Maples strabismus2007

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Maples strabismus2007

  1. 1. Strabismus: Ugh! If it is Strabismus, It Can be Diagnosed with a Cover Test
  2. 2. The Obvious and the Not So Obvious <ul><li>Two Big Areas </li></ul><ul><li>Esotropia </li></ul><ul><li>Exotropia </li></ul><ul><li>I Wonder if it should not be </li></ul><ul><li>Intermittent </li></ul><ul><li>Constant </li></ul><ul><li>What is the Advantage of Strabismus? </li></ul>
  3. 3. Press and Efficacy: Esotropia <ul><li>Plus ( T)NC .6 (T)AC .5 NC .3 AC .1 </li></ul><ul><li>Good Fusion .1 .1 .1 .1 </li></ul><ul><li>Family Hx .1 .1 .1 .1 </li></ul><ul><li>No Ambly .1 .1 .1 .1 </li></ul><ul><li>< 20 ^ .1 .1 .1 .1 </li></ul><ul><li>Minus </li></ul><ul><li>Dense Supp .1 .1 .1 .1 </li></ul><ul><li>Non Concom .1 .1 .1 .1 </li></ul><ul><li>Dense Ambly .1 .1 .1 .1 </li></ul>
  4. 4. Press and Efficacy: Exotropia <ul><li>Plus (T)NC .8 (T)AC .7 TNC .5 TAC .4 </li></ul><ul><li>Good Fusion </li></ul><ul><li>Family Hx </li></ul><ul><li>No Ambly .1 .1 .1 .1 </li></ul><ul><li>< 20 ^ </li></ul><ul><li>Minus </li></ul><ul><li>Dense Supp </li></ul><ul><li>Non Concom .1 .1 .1 .1 </li></ul><ul><li>Dense Ambly .1 .1 .1 .1 </li></ul>
  5. 5. Ugly Factors <ul><li>No Desire To Change </li></ul><ul><li>Anomalous Correspondence </li></ul><ul><li>Amblyopia </li></ul><ul><li>Intractable Diplopia </li></ul><ul><li>Constancy </li></ul><ul><li>Non-Concomitant </li></ul><ul><li>Restrictions </li></ul><ul><li>Prior Surgery? </li></ul>
  6. 6. Do They Want To Change? Strabismic From Head to Toe <ul><li>The Child That Did Not Want a Brother </li></ul><ul><li>The College Student That Wanted A Husband </li></ul><ul><li>Esotropes want Detail and are Willing to Give up Binocularity to Get it (Developmental) </li></ul><ul><li>Exotropes want the “Big Picture” Panoramic Viewing (Genetic, ABI or Functional) </li></ul>
  7. 7. Anomalous Correspondence <ul><li>A Type of Binocularity </li></ul><ul><li>Develops Early---???????????? </li></ul><ul><li>Reaction of Organism to Diplopia </li></ul><ul><ul><li>Sees Double </li></ul></ul><ul><ul><li>Suspends/Suppresses </li></ul></ul><ul><ul><li>Goes into an Anomalous Fusion Cortically </li></ul></ul>
  8. 8. Anomalous Correspondence <ul><li>Depth </li></ul><ul><ul><li>Shallow-Ignore </li></ul></ul><ul><ul><li>Deep-Ugh! </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Embed the Binocularity </li></ul></ul><ul><ul><li>Move to Harmonious Anomalous </li></ul></ul><ul><ul><li>Change to Normal Correspondence </li></ul></ul>
  9. 9. Amblyopia Maples WC, Bither M. Treating the trinity of infantile vision development: infantile esotropia, amblyopia, anisometropia. J Optom Vis Dev 2006;37: 123-130. <ul><li>Eccentric Fixation </li></ul><ul><li>Develops Early </li></ul><ul><li>Secret to Amblyopia (Anisometropic and Eccentric Fixation)----Fixation </li></ul><ul><li>0 Retino Motor Locus </li></ul><ul><li>Treatment-Develop Central Fixation </li></ul>
  10. 10. Constancy <ul><li>INTERMITTENT IS EASIER </li></ul><ul><li>The reason that Exos are easier than Esos may be that there are more Intermittent Exos </li></ul><ul><li>If Intermittent: </li></ul><ul><ul><li>Do not Patch </li></ul></ul><ul><ul><li>Work on Binocularity where you can find binocularity and expand it. WORK BACKWARDS TO BIOUCLAR AND MONOCULAR SKILLS </li></ul></ul>
  11. 11. Intractable Diplopia <ul><li>Late Onset </li></ul><ul><li>Trauma </li></ul><ul><li>Stroke </li></ul><ul><li>Horror Fusionis </li></ul><ul><li>The OMD Who Saw Nothing But ID’s </li></ul><ul><li>Patch (Contact Lens), Blur, Suppress--- </li></ul>
