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This document discusses heterophoria, which is a latent misalignment of the eyes that is kept in check by the fusional reflex. It can be compensated, meaning the eyes are able to fuse at the fixation point without symptoms, or decompensated, where symptoms appear when binocular vision is disrupted. Common types include esophoria (inward deviation), exophoria (outward deviation), and cyclophorias (upward or rotational deviations). Heterophoria is usually asymptomatic but can cause eye strain, headaches, and difficulty changing focus. It is assessed using cover tests and phoria tests like Maddox Rod and Maddox Wing. Treatment involves correcting refractive errors if present,
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- It is a congenital eye movement disorder characterized by limited eye movement, especially abnormal adduction.
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Paralytic squint
PARALYTIC SQUINT
KANISHK DEEP SHARMA
ROLL NO. 50
Uncoordinated eye movement
Angle of squint varies
Motor imbalance
ETIOLOGY
Lesion of nerve
Lesion of muscles
Lesions due to
Injury
Inflammation-syphilis, disseminated sclerosis
Vascular diseases-hemorrhage, aneurysm,arteriosclerosis
Neoplasms-brain tumor
Toxins-alcohol, lead, carbon monoxide
Degeneration-chronic nuclear ophthalmoplegia
Myasthenia gravis
SYMPTOMS
DIPLOPIA
In field of action of paralyzed muscle
Long duration- suppression of false image
Vertigo & nausea
Action required towards paralysed muscle
False projection
Binocular diplopia
Secondry deviation
Defective ocular motility
Complementary head postures
Attempt to lessen diplopia
Head tilt to avoid torsion
SEQUALAE
Weakness of paretic muscle
Overacting contralateral synergistic muscle
Inhibitory palsy of contralateral antagonist
TESTS
Record of visual acuity
Ocular motility
Perimetry
Inspection of compensatory head postures
Diplopia charting
Dark room procedure
Armstrong's glasses
4ft distance, fine linear light
Primary & other positions of gaze measured
Hess charting
Explains muscle paralysis & pathological sequlae
Field of binocular fixation
Forced duction test
MANAGEMENT
Treatment of cause
Conservative measures
Vit B complex, systemic steroids
Diplopia treatment
Occluder on affected eye
SURGERIES
Muscle weakening procedure
Recession, marginal myotomy, myectomy
Muscle strengthening procedures
Resection, tucking advancement
Changing direction of muscle action
THANK YOU
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Diplopia chart
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Strabismus
This document provides information about strabismus (squinting):
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- The anatomy of the extraocular muscles that control eye movement is described, including the actions of the six muscles and their nerve supply.
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Latent squint or (heterophoria)
Latent squint, also known as heterophoria, is a condition where the eyes have a tendency to become misaligned when not being used, such as when one eye is covered, but remain straight during normal use. It occurs when the brain's continuous effort to maintain binocular fusion is removed, such as by covering one eye. Heterophoria is very common and usually does not cause double vision, as the brain corrects for any misalignment. While often asymptomatic, an ophthalmologist can test for latent squint using techniques like the alternate cover test.
ocular Deviations
Ocular deviations can be classified as heterophorias or heterotropias. Heterophorias are latent deviations that are suppressed by fusion, while heterotropias are manifest deviations. Specific types of heterophorias include esophoria, exophoria, hyperphoria, and hypophoria. It is important to record the size of any deviation in prism diopters and the distance at which the test was performed. Heterotropias can be incomitant, meaning the deviation varies with gaze direction, or concomitant, where the deviation remains constant. Incomitant strabismus is often paralytic in origin while concomitant may have an accommodative element.
Squint
This document defines and classifies different types of squint, including:
- Latent squint (heterophoria), where the eyes have a tendency to deviate but remain aligned with fusion.
- Manifest squint (heterotropia), where there is a visible misalignment of the eyes. This includes concomitant squint, where the deviation is the same in all directions of gaze, and paralytic squint, where the deviation varies with gaze direction.
- The causes, signs, and treatments of different types of squint are described, including exercises, optical correction, amblyopia therapy
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Heterophoria refers to a latent misalignment of the visual axes that is corrected by the fusion reflex. When fusion is suspended, the eyes adopt their "fusion free" position, which may involve esophoria, exophoria, or hyperphoria. Heterophorias can be classified based on direction, fixation distance, compensated vs decompensated state, and cause such as anatomical, neurogenic, or accommodative factors. Most people have some degree of heterophoria, though large or decompensated heterophorias may cause symptoms like asthenopia or headaches.
