Please look at the light and tell me what you see Patient: I see two lights that are side by side Assistant: Now I am going to move the lights closer together. Tell me if you still see two lights or if they merge into one. Patient: As you move the lights closer, they are now merging into one light. Assistant: Thank you. That demonstrates you do not have diplopia in primary position. Now I am going to move the light up, down, left, and right. Please tell me if you see one light or two lights as I move it to different positions. This tests for diplopia in different gazes which helps localize the site of the problem causing diplopia

1. DR.VARSHINI SHANKAR
MODERATOR
DR.PUSHKAR DHIR
PRESENTOR

2. HISTORY
INSPECTION
VISUAL ACUITY
EVALUATION OF MOTOR STATUS
HBCT/KRIMSKY/CT
EVALUATION OF SENSORY STATUS (STEROPSIS/
SUPPRESSION /ARC OR RC)
MEASUREMENT OF DEVIATION
ANT.& POST.SEGMENT
SPECIAL TEST TO IDENTIFY PARESIS & RESTRICTION

3. HISTORY
• Age of Patient
• Complaint & HOPC:-
o Age of Squint onset (early onset/ long
duration / constant angle / previous photos)
o Is it Sudden Or Gradual ?
o Direction of deviation patient / parent noted
o Is it Constant? Or Sometimes
(INTERMITTENT)
o Noticed in One Eye or Both?
(U/L OR ALTERNATE)
o Diplopia? Asthenopia? Abn.Head Posture
• Birth History
o Regarding Pregnancy & Delivery
o Developmental Milestones(Delay)
• Family History
o Squint/ Refractive Error / Lazy eye
• Personal History
o DM /HTN / Thyroid
• Treatment History
o Glasses /Occlusion Therapy /Orthoptic
Exercise / Prev. Surgery

4. .….Looks can b really Deceptive
• Lid Fissure:-
• Ptosis
• Mongoloid/Anti mongoloid
• Exophthalmos / enophthalmos
• Nasal Bridge
• Closure of one eye in bright light
• Epicanthal folds
• Head Posture (AHP)
• Face Turn (Right/Left)
• Head Tilt (Right/Left Shoulder)
• Chin (Elevation/Depression)
• Facial Asymmetry
• Fixation Preference
• Nystagmus
INSPECTION

5. PTOSIS

7.  Meri Refraction kon karega 
VISUAL ACUITY

8. Infants
(Birth-14 months)
Pre-Verbal Children
Toddlers
( 14 months – 21/2
years)
Preschoolers
(21/2 years – 5years)
School going children
(5years- 15 years)
1.Fixation preference
test.
•Does he have a
central/steady &
mantained fixation.?
•Does he follow target?
•Does he get upset when u
close one eye?
2.Optokinetic
Nystagmus (OKN)
3.Force Choice
Preferential looking test
(FCPL)
4.Visual Evoked
Potential (VEP)
1.Hundred &
thousand sweet test
2. The Cardiff
acuity Test
3.Dott Visual Acuity
Testing.
1.LEA Symbols
2.Allen Picture Card
3.Broken Wheel Test
4.Tumbling E chart
5.Landolt C chart
6.Sjogren hand test
7.HOTV test
1.Tumbling E chart
2.Landolt C chart
3.Sjogren hand chart
4.Snellen’s chart
5.LogMAR chart.