  12. 12. Non-Concomitant <ul><li>Pathology </li></ul><ul><li>Prior Surgery Worse if Complications </li></ul><ul><li>Restrictions almost always will not have full use </li></ul><ul><li>Duane’s Congenital and Train other Visual Skills </li></ul><ul><li>Brown Can be from infection of the tendon sheath and if so, when infection controlled can decrease </li></ul>
  13. 13. Seven Levels of Dx and Tx <ul><li>Bilateral Integration </li></ul><ul><li>Central Fixation </li></ul><ul><li>Monocular Equality </li></ul><ul><li>Biocular Skills </li></ul><ul><li>Basic Binocular Skills </li></ul><ul><li>Advanced Binocular Skills </li></ul><ul><li>Special (Perceptual/Cognitive/Executive) </li></ul>
  14. 14. Working the System: Testing/Demonstrate <ul><li>Bilateral Skills: Anatomical Interaction </li></ul><ul><ul><li>VO Star </li></ul></ul><ul><ul><li>Harmon Bimanual Circles </li></ul></ul><ul><ul><li>Standing and Seated Posture </li></ul></ul><ul><ul><li>Dry Land Swimming </li></ul></ul><ul><ul><li>Angels in the Snow </li></ul></ul><ul><ul><li>Line Roll </li></ul></ul>
  15. 15. Working the System: Testing/Demonstrate <ul><li>Central Fixation </li></ul><ul><ul><li>Ophthalmoscopic (Visuscope) </li></ul></ul><ul><ul><li>MIT </li></ul></ul><ul><ul><li>Cover Test and Angle Lambda (Kappa) Very Gross </li></ul></ul><ul><ul><li>Past Pointing </li></ul></ul>
  16. 16. Working the System: Testing/Demonstration <ul><li>Monocular Equality </li></ul><ul><ul><li>Fixation: Wolff Wands, VO 12* Star; Fixation Worksheet; Parquetry Blocks; Chalkboard Saccades </li></ul></ul><ul><ul><li>Saccade (Real World): See Above; Wayne Saccades; Hart Chart Challenge; Battle Ship Hart Chart </li></ul></ul><ul><ul><li>Pursuit: Wolff Wands; Marsden Ball; Head Rotations; Chalkboard Pursuits; Mechanical Rotator </li></ul></ul><ul><ul><li>Near Far-Far Near: Hart Chart, Wayne Saccade </li></ul></ul><ul><ul><li>Accommodation: Kraskin Bifocal; Monocular Rock </li></ul></ul>
  17. 17. Working the System: Testing <ul><li>Biocular Skills: In My Opinion-The Key to Effective Amblyopic and Strabismus Therapy </li></ul><ul><li>Suppression </li></ul><ul><li>Anomalous Correspondence </li></ul><ul><li>Double but MORE THAN Double-Equally Real </li></ul><ul><li>“The one I am attending” </li></ul>
  18. 18. Biocular <ul><li>Tests (Anomalous Correspondence-Press) </li></ul><ul><li>Bagolini Lenses </li></ul><ul><li>Polarized Vectogram </li></ul><ul><li>Amblyscope </li></ul><ul><li>Worth Four Dot </li></ul><ul><li>Maddox Rod with Red Lens </li></ul><ul><li>Hering-Bielschowsky After Image </li></ul>
  19. 19. Working the System: Testing <ul><li>Tests (Suppression) </li></ul><ul><ul><li>Bagolini Lenses </li></ul></ul><ul><ul><li>Keystone </li></ul></ul><ul><ul><li>Brock String </li></ul></ul><ul><ul><li>Quoits (Cross) </li></ul></ul><ul><ul><li>Binocular Refractions </li></ul></ul><ul><ul><li>Physiological Diplopia </li></ul></ul><ul><ul><li>Retinal Rivalry </li></ul></ul><ul><ul><li>Others </li></ul></ul>
  20. 20. Working the System: Testing <ul><li>Basic Binocular </li></ul><ul><ul><li>Tons of Tests </li></ul></ul><ul><ul><li>Retinoscopy </li></ul></ul><ul><ul><li>Phorias </li></ul></ul><ul><ul><li>Vergences </li></ul></ul><ul><ul><li>Telebinocular </li></ul></ul><ul><ul><li>Stereo </li></ul></ul>
  21. 21. The Intermittent Trope Can you get Stereo? <ul><li>If Stereo </li></ul><ul><ul><li>Demonstrated with Peripheral Targets Brock Stereo Motivator or Quoits on a Window </li></ul></ul><ul><li>Build Ranges </li></ul><ul><li>Ramp </li></ul><ul><li>Step </li></ul><ul><li>Ability as measured by Accuracy as measured by the Speed and Stamina of the Patient A Ass </li></ul><ul><li>Speed means both Fast AND Slow </li></ul><ul><li>Minimal Differences (Quoits and 1 ^ difference) </li></ul>