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This document discusses tests for measuring stereopsis, or depth perception. It describes four main stereopsis tests:
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Presentation Layout:
Retinoscope, types of retinoscope and uses of retinoscope
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- In spherical ametropia
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- Others: strabismus, amblyopia, pediatric pt.,
cycloplegic refraction
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-To locate the far point of the eye conjugate to the retina
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-Bring far point to the infinity by using appropriate lenses
- Determines amount of ametropia by retinoscopy and objective refraction
References:
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-Borish’s Clinical Refraction by Benjamin W. J.,
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-Retinoscopy-Student Manual by ICEE Refractive Error Training Package (2009)
-Clinical Optics and Refraction By Andrew Keirl, Caroline Christie
-Clinical Refraction Guide - A Kumar Bhootra
-Clinical Procedures in Primary Eye Care by David B. Elliott
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Follow me to get in touch with optometric and ophthalmic updates.
Heterophoria Or Latent Squint
This document discusses heterophoria, a type of latent squint where the eyes are misaligned when fusion is disrupted but aligned when fusion is intact. It defines heterophoria and differentiates it from heterotropia. The types of heterophoria are described as esophoria, exophoria, hyperphoria, and cyclophoria depending on the direction of deviation. Causes, clinical features and symptoms of each type are explained. Compensated heterophoria has no symptoms while decompensated heterophoria causes multiple symptoms like muscular fatigue or defective binocular vision.
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This document provides an overview of Duane's retraction syndrome, including:
- It was first described in the late 19th century and studied in more detail by Duane in 1905, giving the syndrome its current name.
- It is a congenital eye movement disorder characterized by limited eye movement, especially abnormal adduction.
- Symptoms often do not appear until childhood and may include a face turn, strabismus, or limited eye movement.
- It is usually unilateral but can be bilateral, and classification systems describe the degree and direction of limited eye movement.
- Surgery is generally only needed for decompensated cases or poor compensation and aims to correct strabismus
Evaluation of ptosis
This document discusses the evaluation of ptosis, or drooping of the eyelids. It begins by defining ptosis and distinguishing between true and pseudo ptosis. True ptosis is classified as acquired or congenital, with acquired further divided into neurogenic, myogenic, aponeurotic, and mechanical types. The evaluation of ptosis involves a thorough history, measurement of margin-reflex distance, palpebral fissure height, levator function, and upper lid crease. Additional tests include assessing for fatigability, Cogan's twitch sign, and jaw winking phenomenon. Confirmatory tests include the ice test and edrophonium (Tensilon) test. Treatment options mentioned include eyelid
concomitant strabismus
Concomitant strabismus is a type of manifest squint where the amount of deviation remains constant in all directions of gaze and there is no limitation of ocular movements. It can be caused by sensory obstacles like refractive errors, motor obstacles like abnormalities of extraocular muscles, or central obstacles like deficient development of fusion faculty. The main types are esotropia (inward deviation), exotropia (outward deviation), and hypertropia (vertical deviation). Treatment involves correcting refractive errors, amblyopia treatment, orthoptic exercises, and squint surgery to weaken strong muscles or strengthen weak muscles as needed.
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This document provides information on amblyopia, including its definition, epidemiology, pathophysiology, classification, clinical features, diagnosis, and treatment modalities. It defines amblyopia as a reduction in best corrected visual acuity that cannot be attributed to a structural eye abnormality. The main causes are strabismic amblyopia, stimulus deprivation amblyopia, and anisometropic amblyopia. Treatment involves eliminating obstacles to vision, correcting refractive errors, and forcing use of the amblyopic eye through occlusion or penalization of the good eye. Occlusion therapy is the most effective amblyopia treatment.
Restrictive strabismus
This document discusses restrictive strabismus, which is characterized by limited eye movement out of proportion to the ocular deviation. It can be caused by mechanical or neurological issues. The document then classifies restrictive strabismus as either congenital (e.g. Duane's retraction syndrome, Brown's syndrome) or acquired (e.g. thyroid ophthalmopathy, orbital injury, tumors). Specific conditions like Duane's retraction syndrome and Brown's syndrome are further described in terms of symptoms, prevalence, and management approaches including non-surgical and surgical options.
