The document outlines a comprehensive guide to basic motility examinations, including the assessment of sensory and motor functions in pediatric ophthalmology. It discusses various tests for evaluating strabismus, including sensory testing methods like stereoacuity tests and motor assessments, as well as factors affecting measurement accuracy. Techniques for diagnosing and managing ocular motility issues, including forced duction tests and muscle function evaluations, are also presented.

1. Basic Motility Examination
Alvina Pauline D. Santiago, MD
Pediatric Ophthalmology & Strabismus
Basic Course Lectures in Ophthalmology
Sentro Oftalmologico Jose Rizal
Philippine General Hospital 2017

2. Basic Strabismus Evaluation
• Chief complaint and History
• Vision assessment (with vision screening)
• Gross evaluation and slit lamp examination
• Refraction and need for cycloplegia
• Sensory & Motor examination (Motility
Examination)
• Dilated posterior pole evaluation
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3. Sensory Testing
• Perform before any type of monocular occlusion
• e.g., visual acuity testing, cover tests
• Must wear correct prescription
• May need to correct deviation
• Prefer to do on a second visit
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4. Sensory Testing
• Near stereoacuity
• Fly vectograph/ Titmus Fly Test
• Lang stereotest
• Random dot stereograms
• Distance stereoacuity
• Mentor BVAT
• AO vectograph
• Amblyoscope
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5. Stereoacuity tests
• Horizontal disparity
• Stimulate non-corresponding points
• Image disparity measured in sec of arc
• 40-50 sec = central or bifoveal fixation
• 80-3000 sec = peripheral fusion
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6. Titmus fly test
• Monocular cues
• Need polarized glasses
• Image displacement
may be detected by
alternate suppressors
• Turn book 90 degrees,
should be flat
From Rosenbaum & Santiago, Clinical Strabismus Management
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7. Lang Stereoacuity test
• Random dot stereogram
• No need for Polaroid
lenses
• Only for gross and low
grade stereopsis
From Rosenbaum & Santiago, Clinical Strabismus Management
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8. Random Dot Stereogram
• 2 plates of randomly
displayed dots, one plate
to each eye
• Shape of figure
displaced horizontally
relative to other plate
• No monocular cues
• Normal may fail
From Rosenbaum & Santiago, Clinical Strabismus Management
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9. Distance Stereotest
• Mentor BVAT
System
• Very good test
for assessing
control in X(T)
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
From Rosenbaum & Santiago,
Clinical Strabismus Management
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10. Red-Green
Distance Stereotest

11. Sensory Testing
• Worth 4 dot
• near: tests peripheral fusion
• distance: tests central fusion
• Retinal correspondence
• amblyoscope, Bagolini lenses
• 4 pd BO test: foveal suppression
• Normal response
• conjugate saccades OU,
• slow recovery in eye without the prism
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12. Worth Dot Test
• 2 green lights
• 1 red light
• 1 white light
• Red-green glasses
• Usually red over right eye
• At 1/3 m:
• W4D separated by 6 degrees
• Tests peripheral fusion
• At 6 m:
• 1.25 degrees
• Tests central fusion
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13. Worth Dot Test Results
http://image.slidesharecdn.com
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14. Amblyoscope or Haploscope
• Measures fusional vergence
amplitudes
• Angle of deviation
• Area of suppression
• Retinal correspondence
• Torsion
• Instrument convergence
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From Rosenbaum & Santiago, Clinical Strabismus Management 1999