  22. 22. Rules of Engagement ”Where the Eye looks and were the Brain thinks it looks is different” <ul><li>Start Were They Are and Go Where They Ain’t </li></ul><ul><li>Start Slow and Start Low </li></ul><ul><li>Synapses that Fire Together Continue to Fire Together </li></ul><ul><li>Analyze the Procedure: All VT is Bio-Feedback </li></ul><ul><li>Patient & Therapist MUST BE involved </li></ul><ul><li>Know What you are Attempting to Accomplish </li></ul><ul><li>Be Enthustatic </li></ul><ul><li>Accomplishment is the Best Reward </li></ul>
  23. 23. Working the System: Therapy <ul><li>Central Fixation </li></ul><ul><ul><li>Pleoptics </li></ul></ul><ul><ul><ul><li>Ophthalmoscopic Bleaching </li></ul></ul></ul><ul><ul><ul><li>Fixation/Saccade/Pursuit </li></ul></ul></ul><ul><ul><ul><li>Smaller and Smaller </li></ul></ul></ul><ul><ul><li>MIT </li></ul></ul><ul><ul><li>Eye Hand Activities </li></ul></ul>
  24. 24. Working the System: Therapy <ul><li>Bilateral Skills </li></ul><ul><ul><li>Yoked Prisms with Motor Activities </li></ul></ul><ul><ul><ul><li>Line Roll </li></ul></ul></ul><ul><ul><ul><li>Line Walk </li></ul></ul></ul><ul><ul><ul><li>Harmon (Lowman) Board </li></ul></ul></ul><ul><ul><li>Harmon Circles </li></ul></ul><ul><ul><li>Van Orden Circles </li></ul></ul>
  25. 25. Working the System: Therapy <ul><li>Monocular Equality (Biocular & Binocular) </li></ul><ul><li>Monocular Disassociated Binocular (MDB) Marsden Ball </li></ul><ul><li>MDB Pointers </li></ul><ul><li>AN 12 pointed Star MDB </li></ul><ul><li>Kraskin Bifocal Rock MDB </li></ul><ul><li>Modified Modified UpDegrave MDB </li></ul>
  26. 26. Working the System: Therapy <ul><li>Biocular </li></ul><ul><ul><li>Squinchel </li></ul></ul><ul><ul><li>Marsden Ball </li></ul></ul><ul><ul><li>Physio Diplopia </li></ul></ul><ul><ul><li>Quoits </li></ul></ul><ul><ul><li>Brock String </li></ul></ul><ul><ul><li>12 Pointed Star </li></ul></ul>
  27. 27. Working the System: Therapy <ul><li>Binocular Esotrope </li></ul><ul><ul><li>Luster </li></ul></ul><ul><ul><li>Gross/Peripheral/Moving Targets </li></ul></ul><ul><ul><ul><li>Give Me 5 on the Balance Board </li></ul></ul></ul><ul><ul><ul><li>Touch my Fingers </li></ul></ul></ul><ul><ul><ul><li>Top Clear/Bottom Clear/Both Clear (= Blur) </li></ul></ul></ul><ul><ul><ul><li>Quoits-Suppression and Fusion </li></ul></ul></ul><ul><ul><ul><li>Keystone without Detail </li></ul></ul></ul><ul><ul><ul><li>Encourage Periphery </li></ul></ul></ul><ul><ul><ul><li>Motor Activities </li></ul></ul></ul>
  28. 28. Working the System: Therapy <ul><li>Extotropes </li></ul><ul><ul><li>Rx (+) and tend to be poorer academic achievers </li></ul></ul><ul><ul><li>“ Take This Job and Shove It” “ I Quit” </li></ul></ul><ul><ul><li>High Sx: See COVD-QOL Checklist </li></ul></ul><ul><ul><li>Functional or Nerve/Muscle Damage </li></ul></ul><ul><ul><li>Needs “Orthoptics”: Fixations, Pursuits, Vergence, ACCOMMODATION </li></ul></ul><ul><ul><li>Get Stereo; Let Stereo Go; Regain Stereo </li></ul></ul><ul><ul><li>See 1/See 2 </li></ul></ul>
  29. 29. Skeffington’s Model <ul><li>Exotropia </li></ul><ul><ul><li>Divergence Excess Needs + at Near (Cooper, NO!) </li></ul></ul><ul><ul><li>Sympathetic and Parasympathetic-Exos Peripheral Dominant </li></ul></ul><ul><ul><li>Social and Biological Clash </li></ul></ul><ul><ul><li>Myopia/Esotropia </li></ul></ul><ul><ul><li>Hyperopia (Normal Refraction)/Exotropia </li></ul></ul>
  30. 30. Working the System: Therapy <ul><li>Esotropes </li></ul><ul><ul><li>Minimal +; Monocular (-) Followed by Low + </li></ul></ul><ul><ul><li>Tend to be High Achievers (Bull Dogs) Low Sx </li></ul></ul><ul><ul><li>Want their own Way (Spoiled?-Indulgent Parents) </li></ul></ul><ul><ul><li>Will tell you what they think you want to hear </li></ul></ul><ul><ul><li>Developmental or SERIOUS PATHOLOGY </li></ul></ul><ul><ul><li>Ah, Ha is Needed. That is how you do it </li></ul></ul>

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