ARC: abnormal retinal correspondence, eccentric fixation
The document discusses retinal correspondence and abnormal retinal correspondence (ARC) in patients with strabismus. It defines normal retinal correspondence as when stimulation of corresponding retinal points produces single vision, while ARC is when non-corresponding points produce single vision. ARC can be harmonious, unharmonious, or paradoxical depending on its relationship to the objective angle of deviation. Several clinical tests are described to assess retinal correspondence, including Bagolini's striated glasses test, red filter test, synoptophore, and Worth's four dot test. Occlusion therapy is mentioned as a treatment to prevent worsening of ARC and promote normal correspondence.
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1) Hering's law of equal innervation and Sherington's law of reciprocal innervation which are important in diagnosing paralytic strabismus.
2) The sequelae of ocular muscle palsy including overactions and underactions of muscles.
3) Methods for investigating incomitant strabismus including cover tests, motility examination, and Hess screen plots to identify the affected muscle.
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This document discusses various retinal dystrophies including:
1) Generalized photoreceptor dystrophies such as retinitis pigmentosa, which affects rod photoreceptors and later cones, causing progressive vision loss.
2) Macular dystrophies that primarily affect the macula.
3) Generalized choroidal dystrophies affecting the choroid layer.
4) Vitreoretinopathies involving the vitreous or retina.
Retinitis pigmentosa is described in detail, outlining its genetics, symptoms, fundus findings, investigations and treatment options. Atypical forms of retinal pigmentosa associated with other systemic disorders are also mentioned.
Heterophoria;Definiton,classification and etiology
Heterophoria is a latent eye misalignment where the eyes are directed at the fixation point but tend to deviate when fusion is interrupted. It is classified based on direction of deviation (esophoria, exophoria, hyperphoria, cyclophoria) and symptoms (compensated vs decompensated). Esophoria involves a nasal deviation, exophoria a divergent deviation, and hyperphoria/hypophoria an upward/downward deviation of one eye. Compensated heterophoria causes no symptoms while decompensated heterophoria occurs when the deviation cannot be controlled due to weak fusion, leading to issues like blurred vision, diplopia,
Paralytic squint
PARALYTIC SQUINT
KANISHK DEEP SHARMA
ROLL NO. 50
Uncoordinated eye movement
Angle of squint varies
Motor imbalance
ETIOLOGY
Lesion of nerve
Lesion of muscles
Lesions due to
Injury
Inflammation-syphilis, disseminated sclerosis
Vascular diseases-hemorrhage, aneurysm,arteriosclerosis
Neoplasms-brain tumor
Toxins-alcohol, lead, carbon monoxide
Degeneration-chronic nuclear ophthalmoplegia
Myasthenia gravis
SYMPTOMS
DIPLOPIA
In field of action of paralyzed muscle
Long duration- suppression of false image
Vertigo & nausea
Action required towards paralysed muscle
False projection
Binocular diplopia
Secondry deviation
Defective ocular motility
Complementary head postures
Attempt to lessen diplopia
Head tilt to avoid torsion
SEQUALAE
Weakness of paretic muscle
Overacting contralateral synergistic muscle
Inhibitory palsy of contralateral antagonist
TESTS
Record of visual acuity
Ocular motility
Perimetry
Inspection of compensatory head postures
Diplopia charting
Dark room procedure
Armstrong's glasses
4ft distance, fine linear light
Primary & other positions of gaze measured
Hess charting
Explains muscle paralysis & pathological sequlae
Field of binocular fixation
Forced duction test
MANAGEMENT
Treatment of cause
Conservative measures
Vit B complex, systemic steroids
Diplopia treatment
Occluder on affected eye
SURGERIES
Muscle weakening procedure
Recession, marginal myotomy, myectomy
Muscle strengthening procedures
Resection, tucking advancement
Changing direction of muscle action
THANK YOU
Eccentric Fixation
This document discusses eccentric fixation (EF), a condition where an eye fails to fixate with the fovea and instead fixates at another retinal point. It describes several theories for the cause of EF, including suppression, anomalous correspondence, motor, and sensory motor theories. It outlines methods for investigating EF, such as ophthalmoscopy and visuscopy. Treatment options discussed include occlusion therapy and pleoptic treatment to encourage foveal fixation, though EF is often difficult to fully correct once established. The document also discusses microtropia, a small-angle strabismus associated with EF and amblyopia.