15. Motor Testing
Ocular rotations
Measuring the deviation
Anomalous head posture
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16. Ocular Rotations
• Duction: monocular
• Version: binocular
• Hering’s law
• Sherrington’s law
• Alert to pattern deviations: e.g., A, V
• Grading scheme:
• e.g., inferior oblique & superior oblique
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17. Ocular Rotations
Cardinal gaze positions
RLR
LMR
RMR
LLR
RSR
LIO
RIR
LSO
RIO
LSR
RSO
LIR
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18. Ocular Motility Evaluation
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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19. Ocular Motility Evaluation
RLR
LMR
RMR
LLR
RSR
LIO
RIR
LSO
RIO
LSR
RSO
LIR
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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20. (L) Inferior oblique dysfunction
+4 +1
-4 -1
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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21. (R) Superior oblique dysfunction
+4 +1
-4 -1
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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22. Motor Testing
• Light reflex tests
• Cover tests
• Other tests
• wear correction
• no prisms
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23. Motor Testing: Light Reflex Tests
• Bruckner test
• Hirschberg light reflex
• Krimsky/modified Krimsky
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24. Bruckner Test ®Ametropia
®Strabismus
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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25. Hirschberg’s Corneal Light Reflex
• 3.5 mm pupil:
• 15 deg at pupil edge
• 30 deg between limbus
and edge of pupil
• 45 degrees at limbus
• Not a true linear relationship:
21 pd/mm decentration
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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26. Krimsky vs Modified Krimsky
• in front of deviating
eye (modified
Krimsky)
• underestimates true
angle
• better at near
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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27. LIGHT REFLEX, COVER TESTS
(Courtesy of R. Pena, MD)
MODIFIED KRIMSKY
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28. Motor Testing: Cover Tests
• Primary gaze
• Right and left gaze
• Up and down gaze
• Right and left head tilt
• Oblique gazes, occasionally
• Near: primary and down gaze
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29. Cover Tests
• Requirements:
• Appropriate correction
• Know if correction with or without prisms
• Accommodative target (above threshold)
• Distance:
• 6 m: 1/6 D of accommodation
• (approximates infinity)
• > 6 m: X(T)
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30. The Ideal Target
• Above threshold
• e.g. Snellen acuity 20/20
• present 20/50 to 20/70
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31. The Ideal Target
• With sufficient detail and contour
• Should sustain interest
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32. Toys as Targets
• One toy one look
• With detail
• May be coupled with a
light
• Sounds for tracking but
not vision testing
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33. The Ideal Target
• Maximum plus, least minus correction
• Allows minimal accommodation at 6 m
• Accommodation exerted only 1/6 Diopter,
considered zero for strabismus measurement
purposes
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34. Factors Affecting Measurement
• Prism placement:
• plastic prisms: frontal
• glass prisms: prentice
• Stacking prisms
• Splitting prisms From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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35. Factors Affecting Measurement
• Method of testing:
• Light reflex:
• Bruckner
• Hirschberg
• Krimsky/modified
Krimsky
• Different cover tests
• Cover Test
• Alternate Cover Test
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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36. Factors Affecting Measurement
• Patient factors:
• Accommodation and AC/A ratio
• Axial length and globe size
• Amblyopia and eccentric fixation
• Refractive error and induced prisms
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37. Cover Tests

38. Cover Uncover Test
• Must be performed
before alternate
cover test
• Cover test: tropia
• Uncover test: phoria
• also for fixation
preference
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https://www.youtube.com/watch?v=f5HbIZi4u70

39. Alternate Prism Cover Test
• Prisms before deviated eye
• primary vs. secondary deviation
• Unless strabismic eye is preferred for fixation
• Evaluates total deviation: manifest (tropic) and
latent (phoric)
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40. ALTERNATE PRISM & COVER TEST
Gold standard for
measuring deviation
LIGHT REFLEX, COVER TESTS
(Courtesy of R. Pena, MD)
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41. Simultaneous Prism Cover Test
• Tropia under binocular conditions
• Monofixation syndrome
• Estimate angle of deviation
• Present prism and cover simultaneously
• Absence of movement in tropic eye means correcting
prisms are accurate
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42. SIMULTANEOUS PRISM & COVER TEST
Used for monofixation
LIGHT REFLEX, COVER TESTS
(Courtesy of R. Pena, MD)
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43. Prism Under Cover Test
• For Dissociated Vertical Deviation
• Evaluate one eye at a time
• Prism and cover presented to the same eye
• Separate true hypertropia by using BU prism
neutralization in other eye
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44. PRISM UNDER COVER TEST
Used for DISSOCIATED
VERTICAL DEVIATION (DVD)
LIGHT REFLEX, COVER TESTS
(Courtesy of R. Pena, MD)
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45. Dissociated Vertical Deviation
Courtesy of N. Paderna, MD
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DVD OD
DHD OS

