The document provides information on evaluating cases of orthoptics. It discusses evaluating a patient's history, visual acuity, eye movements, sensory status, and degree of strabismus. The evaluation includes assessing visual acuity, refraction, eye alignment using various objective tests like cover tests, assessing binocularity using stereopsis tests, and determining the presence of suppression or abnormal retinal correspondence. The document outlines the various tests used to evaluate motor and sensory functions in patients with strabismus.
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Evaluating Cases of Orthoptics
1. EVALUATING THE CASES OF
ORTHOPTICS !
Optom. Ankit S. Varshney
B.Optom, M.Optom, Ph.D. in Optometry (pursuing) Fellow of IACLE (Aus.), Fellow of ASCO(Mum.)
Prof. at (Shree Bharatimaiya College of Optometry & Physiotherapy, Surat)
Life Member of Indian Optometric Association (IOA)
Associate Member of Association of Schools and Colleges of Optometry(ASCO)
Member of Optometry Council of India(OCI)
Educator Member of International Association of Contact lense Educators (Australia)(IACLE)
Mail id: ankitsvarshney@yahoo.com
Whatsapp no. +918155955820
6. EVALUATION
INCLUDES
1. History
2. Visual acuity
3. General examination
4. Evaluation of the motor state
5. Evaluation of the sensory state
6. Anterior and Posterior segment
evaluation Optom. Ankit Varshney 6
7. ASK RELEVANT QUESTIONS ONLY!
Age of patient at onset.
Who noticed first
Mode of onset – sudden / gradual / intermittent
If intermittent – precipitating factors
Which eye deviates
Nature and direction of deviation
Any alternation with gazes & time
Amount of squint
Whether for near or distanceOptom. Ankit Varshney 7
8. CHIEF C/O
PERSONAL H/O
FAMILY H/O
TREATMENT H/O
Optom. Ankit Varshney 8
History
9. History- subjective ocular complaints
Blurred Or Double Vision
Headache, Asthenopia
Diplopia, Past Pointing, Vertigo
Presence Of Face Turn, Head Tilt, Abnormal Head
Movement
Closure Of One Eye In Bright Sunlight
Optom. Ankit Varshney 9
10. History - precipitating causes
History of head or face injury
History of recent illness
Any eye disease prior to onset
necessitating occlusion of one eye with
pad.
Maternal history and birth history
Optom. Ankit Varshney 10
11. PERSONAL HISTORY
ANTENATAL- DRUGS, ILLNESS
PERINATAL- TYPE OF DELIVERY
PREMATURITY
BIRTH WT.
NEONATAL JAUNDICE,
CONVULSIONS..
DEVELOPMENTAL H/O- MOTOR, SPEECH, HEALTH,
HANDEDNESS
Optom. Ankit Varshney 11
12. History - previous treatment
Spectacle correction and its effect on squint
Occlusion or orthoptic treatment
Surgery
Response To Treatment
Optom. Ankit Varshney 12
13. FAMILY HISTORY
PARENTS, GRANDPARENTS, UNCLE,
AUNTS…
SQUINTING
HIGH REFRACTIVE ERROR
TREATMENT TAKEN FOR SQUINTS.
Optom. Ankit Varshney 13
14. 2. VISUAL ACUITY
Uniocular for distance and near, also
pinhole VA
With and without spectacles
Binocularly specially in patient
with nystagmus
Fixation pattern
Optom. Ankit Varshney 14
15. REFRACTION
Refraction is a must for all patients with
strabismus
Agent- <10yrs.- 1% Atropine sulphate
>10yrs.- 1% Cyclopentolate +
5% Homatropine
Proper refractive error corrn. Reqd.
Optom. Ankit Varshney 15
16. FUNDUS EXAMINATION.
MEDIA & FUNDUS EXAM. MUST BE DONE IN
ALL PATIENTS WITH STRABISMUS
DIRECT OPHTHALMOSCOPE
ALSO USED IN BRUCKNER’S TEST
PUPILLARY REACTIONSOptom. Ankit Varshney 16
17. NEAR POINT OF CONVERGENCE
PRINCE RULE, RAF RULE
BREAK POINT
NORMAL – 5 TO 10 cm
CONVERGENCE
MAINTAINANCE
Optom. Ankit Varshney 17
• <5 EXCESSIVE
• >10 DEFECTIVE
• ACCOM.TARGETWITH SUBJECTIVE
AND OBJECTIVE METHODS
18. Near Point Of Convergence
Optom. Ankit Varshney
18
•The RAF Rule is used for measurement of distances from the spectacle plane to the
target.