Diplopia chart
The document discusses diplopia, or double vision, including its definition, causes, types (monocular vs binocular), mechanisms, how to perform a diplopia chart test to evaluate the condition, and treatment approaches including conservative options with glasses/prisms or surgical correction of strabismus. Diplopia charting involves having the patient view a light source in different gaze positions while wearing a red filter over one eye to determine the location and characteristics of the double images.
Strabismus
This document provides information about strabismus (squinting):
- It affects 7.5 million people in the US and an estimated 130-260 million worldwide. Strabismus occurs when the eyes are not properly aligned on the point of focus.
- The anatomy of the extraocular muscles that control eye movement is described, including the actions of the six muscles and their nerve supply.
- Paralytic squints can be caused by neurogenic or myogenic factors. The document discusses third and fourth nerve palsies as examples. Treatment options for strabismus include optical devices, botulinum toxin injections, orthoptic exercises, and surgery.
Latent squint or (heterophoria)
Latent squint, also known as heterophoria, is a condition where the eyes have a tendency to become misaligned when not being used, such as when one eye is covered, but remain straight during normal use. It occurs when the brain's continuous effort to maintain binocular fusion is removed, such as by covering one eye. Heterophoria is very common and usually does not cause double vision, as the brain corrects for any misalignment. While often asymptomatic, an ophthalmologist can test for latent squint using techniques like the alternate cover test.
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ARC: abnormal retinal correspondence, eccentric fixation
ARC: abnormal retinal correspondence, eccentric fixation
Heterophoria;Definiton,classification and etiology
Heterophoria;Definiton,classification and etiology
Similar to Heterophoria.pptx
ocular Deviations
Ocular deviations can be classified as heterophorias or heterotropias. Heterophorias are latent deviations that are suppressed by fusion, while heterotropias are manifest deviations. Specific types of heterophorias include esophoria, exophoria, hyperphoria, and hypophoria. It is important to record the size of any deviation in prism diopters and the distance at which the test was performed. Heterotropias can be incomitant, meaning the deviation varies with gaze direction, or concomitant, where the deviation remains constant. Incomitant strabismus is often paralytic in origin while concomitant may have an accommodative element.
Squint
This document defines and classifies different types of squint, including:
- Latent squint (heterophoria), where the eyes have a tendency to deviate but remain aligned with fusion.
- Manifest squint (heterotropia), where there is a visible misalignment of the eyes. This includes concomitant squint, where the deviation is the same in all directions of gaze, and paralytic squint, where the deviation varies with gaze direction.
- The causes, signs, and treatments of different types of squint are described, including exercises, optical correction, amblyopia therapy
strabismus
1. Pseudostrabismus is when there is an appearance of eye misalignment but no actual squint, caused by factors like abnormal angles between the visual and anatomical eye axes.
2. Heterophoria is a latent eye misalignment that becomes manifest when fusion is suspended, and can be esophoria (convergent) or exophoria (divergent).
3. Convergence insufficiency, accommodation insufficiency, divergence insufficiency and near reflex insufficiency are different vergence and accommodation abnormalities that can cause visual symptoms and are treated with exercises and lenses.
Horizontal Deviations
This document discusses different types of horizontal deviations including esophoria, exophoria, convergence excess, and divergence excess. It describes the causes, symptoms, investigation, and management for each type. For esophoria, the most common cause is uncorrected hyperopia. Symptoms include headaches and blurred vision. Management includes refractive correction, orthoptic treatment, and prisms if needed. For convergence excess, excessive accommodation is often a factor, while for divergence excess, anatomical factors may play a role.
Squint 4th grade
This document provides information about strabismus (squint) including its definition, causes, types, and methods of examination and treatment. It defines strabismus as an ocular deviation resulting from an extraocular muscle imbalance. The main causes discussed are optical obstacles like refractive errors, sensory obstacles like uniocular vision defects, and motor obstacles involving the muscles or nerves. The document describes examining a patient for squint including testing visual acuity, eye movements, the cover-uncover test, and assessing binocular vision. It also discusses heterophoria (latent squint), paralytic squint, and treatment approaches.
