1) The document discusses orbital complications that can arise from zygomatic fractures, including diplopia and enophthalmos. Diplopia is double vision that can result from impaired extraocular muscles due to trauma or nerve palsies. Enophthalmos is the retropositioning of the eye within the orbit.
2) Methods for evaluating diplopia include diplopia charting using a simple or electronic Hess screen to map deviations in eye position and movements. Common causes of nerve palsies like III, IV, and VI are also reviewed.
3) Enophthalmos is evaluated using exophthalmometry and is related to increased orbital volume from fractures. Surgical correction may be
The document describes the Hess screen test procedure and principles for evaluating eye muscle function and diagnosing ocular motility disorders. Key points covered include how the test is performed, what different Hess chart presentations indicate in terms of muscle underaction and overaction, and how the test can be used to measure deviations and assess conditions over time.
Diplopia, or double vision, occurs when more than one image of an object is seen simultaneously. It can be caused by abnormalities in the eyes themselves or issues with eye movement coordination. A diplopia chart is used to evaluate the type and location of double vision by having the patient report the appearance of light sources in different gaze positions. Interpretation of the chart provides clues to which eye muscles may be affected and whether the cause is neurogenic, restrictive, or myogenic in nature. Treatment options include glasses, prisms, eye patching, or strabismus surgery depending on the deviation and goal of eliminating diplopia.
The Hess chart provides information about eye movements and deviations in different gazes. Key features include the size and shape of the fields, positions of the central dots indicating deviations, and displacements showing underactions and overactions. Together these can indicate the affected eye and muscle(s), type of strabismus, whether it is recent or longstanding, and help make a diagnosis such as thyroid eye disease or cranial nerve palsy. Hess charts are useful for monitoring changes over time both clinically and following strabismus surgery.
The Hess chart is used to diagnose strabismus and monitor patients with incomitant strabismus. It involves presenting red lights in different gaze positions while the patient uses red-green glasses and a pointer to indicate if the lights are aligned. Deviations between the plotted points and template indicate the angle of deviation and can identify paretic or overacting muscles. The Hess chart helps locate muscles affected by palsies or contractures and determine if strabismus is due to a primary palsy or secondary involvement of other muscles.
The Hess screen test involves presenting lights in different positions of gaze on a screen and having the patient superimpose lights while viewing through colored lenses to dissociate the eyes. This allows evaluation of eye muscle function and detection of underaction or overaction. Key details include:
- The Hess screen contains lights indicating positions of gaze and is viewed through red-green lenses to dissociate the eyes.
- The procedure involves illuminating lights and having the patient superimpose them while viewing through the lenses.
- Interpretation of the plotted results can detect muscle underaction or overaction, indicating conditions such as nerve palsies or restrictions in eye movement.
This document discusses the case of a 25-year-old male presenting with double vision since 2 months following a head trauma. On examination, he was found to have a left eye esotropia with an abduction deficit grade of 4, indicating a left sixth nerve palsy. Sensory testing showed binocular uncrossed diplopia maximum in left gaze. The patient was diagnosed with an acquired post-traumatic left sixth nerve palsy. He was initially managed conservatively with fogged glasses with regular follow-up to monitor recovery.
This document discusses diplopia charting, which is used to diagnose ophthalmoplegia by recording double vision. It outlines the etiology, principles, objectives, procedure, interpretations and applications to specific cranial nerve palsies. Diplopia charting involves having the patient view a light source through colored lenses to indicate the position of double images in different gazes. This provides information to localize affected extraocular muscles and diagnose conditions like cranial nerve palsies. Precise documentation of findings from diplopia charting combined with patient history and exam can help identify neuro-ophthalmic pathologies.
This document discusses diplopia (double vision), including its definition, causes, evaluation, and management. It begins by defining diplopia as seeing double due to misalignment of the eyes. The document then discusses the anatomy involved, types of diplopia (monocular vs binocular), approaches to evaluation, common causes like myasthenia gravis and various cranial nerve palsies, methods of examination, and treatment options which can include patching therapy, addressing underlying causes, eye exercises, and in some cases surgery.
The document describes the Hess screen test procedure and principles for evaluating eye muscle function and diagnosing ocular motility disorders. Key points covered include how the test is performed, what different Hess chart presentations indicate in terms of muscle underaction and overaction, and how the test can be used to measure deviations and assess conditions over time.