9. FIXATION PREFERENTIAL TEST (CSM METHOD)
There are 2 types fixations are present:-
1.Centric 2.Eccentric
Component of Fixation
C= location of Corneal Reflex (Central/Uncentral)
S= Steady
M= Ability to maintain alignment first with one eye then with other
If Nystagmoid movements , VA ACUITY IN PATIENTS WITH NYSTAGMUS IS BINOCULAR
UC= uncentral
US= unsteady

10. MOTOR EXAMINATION

11. Extra-Ocular Movements
EOM
MONOOCULAR BINOCULAR
VERSIONS
(Conjugate
Movements)
VERGENCES
( Disconjugate
Movements)
???? ANGRY ?????
OR
????B/L MR OVER-ACTION

12. Points to Remember for EOM
• To check if all eye muscles r working together.
• Patient and examiner positioned at same level
• Correct any anomalous head position
• Room should be properly illuminated.
• Sit in front of the patient so that BE eyes can be seen simultaneously.
• Remove any Spectacles.( to remove prismatic effect)
• USE A PENLIGHT.
• 40 CM DISTANCE,SHINE ON FOREHEAD
• Move in 6 diagnostic/H position.

13. When Test Marks come
DEXTRO-ELEVATION LEVO-ELEVATION
DEXTRO-DEPRESSION LEVO-DEPRESSION

14. • ADDUCTION:- is normal when NASAL 1/3RD CORNEA crosses nasal punctum
• ABDUCTION:- is normal when TEMPORAL LIMBUS touches lateral canthus.
• INFERIOR OBLIQUES:- on lateral version , upwards deviation from the
horizontal line passing through centre of pupil
• SUPERIOR OBLIQUES :- on lateral version, downwards deviation from
the horizontal line.
• ELEVATION :-
• DEPRESSION :-

16. .

17. Vergence
Movement
NPC NPA
NPC = role of DOT CARD
NPA= role of FLIPPERS
Fusional Convergence= = role
of CAT CARD/SYNAPTOPHORE
Fusional Divergence= =

18. !!D FORGOTTEN REFLEX!!
Bruckner Reflex
• Done with DO
• Distance of 3fts
• Power of DO is 0
• Helps to Detect:-
Squint
Anisometropia
Leukocoria
Anisocoria

19. BRUCKNER
REFLEX

20. Hirschberg Corneal Reflex (HBCT)
• 1mm shift = 7° or 15 *Uses 1st Purkinje Image
00ºº
1515ºº
4545ºº
2828ºº

21. SQUINT
Apperent squint
(Pseudo-squint)
Latent squint
(Hetro-phoria)
Comitant
Paralytic/Paresis Ristrictive Spastic
Incomitant
Manifest squint
(Hetro-tropia)
Squint

22. PRE-REQUISTE FOR CT/CUT/ALT
• Vision More than 6/60 in BE to see the target
• Central fixation in BE
• If Bifocals are worn, near deviation measured
through reading segment

23. SQUINT
TERMINOLOGIES
• IDS-RXT
• IDS-AXT
• LET
• ICS-RET
• ACCOMODATIVE
ESOTROPIA
!!!!! KYA LOCHA HAI YE!!!!

25. Cover Test / Cover-Uncover/
Alternate Cover Test
• Helps to establish Ortho-tropic or not.
• Is Squint Latent= Phoria
• Is Squint Manifested = Tropia
• Direction of Deviation
• Fixation Behavior
• Check for Distance & Near

26. Cover test in all gazes
for distance and near

27. Cover Test
• Done for distance & near
• Covering one eye of patient with
normal binocular vision interrupts
fusion.
• See for the movement OF OTHER EYE
• When eye is uncovered ,it will
reestablish binocular fixation
• Imp. of Test:- Detects & Confirms
Tropias

28. Cover- Uncover Test
• Examiner OBSERVE THE
COVERED EYE AS COVER IS
REMOVED.
• In Hetrophoria,covered eye will
deviate toward hetrophoric
position.
• When eye uncovered 
Reestablish Binocular Vision.
• Imp.of Test:- used to find out
PHORIAS

29. Alternate Cover Test
• Identify (Tropia + Phoria)
• Hold occluder over one eye for
several seconds
o Dissociates binocular vision
• Rapidly move occluder to other
eye
• Observe Refixation shift of
unoccluded eye

30. Objective Test
• Hirshberg Test
• Prism Alt.Cover Test(PACT)
• Krimsky Test
• Synaptophore Test
Subjective Test
• Maddox Rod
• Hess Screen Test
• Synaptophore Test

31. Krimsky Test /Modified HBCT
• Angle of strabismus is evaluated,
when the light is projected straight
ahead, and subsequent prisms
(prism bar) are placed
• Based on HERRING LAW of
equal innervation
BEFORE THE FIXING EYE
until symmetrical light reflexes are
seen on the cornea of both eyes.