HYPERMETROPIA REFRACTIVE ERROR OF AN EYE
TYPES
DEFINATION
ETIOLOGY
TREATMENT
help full for optometry students
@optometry
@ophthalmology
Hypermetropia
Hypermetropia, also known as hyperopia or longsightedness, is a refractive error where the eye focuses images behind the retina. It has various causes including a short axial length of the eye or flattened cornea. Symptoms include blurry near vision and asthenopia. Treatment involves prescribing convex lenses to correct refractive errors or refractive surgery for more severe cases. Early treatment of hypermetropia in children is important to prevent amblyopia and strabismus.
Vertical Deviations
Vertical Deviations
Hyperphoria is a latent, or hidden, upward deviation of one eye. It is often associated with other conditions like horizontal misalignments or incomitant, or non-equal, muscle deviations. Primary hyperphoria of less than 3 degrees is generally due to slight anatomical differences between the eyes. Symptoms can be relieved through refractive correction, orthoptic treatment with prisms, or in rare cases surgery. Dissociated vertical deviation is a rare anomaly where the covered eye moves upward behind the cover regardless of which eye is covered.
Ocular methods
This document provides an overview of ocular examination methods. It discusses abnormal head posture and its components which can indicate underlying eye muscle weakness. It describes tests to evaluate the visual axis like cover tests. It also outlines uniocular and binocular eye movements including versions, vergences, and cardinal positions. Examination of structures like the eyelids, lashes, conjunctiva and cornea are explained. Methods to evaluate ptosis, lid position and levator function are provided. The document is a comprehensive guide to evaluating the eyes.
Esotropia ophthalmology presentation HSAH.pptx
This document provides an overview of esotropia, including its types, causes, and clinical features. Esotropia is a convergent misalignment of the eyes. There are two main types - infantile esotropia, which presents in the first 6 months of life, and accommodative esotropia, which is usually caused by hyperopia. Accommodative esotropia can be fully, partially, or non-refractive. Clinical assessment of esotropia involves measuring visual acuity and the angle of deviation using tests such as cover-uncover and prism cover tests. Treatment involves correcting refractive errors with glasses and potentially strabismus surgery.
Heterophoria n tropia
This document discusses the measurement of heterophoria and heterotropia. It begins with introducing heterophoria as a latent strabismus where the eyes are normally directed to the point of fixation but deviate when dissociated. It then discusses the detection of phoria and tropia through examining the position of the globes and observing head position. Next, it describes determining the presence of a deviation using cover tests and measuring the deviation using objective methods like the prism and cover test and major amblyoscope as well as subjective methods.
Refractive error's
This document discusses various types of refractive errors including myopia, hypermetropia, and astigmatism. It defines each condition and describes their causes and symptoms. For myopia, it explains different types such as congenital myopia, nocturnal myopia, and induced myopia. It also lists potential complications of untreated high myopia. Treatment options for refractive errors include glasses, contact lenses, LASIK, and refractive lens exchange procedures. The document is intended to provide information on refractive errors and vision correction.
hypermetropia.pptx
Hypermetropia, also known as farsightedness or hyperopia, is a refractive error where the eye focuses light behind the retina. It occurs when the eyeball is too short or the cornea is too flat. Hypermetropia can be classified as physiological, pathological, or functional. It is commonly diagnosed using a retinoscope or autorefractor. Symptoms include blurry vision and eye strain. Treatment options include corrective lenses, refractive surgery such as LASIK, or intraocular lens implantation.
Hypermetropia and Aphakia
Hypermetropia, or farsightedness, occurs when the eye is too short, causing light rays to focus behind the retina. There are several types of hypermetropia based on its cause, including axial hypermetropia due to a short eyeball, and index hypermetropia which occurs in older patients due to changes in the lens. Hypermetropia is classified by severity and can range from asymptomatic to causing blurred vision. Treatment involves prescribing convex lenses to optically shift the focal point of light rays to the retina.
Classification of strabismus
This document discusses the classification and terminology used for strabismus (eye misalignment). It defines different types of strabismus such as phoria, tropia, and heterophoria based on the presence of fusion. It also classifies strabismus based on factors like deviation direction, variation with gaze, age of onset, and etiology. Various types of strabismus deviations and causes like paralytic, mechanical, and orbital are described. References for further information on strabismus classification are provided.