46. Techniques in Finding Strabismus
• Bruckner test
• Spielmann
translucent occluder
From Rosenbaum & Santiago, Clinical Strabismus Management
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47. Other Tests
• Red glass test
• Maddox rod
• horizontal, vertical
• torsional
• Parks 3-step test for isolated cyclovertical muscle
palsy
• 3rd step is Bielschowsky maneuver
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48. (L) Superior oblique palsy
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49. Parks 3-step Test
Left Hypertropia
1. Of 8 cyclovertical
muscles: 4
LSO, LIR, RSR, RIO
2. Of 4 cyclovertical
muscles: 2
increase on R gaze: LSO,
RSR
3. Of 2 cyclovertical
muscles: 1
increase of L tilt: LSO
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50. (Masked) Bilateral
superior oblique palsy
• V pattern
• Reversal of hypertropia
• Frame 1 and 3
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51. Torsion Evaluation
• Funduscopy
• Fundus photography
• Blind spot mapping
• Red-Green Hess/Lee Screen
• Double Maddox Rods
• Oblique (& Vertical) muscle dysfunction
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52. Normal Optic Nerve Head-
Fovea Angle Relationship
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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53. Direct Ophthalmoscope View:
Fundus Torsion
Excyclorotation Incyclorotation
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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54. Indirect Ophthalmoscope View:
Fundus Torsion
Excyclorotation Incyclorotation
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Flipped image from Rosenbaum & Santiago, Clinical Strabismus Management 1999

55. Inferior Oblique Overaction
PREOP POSTOP
From Rosenbaum & Santiago, Clinical Strabismus
Management 1999
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56. Torsion Test: Double Maddox
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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57. Tests of Muscle Function
• Forced duction test
• Force generation test
• Saccadic velocity analysis
• EMG
• Dynamic MRI
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58. Indications
• Incomitant deviation
• Limited ocular rotation
• Distinguish between restriction and paresis/palsy
• Distinguish between paresis and palsy
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59. Passive Forced Duction
• Some indications:
• Trauma
• Endocrine
• Postoperative restriction of
motility
• Longstanding deviation with
secondary contracture
• Congenital restrictions
• Brown
• Duane
• Transposition procedures
• Orbital diseases
• Tumors
• Inflammation
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60. Advantages
• Help in deciding between treatment options
• Monitor improvement of paretic muscles
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61. Tests of Muscle Function
• Paresis vs. restriction
• Forced duction test
• Force generation test
• Saccadic velocity analysis
• Differential intraocular pressure
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62. EMG: Electromyography
• Limitations:
• may record activity even if muscle still paretic
• response suppressed by GA
• still used in some cases of Duane syndrome and
Botulinum injection
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63. Passive Forced Duction
• Children > 7 yrs, adults
• Topical anesthetic
• Cover one eye: ensures
fixation
• Look as far as possible in
the direction of limited
ocular rotation
• Provide fixation target
• Watch out for “falling
off” of eye
#BasicMotilityExam
(c) APSantiago 2017
63
From Rosenbaum & Santiago, Clinical Strabismus Management 1999