Diplopia, or double vision, occurs when more than one image of an object is seen simultaneously. It can be caused by abnormalities in the eyes themselves or issues with eye movement coordination. A diplopia chart is used to evaluate the type and location of double vision by having the patient report the appearance of light sources in different gaze positions. Interpretation of the chart provides clues to which eye muscles may be affected and whether the cause is neurogenic, restrictive, or myogenic in nature. Treatment options include glasses, prisms, eye patching, or strabismus surgery depending on the deviation and goal of eliminating diplopia.
The Hess chart provides information about eye movements and deviations in different gazes. Key features include the size and shape of the fields, positions of the central dots indicating deviations, and displacements showing underactions and overactions. Together these can indicate the affected eye and muscle(s), type of strabismus, whether it is recent or longstanding, and help make a diagnosis such as thyroid eye disease or cranial nerve palsy. Hess charts are useful for monitoring changes over time both clinically and following strabismus surgery.
The Hess chart is used to diagnose strabismus and monitor patients with incomitant strabismus. It involves presenting red lights in different gaze positions while the patient uses red-green glasses and a pointer to indicate if the lights are aligned. Deviations between the plotted points and template indicate the angle of deviation and can identify paretic or overacting muscles. The Hess chart helps locate muscles affected by palsies or contractures and determine if strabismus is due to a primary palsy or secondary involvement of other muscles.
The Hess screen test involves presenting lights in different positions of gaze on a screen and having the patient superimpose lights while viewing through colored lenses to dissociate the eyes. This allows evaluation of eye muscle function and detection of underaction or overaction. Key details include:
- The Hess screen contains lights indicating positions of gaze and is viewed through red-green lenses to dissociate the eyes.
- The procedure involves illuminating lights and having the patient superimpose them while viewing through the lenses.
- Interpretation of the plotted results can detect muscle underaction or overaction, indicating conditions such as nerve palsies or restrictions in eye movement.
This document discusses the case of a 25-year-old male presenting with double vision since 2 months following a head trauma. On examination, he was found to have a left eye esotropia with an abduction deficit grade of 4, indicating a left sixth nerve palsy. Sensory testing showed binocular uncrossed diplopia maximum in left gaze. The patient was diagnosed with an acquired post-traumatic left sixth nerve palsy. He was initially managed conservatively with fogged glasses with regular follow-up to monitor recovery.
This document discusses diplopia charting, which is used to diagnose ophthalmoplegia by recording double vision. It outlines the etiology, principles, objectives, procedure, interpretations and applications to specific cranial nerve palsies. Diplopia charting involves having the patient view a light source through colored lenses to indicate the position of double images in different gazes. This provides information to localize affected extraocular muscles and diagnose conditions like cranial nerve palsies. Precise documentation of findings from diplopia charting combined with patient history and exam can help identify neuro-ophthalmic pathologies.
This document discusses diplopia (double vision), including its definition, causes, evaluation, and management. It begins by defining diplopia as seeing double due to misalignment of the eyes. The document then discusses the anatomy involved, types of diplopia (monocular vs binocular), approaches to evaluation, common causes like myasthenia gravis and various cranial nerve palsies, methods of examination, and treatment options which can include patching therapy, addressing underlying causes, eye exercises, and in some cases surgery.
The Hess screen test is used to evaluate eye muscle function and diagnose abnormalities. It involves the patient fixating on lights illuminated on a screen while wearing colored lenses over each eye. Patterns in how the lights are seen can reveal underaction or overaction of extraocular muscles, and determine if a deviation is comitant or incomitant. The test allows diagnosis of conditions like neurogenic or mechanical palsies, and helps evaluate their effects over time and before/after surgery. Interpretation involves analyzing features like the size and direction of any deviation, whether fields are similar between eyes, and if patterns indicate particular affected muscles or nerves.
This document discusses esotropia, which is an inward turning of one or both eyes. It defines esotropia and describes the different types including accommodative esotropia, congenital esotropia, and microtropia. It outlines the causes, characteristics, diagnosis, and management of each type of esotropia. Some key points covered include the role of accommodation and refractive error in accommodative esotropia, the importance of early treatment for congenital esotropia to prevent amblyopia, and the use of occlusion therapy, refractive correction, surgery, and botulinum toxin injection in the management of esotropia.