Errors of refraction
This document summarizes different types of refractive errors including emmetropia, ametropia, myopia, hypermetropia, and astigmatism. It defines each condition and describes the causes, types, grading, symptoms, diagnosis, and treatment. Myopia is defined as a refractive error where light focuses in front of the retina. It can be axial, curvature, or index-related. Hypermetropia is where light focuses behind the retina and can also be axial, curvature, or index-related. Astigmatism causes unequal refraction in different meridians leading to focal lines rather than a point. Treatment involves corrective lenses, contact lenses, or refractive surgery depending on the type and
Orthoptic approach to dipolopia
This document discusses diplopia (double vision) from an orthoptic perspective. It defines diplopia and describes the requirements for binocular single vision. There are three main types of diplopia: physiological, pathological, and functional. Pathological diplopia can be binocular or monocular. The two most common mechanisms for diplopia are misalignment of the visual axes and abnormalities of the ocular media or refractive errors. A thorough history, examination, and testing are required to determine the type and cause of diplopia and guide treatment.
Evaluation of squint
- Squint, or strabismus, is a misalignment of the visual axes that leads to loss of binocular single vision. It can be caused by issues in the orbit, eye muscles, motor nerves, or brainstem.
- Strabismus is classified as apparent, latent, or manifest. Manifest strabismus is further divided into concomitant, where the deviation is the same in all gazes, and incomitant, where the deviation varies with gaze.
- Evaluation of strabismus involves assessing history, visual acuity, refractive error, eye alignment tests, and binocular vision. Accurately measuring any refractive errors and prescribing corrections as needed is important for diagnosis and treatment of
HYPERMETROPIA AND ITS MANAGEMENT.pptx
All about hypermetropia (One of the refractive error of the eye), etiology, classification, investigation and management plan
Ocular examination
This document discusses the evaluation of ocular examination in cataract patients. It covers various components of the eye exam including head posture, facial asymmetry, visual axis, ocular movements, eyelids, conjunctiva and more. Abnormal head postures can indicate strabismus while facial asymmetry may be due to dental, skeletal or muscular issues. Tests like cover tests are used to evaluate the visual axis and detect strabismus. Ocular movements involve evaluations of ductions, versions, vergences and following diagnostic positions of gaze. The eyelids, lashes, glands and tumors are also examined for abnormalities.
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- 2. Orthophoria- Eyes are perfectly aligned i.e. no deviation even after disruption of fusional reflex. Heterotropia- Manifest misalignment Heterophoria- Latent misalignment
- 4. “A deviation kept latent by the fusional reflex” When heterophoria is present, both visual axes are directed towards the fixation point but deviate on dissociation.
- 5. Compensated heterophoria This means that there is a desire to deviate, but this desire is checked by the binocular vision. 3-4 heterophoria can be normally compensated Decompensated heterophoria Deviation occurs only when binocular vision is disturbed
- 6. Esophoria Tendency of inward deviation Exophoria Tendency of outward deviation Hyperphoria Tendency of upward deviation of one eye Incyclophoria Tendency of 12 o’clock point for inward deviation Excyclophoria Tendency of 12 o’clock point for outward deviation
- 8. 1) Refractive errors Hypermetropia causes esophoria due to over accommodation leading to over convergence Myopia causes exophoria due to less accommodation leading to less convergence Oblique astigmatism may cause cyclophoria
- 9. 2) Physiological causes: Prolonged neglect of near work causes weak convergence and complain of exophoria. Esophoria is common in children while exophoria in adults. Prolonged uniocular work may cause phoria 3)Weakness of one or more extra ocular muscles.
- 10. Symptoms Heterophoria is very common and it is usually asymptomatic (compensated). When it is decompensated the patient will complain of asthenopia: Eye strain -ocular pain, headache and redness Transient deviation of both eyes will cause transient diplopia.
- 11. Difficulty in changing focus from near to far or vice versa Deviation in night or during fever Blurring of print
- 12. Signs Refraction may show -myopia in case of exophoria -hyperopia in case of esophoria Visual acuity is normal after correction of errors
- 13. Cover test Maddox Rod test is used to confirm phoria at distance Maddox wing test used to measure phoria for near.
- 14. If no symptoms (compensated) we give no treatment. If symptomatic (decompensated) we do: 1. Correction of refractive error if present. 2. Training of the weak muscles by exercises or training prisms (base of prism is placed towards direction of deviation) 3. Surgery is indicated in few cases with very large degrees of latent deviation not responding to above treatment.