32. Prism Alt.Cover Test
1.Maximum Deviation of eyes to be achieved to
bring out full amt. of deviation ( can be done by
patching one eye for 45/60mins)
2.Place Neutralizing prism over one eye.
3.Repeat Alternate testing
4.Cover should be placed alternatively over each
other for some time.
5.NEVER NEVER NEVER allow patient to
regain Fusion while cover is transferred.
6. Check for Distant & Near Vision

33. SENORY
EXAMINATION
STEREOPSIS
SUPPRESSION & DIPLOPIA
RETINAL CORRESPONDANCE
TO BE DONE WITH FULL OPTICAL
CORRECTION
TO BE DONE PRIOR TO ANY

34. STEREOPSIS
TITMUS FLY TEST
(Based on Vectographic Principle)
RANDOM DOT TESTS
• RANDOM DOT E TEST
• TNO TEST (Based on Anaglph mehtod)
LANG TEST
(L-sterotest1 & 2)
LANG 2 Pencil Test
SYNAPTOPHORE
(Based on Haploscopic Principle)
SUPPRESSION
WORTH 4 DOT TEST
4D/20D BASE OUT TEST
BAGOLINIS FILTER TEST
MADDOX ROD TEST
AFTER IMAGE TE4ST

35. Gross Stereoacuity
 Top of Upper Wings:2000seconds
 Bottom of Lower Wings:1150 sec
 Tip of Abdomen:700 sec
Fine Stereoacuity
Circles
 1-3:800-200sec
 4-6:140-80 sec
 7-9:60-40 sec
Animals
 A row:400sec
 B row:200sec
 C row:100sec

36. • Graded from 15-480 arc sec
• 8 plates; 480/240/120/60/30/15
• 1ST 3 plates to check for presence of
stereopsis
• 4 is SUPPRESSION TEST PLATE
• If a child see 2 circle ask for larger circle
• 5,6,7for degree of steropsis
• Special Glasses Required
• Kept at distance of approx 30 cms
• Cost around 20,000!!!!!!!!!
• Checks NEAR STEROPSIS ONLY

37. FRISBY DAVIS DISTANCE TEST(FD2)

38. • Red / Green glasses
(Red over right eye)
• Dark Room
• Illuminated Target
• VARY TESTING DISTANCE TO IDENTIFY
SIZE OF SUPPRESSION SCOTOMA.
• White light is only binocular fusion target

40. • Done with a Projector/Chart
(6m)
• Test for Macular Scotoma
• Done with a Flashlight
• At Near (1/3m)-subtends 6
degree arc
• Tests for Extramacular
Suppression

41. W4dt interpretations
• Distant W4DT means fusion occurs at macular
level
• Near W4DT means fusion occur at
extramacular/peripheral retina.

42. • Narrow striation running in
one principal meridian.
• Lenses oriented at 45o and
135o
• Evaluation of DISTANCE
AND NEAR retinal
correspondence with minimal
dissociations.

43. R
L
F
FL FR
BG L
BG R

44.  Multiple cylindrical high plus lenses stacked ontop of eachother.
 Converts point source to streak
 Streak is perpendicular to cylinders!
 Dissociative
 Blocks fusion (measures phoria)
 No control of
accommodative convergence
 Less useful for horizontal deviations

45. Uncrossed : Rt EsoCrossed : Rt Exo

46. STIMULATOR

47. • DEMONSTARTE

48. Patient is asked to comment on
–Position
–Brightness
–Separation between images
Diplopia Test