•To measure NPC the slide is moved closer to the patient until diplopia is reported (break),
then pushed back until single vision is regained (recovery)
22. MEASUREMENT OF DEVIATION
OBJECTIVE TESTS :
MINIMAL COOPERATION REQUIRED
ONLY STEADY FIXATION
SUBJECTIVE TESTS :
PT’S RESPONSE DETERMINES THE
RESULTS
CLINICAL EVALUATION OF SENSORY
STATUS Optom. Ankit Varshney 22
23. HIRSCHBERG CORNEAL REFLECTION TEST
ROUGH BUT HANDY METHOD :
ESTIMATE APPROXIMATE ANGLE OF
MANIFEST SQUINT
MORE IMPORTANT FOR
Optom. Ankit Varshney 23
1. BLIND EYE
2. DEEP AMBLYOPIC EYE WITH LOW VA
3. UNABLE TO MAINTAIN FIXATION FOR
LONGER TIME e.g. YOUNG CHILDREN
26. COVER TEST
I. DISSOCIATION OF BINOCULAR VISION BY COVER
II. ALWAYS BE DONE FOR NEAR AND DISTANCE FIXATION
TO ESTABLISH ANY DIFFERENCE WITH ACCOMODATION
III. SHOULD BE DONE WITH GLASSES AND WITHOUT
IV. AND IN ALL NINE GAZES FOR INCOMITANT SQUINT.
Optom. Ankit Varshney 26
Three observations:
1. Watching one eye as the other eye is covered.
2. Watching the uncovered eye when the cover is removed.
3. Watching the covered eye when its cover is removed.
27. BEFORE TEST
NO MOVEMENT AFTER COVER
ESOTROPIA
EXOTROPIA
HYPERTROPIA
HYPOTROPIA
DIRECT COVER TEST
Optom. Ankit Varshney 27
29. UNI LATERAL RE ESOTROPIA:
AFTER UNCOVER, LE AGAIN
TAKE FIXATION
Optom. Ankit Varshney 29
30. Cover-uncover test
Detects phorias
Deviation of eye under cover noted; fusional
movement on removal of the cover noted
Test is repeated covering the other eye;
performed for distance as well as near.
Disadvantage small phorias may be
missed
Optom. Ankit Varshney 30
32. ALTERNATE-COVER TEST
COVER EACH EYE ALTERNATELY TO BREAK
COMPLETE FUSION AND WATCH BEHAVIOR OF
EACH EYE WHEN COVER IS REMOVED AND
TRANFERED TO OTHER EYE.
FOR, BASIC DEVIATION, INTTERMITANT
TROPIAS, PHORIAS WITH STRONG FUSION
Optom. Ankit Varshney 32
• Patient should fixate with each eye
• Detects total strabismus
(manifest + latent )
36. MADDOX ROD TEST
PRINCIPLE
INSTRUMENT
METHOD
Optom. Ankit Varshney 36
37. Maddox Rod
Optom. Ankit Varshney
37
H: Ortho ESOphoria or
ESOtropia
EXOphoria or
EXOtropia
V: Ortho
R hyper
or
L hypo (phoria or tropia)
R hypo deviation
or
L hyper
(phoria or tropia)
Patient’s view with
Maddox Rod
over right eye.
Appearance is
reversed if the
Maddox Rod is
over the left eye.
Maddox Rod axis horizontal: vertical streak
Maddox Rod axis vertical : horizontal streak
39. PRISM BAR COVER TEST
PRINCIPLE :
– AFTER COVERING FIXATING EYE, MOVEMENT OF OTHER EYE IS
DIRECTLY PROPORTIONAL TO DISTANCE OF FOVEA FROM
PERIPHERAL STIMULATED AREA.
– PLACING PRISM WITH INCREASING DIOPTRE BRINGS IMAGE
CLOSER TO FOVEA, WHEN PRISM STRENGTH EQUALS TO
DEVIATION, (IMAGE ON FOVEA) NO MOVEMENT
Optom. Ankit Varshney 39
42. RE ESO
ALT. COVER EYES
PRISM BASE OUT PLACED
COVER TRANSFERRED TO
PRISM
NO MOVEMENT
Optom. Ankit Varshney
42
43. Prism-cover test
Advantages
Accurate to within 2 prism diopters
Provides complete dissociation thus
measure maximum deviation
Gives comparison of angle at different
distance
Disadvantages
Inaccurate in large deviation
Cyclotropia can’t be measured
Optom. Ankit Varshney 43
44. KRIMSKY PRISM TEST
BASED ON HERING’S LAW
VALUABLE IN PATIENT WITH BLIND OR DEEPLY
AMBLYOPIC EYE OR ECC FIXATION.