64. Passive Forced Duction
“Can the forceps rotate the eye further
than the patient can using maximal
innervation in that gaze field?”
• Grasp limbus opposite the side of limited gaze
• Tenon’s and conjunctiva fused in one layer
• limits stretching/tearing of conjunctiva
• provides firm grasp
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65. Passive Forced Duction
• Follow natural arc of globe
• For rectus muscles
• Slight proptosis
• No retroplacement
• Vertical rectus: 23 deg abduction
• Results:
• cannot move globe further: restriction
• can move globe further: paresis
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66. Passive Forced Duction
• For oblique muscles
• Retroplace globe
• Follow oblique muscle path
• Guyton’s oblique traction test
• Stress test for obliques
• Retroplace globe
• Torsional movement
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67. Oblique traction testing
From Rosenbaum & Santiago, Clinical Strabismus Management 1999#BasicMotilityExam (c) APSantiago 201767

68. Oblique traction testing
#BasicMotilityExam (c) APSantiago 201768From Rosenbaum & Santiago, Clinical Strabismus Management 1999

69. Oblique traction testing
#BasicMotilityExam (c) APSantiago 201769From Rosenbaum & Santiago, Clinical Strabismus Management 1999

70. Intraoperative Forced Duction Testing
• Perform routinely to feel “normal”
• Perform esp after resections
• may be ortho in primary
• overcorrection in certain gazes
• Perform after transpositions
• Intraoperative adjustable suture
• Perform after removing suspected restrictions
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71. Forced Duction Results
• Absolute restriction
• Graves, Brown
• Uniform restriction
• Scar tissue, muscle contracture
• Leash phenomenon
• Scar tissue, long standing contracture
• Duane syndrome
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72. Pitfalls: Forced Duction
• Patient apprehension
• Errors in technique
• “Falling off”
• Failure to proptose for rectus or retropulse globe for obliques
• Succinylcholine (Anectine)
• Posterior restrictions
• Co-contractions
• Co-existing paresis and restriction
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73. Active Force Generation
• Apply a counteracting force
• Using the same grasp on
limbus
• Counter-traction to feel
resistance
• WOF: corneal abrasion,
conjunctival hemorrhage
#BasicMotilityExam (c) APSantiago 201773From Rosenbaum & Santiago, Clinical Strabismus Management 1999

74. Active Force Generation
• Differential IOP
• Paresis vs. palsy
• Combined paresis and restriction
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75. FDT, FGT, Diagnosis
Diagnosis Forced Duction Force
Generation
Mechanical
restriction
Restricted Normal
Muscle palsy Free Absent
Paresis &
restriction
Free Weak
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Common pitfall: mild paresis
Correlate with saccadic velocity analysis

76. Saccadic Velocity Analysis
• Study eye movement velocity
• muscle activity
• return of muscle function
• EOG : problem when testing vertical saccades
• Infrared
• Scleral search coil
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77. Office Saccadic Velocity
• Look at 2 separate targets
• At least 20 deg movement sufficient
• Compare
• briskness of agonist and antagonist
• with fellow eye
• Bring the eye where muscle has
• maximum function
• full unrestricted motion From Rosenbaum & Santiago, Clinical
Strabismus Management 1999
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78. Pitfalls: Saccadic Velocity
• Errors in technique
• failure to bring eye
where muscle is still
functioning
• Pharmacologic
• Fatigue
• Time of day
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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79. Clinical Applications:
Saccadic Velocity Analysis
• Paralytic Strabismus
• Restrictive Strabismus
• Lost or slipped muscles
• Neurologic Disorders
• Myasthenia Gravis (MG)
• normal then weakens; use
with Tensilon
• Progressive External
Ophthalmoplegia (PEO)
• general slowing
• Inter-nuclear
ophthalmoplegia (INO)
• slowed adduction
• normal abduction
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80. Slowed Saccadic Velocities
• LR palsy abduction
• SO palsy downgaze
• Moebius horizontal
• Myasthenia normal then slows
• Slipped/Lost reduced 20-50%
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81. Magnetic Resonance Imaging
• Cross-sectional area
• Applications:
• EOM palsy
• EOM heterotopy
• Severed/extirpated muscles
• Entrapment
• Mass
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82. Normal coronal section
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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83. From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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84. Laser vision ;-)
No more than a pinhole effect!
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