!

MEASUREMENT OF VERGENCE

VERGENCE 6M : Δ 33CM:Δ

CONVERGENCE 14-20 35-40

DIVERGENCE 5-8 15-20

VERTICAL VERGENCE 2-4 2-4

INCYCLOVERGENCE 10-12° 10-12°

EXCYCLOVERGENCE 10-12° 10-12°

• NEAR POINT OF CONVERGENCE – PRINCES RULE NEAR POINT RULER ROYAL AF BINOCULAR GUAGE LIVING STONE GUAGE• CONVERGENCE SUSTENANCE• MEASUREMENT WITH PRISM

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SENSORY SYSTEM EXAMINATION

• BINOCULARITY& DIPLOPIA RED GREEN GOGGLES BAGOLINI’S GLASSES MADDOX ROD DARK RED FILTER WORTH FOUR DOT TEST • CORRESPONDENCE• SUPPRESSION- BAGOLINI’S GLASSES WORTH FOUR DOT TEST SYNOPTOPHORE AFTER IMAGE TESTING• AMBLYOPIA• STEREOPSIS - LANGS TWO PENCIL TEST TITMUS STEREO TEST

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BAGOLINIS STRIATED GLASSESSYMMETRICAL CROSSRESPONSE

NRCARC - HARMONIOUS

ASYMMETRICAL CROSS RESPONSE

INCOMITANT WITH ARC, DIPLOPIA

SINGLE LINE SUPPRESSION OTHER EYE

CROSS RESPONSE WITH CENTRAL GAP IN ONE LINE

CENTRAL SUPPRESION SCOTOMA IN THAT EYE

Page 25: Squint examination & management- simplified !!

MADDOX ROD TEST• SINGLE MADDOX ROD TEST –

DETECTS PHORIA• DOUBLE MADDOX ROD TEST – PATIENT ASKED TO ALIGN THE

TWO LINES OF MADDOX ROD IN PARALLEL FUSION

Page 26: Squint examination & management- simplified !!

MADDOX WING TEST

• RE – WHITE VERTICAL &RED HORIZONTAL ARROW

• LE – HOIZONTAL & VERTICAL ROWS OF NUMBERS

• HORIZONTAL DEVIATION – WHITE ARROW POINTS

• VERTICALDEVIATION - RED ARROW INTERSECTS• CYCLOPHORIA – RED ARROW PARRALLEL TO

NUMBERS

Page 27: Squint examination & management- simplified !!

WORTH FOUR DOT TEST4DOTS NRC WITH NORNAL BSV

HARMONIOUS ARC , MANIFEST SQUINT

3DOTS SUPPRESSION RIGHT EYE

2DOTS SUPPRESSION LEFT EYE

5DOTS NRC WITH MANIFEST SQUINTESODEVIATION UNCROSSEDEXODEVIATION CROSSEDVERTICAL

Page 28: Squint examination & management- simplified !!

SYNOPTOPHORE• SIMULTANEOUS PERCEPTION –

DISSIMILAR SLIDES• FUSION –

DISSIMILAR PERIPHERALS• STEREOPSIS –

SOME AREAS DISPARATE

STIMULATION, 3D EFFECT

Page 29: Squint examination & management- simplified !!

AFTER IMAGE TESTING

• HIGHLY DISSOCIATING ORTHOPTIC TEST FOVEA FLASHED WITH LINEAR AFTER IMAGE , R/E HORIZONTAL, L/E-VERTICAL

• CROSS RESPONSE - NRC± SQUINT• ASYMMETRIC CROSSING – ARC + SQUINT,

DISPLACEMENT PROPORTIONAL TO ANGLE OF SQUINT

• SINGLE – SUPPRESSION

Page 30: Squint examination & management- simplified !!

TESTING OF SUPPRESSION SCOTOMA• PRISM – TO DISPLACE OBJECT PARIPHERALLY TILL IT CAN BE

VISUALISED• SYNOPTOPHORE • HESS/ LEES SCREEN• POLAROID SCOTOMETER• GRADED DENSITY FILTER BAR OF BAGOLINI - DEPTH

Page 31: Squint examination & management- simplified !!