PRECISE THEN HIRSCHBERG’S TEST
Optom. Ankit Varshney 44
45. RE ESO WITH POOR VISION
PRISM ON FIXING EYE
K’REFLEX IN CENTRE IN
DEVIATED EYE
OPTICAL PRINCIPLE
Optom. Ankit Varshney 45
46. SYNOPTOPHORE
DIVISION OF “ PHYSICAL SPACE INTO TWO SEPARATE AREAS OF VISUAL SPACE”
Optom. Ankit Varshney 46
• FOR DISTANCE & NEARVISION:
– NEAR MEASUREMENTWITH MINUS LENSES (IPD 6 cms)
• MEASUREMENTOF SUBJECTIVE & OBJECTIVEANGLE OF DEVIATION
FOCAL PLANE AT OPTICAL INFINITY
ROLE OF PROXIMAL CONVERGENCE
EXAMINATION IN EXTREME
POSITION OF GAZE
ADJUSTMENT FOR NEAR
IMPORTANT CONSIDERATION
48. Sensory Evaluation
Goals: to establish
Presence of diplopia or suppression
Presence and degree of amblyopia
Type of retinal correspondence
Stereopsis
Optom. Ankit Varshney 48
49. TEST FOR
STEREOPSIS
Titmus test: fly 3000 sec of arc
circles 800-40 sec of arc
animals 400-100 sec of arc
TNO test: 480-15sec of arc.
No monocular clues are given.
Lang’s test:1200-550 sec of arc
Frisby test: 600-15 sec of arc
Synaptophore
Optom. Ankit Varshney 49
54. LANG
YOUNG CHILDREN
NOT REQ. SPECIAL SPECTS
TARGETS SEEN BY EACH EYE
THROUGH BUILT IN
CYLINDRICAL LENS ELEMENT
D.D.1200 -600SECS OF ARC
Optom. Ankit Varshney 54
55. FRISBY
THREE TRANSPARENT PLASTIC
PLATES
OF VARYING THICKNESS
EACH PLATE :- 4 SQUARES OF
SMALL RANDOM SHAPES --1
WITH HIDDEN CIRCLE
D.D. 600 -15SECS OF ARC
Optom. Ankit Varshney 55
57. TESTs FOR SUPPRESSION
Worth’s 4 dot test
Bagolini Striated Glass Test
4 diopter base out prism test
Major amblyoscope
Optom. Ankit Varshney 57
58. TEST FOR ARC
WFDT
After image test
Bagolini’s striated glasses
Synoptophore
Red Filter Test
Optom. Ankit Varshney 58
59. THE WORTH FOUR DOT TEST
Optom. Ankit Varshney 59
•LOOKING THROUGH RED – GREEN
GLASSES RT-RED, LT-GREEN
•TO FOUR DOTS(1RED, 2 GREEN,1 WHITE)
60. PERIPHERAL FUSION WITH ORTHOPHORIA
OR TROPIA WITH ARC.
SUPPRESSION OF LEFT EYE
SUPPRESSION OF RIGHT EYE
UNCROSSED DIPLOPIA WITH ESOTROPIA
CROSSED DIPLOPIA WITH EXOTROPIA..
Optom. Ankit Varshney 60
WFDT : INTERPRETATIONS
61. STRIATED GLASSES TEST
OF BAGOLINI
STRIATED GLASSES PLACED AT
45 AND 135 DEGREE
(AS OBLIQUE MERIDIAN IS LESS
LIKELY TO SUPPRESS)
PT. FIXATES A SMALL LIGHT AT
NEAR & DIST. LIGHT PERCIVED
TO EACH EYE PERPENDICULAR
TO STRIATION.
Optom. Ankit Varshney 61
62. ORTHOPHORIA WITH NRC OR
TROPIA WITH ARC.
FIXATION POINT SCOTOMA (WITH
TROPIA; ARC) OR FOVEAL SCOTOMA
(ORTHOPHORIA ; NRC) OF RT EYE.
SUPPRESSION OF RIGHT EYE
DIPLOPIA WITH TROPIA.Optom. Ankit Varshney 62
63. 4 Diopter Base - Out
Prism Test
Optom. Ankit Varshney 63
65. DIPLOPIA CHARTING
PRINCIPLE
PROCEDURE-
* RED-GREEN GOGGLES
* HEAD POSITION
* LIGHT SOURCE
* CLOSE EACH EYE ONEBYONE
* NINE DIAGNOSTIC POSITIONS OF GAZE
Optom. Ankit Varshney 65
66. HESS CHARTING
PRINCIPLE
- foveal projection
- laws of innervation
- dissociation of eyes by means of complementary colors.
ARCHITECTURE OF THE SCREEN :-DIAGNOSIS OF POSSIBLE
PARESIS OR PARALYSIS WITH NRC
– 3X31/2 FT. SCREEN LINES 50 ANGLE
– RED DOTS AT 150 AND 300
– EXAMINATION AT ½ METER DISTANCE
Optom. Ankit Varshney 66