STEREOACUITY• LANGS TWO PENCIL TEST – DIFFERENTIATES ARC FROM

SUPPRESSION• TITMUS STEREO TEST – VECTOGRAPH USED IN CHILDREN GROSS STEREOPSIS 3000 SECS OF ARC • RANDOM DOT STEREOGRAM & TNO TEST

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FIXATION DISPARITY• FIXATION DISPARITY CURVES – UNDER FORCED VERGENCE WITH 3,6,9,12 Δ BASE IN / OUT

ALTERNATIVELY DISPARITY & ASSOCIATED PHORIA CHARTED• FORCED FIXATION DISPARITY CURVES – DIFFERENT SPHERICAL LENSES

2 TO 3 D IN 0.5 TO 1.0 STEPS USED TO MEASURES AC/A RATIO

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• SHEEDYS DISPAROMETER – CENTRAL FIXATION TARGET 2 HALF SPLIT HORIZONTAL / VERTICAL LINES , EACH ½ VISIBLE TO ONE EYE

• WESSONS CARD – VIEWED THROUGH POLAROID GLASS; UPPER1/2 – VERTICALL LINES , LOWER1/2 - ARROW , REST SEEN BINOULARLY

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MANAGEMENT• OPTICAL CORRECTION FOR REFRACTIVE ERROR CORRECTION• OCCLUSION THERAPY• ORTHOPTIC EXERCISE• OCULAR SURGERY

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WEAKENING PROCEDURES

• RECESSION – SLACKENS MUSCLE BY MOVING IT AWAY FROM ITS INSERTION • DISINSERTION/ MYECTOMY – DETACHING

MUSCLE FROM ITS INSERTION WITHOUT REINSERTION• FADENS POSTERIOR FIXATION SUTURE –

DECREASES THE PULL OF MUSCLE IN ITS FIELD OF ACTION• MYOTOMY / TENOTOMY

Page 36: Squint examination & management- simplified !!

STRENGTHENING PROCEDURES

• RESECTION – SHORTENS MUSCLE TO ENHANCE ITS EFFECTIVE PULL. CUT END REATTACHED TO ORIGINAL POSITION, ONLY FOR RECTI• TUCKING – OF MUSCLE / ITS TENDON TO

ENHANCE THE ACTION OF SO MUSCLE IN CONGENITAL 4 CN PALSY• ADVANCEMENT – OF THE MUSCLE NEARER TO

LIMBUS CAN BE USED TO ENHANCE THE ACTION OF PREVIOUSLY RECESSED RECTUS

Page 37: Squint examination & management- simplified !!

GENERAL PRINCIPLES OF SQUINT SURGERY• 1MM RESECTION OR RECESSION OF MR CORRECTS 3

OF DEVIATION & FOR LR IT IS 2• MR SHOULD NOT BE RECESSED MORE THAN 5.5 MM

& FOR LR IT IS 7 MM• UNDERCORRECTION BETTER IN CHILDREN 5 – 10 • PREFERRABLE TO OPERATE ON ELEVATORS THAN ON

DEPRESSORS . 3MM RECESSION CORRECTS 10

Page 38: Squint examination & management- simplified !!

CHOICE OF SURGERY• CONVERGENT SQUINT – MR RECESSION & LATERAL RECTUS

RECTION, MR RECESSION BOTH EYES• DIVERGENT SQUINT – LR RECESSION & MR RESECTION,

RECESSION LR BOTH EYES• ALTERNATING SQUINT – BIMEDIAL / BILATERAL RECESSION

Page 39: Squint examination & management- simplified !!

CHEMODENERVATION• TEMPORARY PARALYSIS WITH BOTULINUM TOXIN• TO DETERMINE RISK OF POST OPERATIVE DIPLOPIA • TO ASSESS POTENTIAL FOR BSV• IN LR PALSY• COSMETICALLY POOR DEVIATIONS

Page 40: Squint examination & management- simplified !!