The document discusses various types of diplopia (double vision) and visual field defects, their causes and treatments. It describes defects that can occur due to cranial nerve palsies or strokes affecting the third, fourth, sixth or optic nerves. Treatments mentioned include Fresnel prisms, eye patching, Botox injections, eye muscle surgery, visual field testing, and vision therapy. The orthoptist aims to restore binocular single vision through various orthoptic treatments and management strategies for visual defects.
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.
The document discusses paralytic strabismus, including:
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.
1. Monocular elevation deficiency (MED), also known as double elevator palsy, is characterized by an inability to elevate one eye in all fields of gaze, resulting in hypotropia of the affected eye.
2. The condition can be congenital or acquired, with causes including superior rectus palsy, inferior rectus restriction, and supranuclear lesions.
3. Surgical management of MED depends on forced duction test results and may include inferior rectus recession, superior rectus resection, or Knapp's procedure to transpose the horizontal rectus muscles. The goal is to improve eye position and increase binocular vision.
This document provides an overview of evaluating a patient presenting with diplopia (double vision). It discusses taking a thorough history and performing a physical exam to determine if the diplopia is monocular or binocular. A variety of tests are described to localize the cause and characterize the deviation, such as which muscles are affected and how the diplopia changes with different gazes or head positions. Causes can be supranuclear, nuclear, internuclear, infranuclear or myogenic/restrictive. Imaging may be needed to identify structural lesions.
This document discusses strabismus, which is a misalignment of the visual axes of the eyes. It defines key terms like phoria, tropia, intermittent tropia, and provides details on the anatomical and visual axes. It describes various types of strabismus like concomitant, incomitant, horizontal, vertical, and torsional deviations. It also discusses the mechanisms, causes, adaptations, and evaluations of strabismus, including cover tests, versions, ductions, fusional amplitudes, stereopsis tests, and diplopia evaluation methods.
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.
It is one of the most viewed document from Pgblaster India website: Disorders of ocular motility with an emphasis on squint. In this document I have tried to give some important concepts of the different types of squints in simple words.At a glance, it is a much harder and complex topic of ophthalmology but I had made it as simpler as I could. Hope it will help you..
This document discusses congenital infantile esotropia. It defines esotropia as eyes turning inward and provides background on types. Congenital infantile esotropia is characterized by a large-angle esotropia present before 6 months of age. It may be associated with cerebral palsy or low birth weight. Treatment involves correcting refractive errors, amblyopia therapy, and bilateral medial rectus recession surgery between 6 months to 2 years of age. Post-surgical outcomes include orthophoria, small residual deviations managed with observation, or large residual deviations requiring repeat surgery.
The document provides an overview of eye anatomy and examination procedures. It describes the external structures of the eye including the eyelids, muscles, and lacrimal apparatus. Internally, it outlines the three layers of the eye - sclera, choroid, and retina. Examination steps are detailed including visual acuity tests, pupil examination, eye muscle function, ophthalmoscopy, and visual field testing. Common eye signs and conditions like strabismus, cataracts, and hemorrhages are also summarized.
The document provides information about performing and interpreting a Hess screen test. It describes the test setup which uses a metal plate with grids to plot eye movements. Each eye is tested separately by having the patient fixate while wearing colored glasses. Abnormal findings may indicate underacting or overacting muscles, the degree of deviation, and whether the condition is congenital or acquired. Examples of plotted Hess charts are presented and analyzed to diagnose specific conditions like Duane's retraction syndrome or third nerve palsy.
This document summarizes key concepts in binocular vision and ocular motility. It discusses two theories of binocular vision development: correspondence and disparity theory, and the neurophysiologic theory. It describes sensory adaptations that develop binocular vision such as Worth's three levels of fusion. Common motility problems are reviewed like esotropia, exotropia, and cranial nerve palsies. The extraocular muscles are defined including origin, insertion and action. Laws of ocular motility like Hering's law and Sherrington's law are also outlined.
The document discusses the evaluation of strabismus. It defines strabismus and the different types such as phoria, tropia, comitant, and incomitant. It describes the history to obtain and various tests used in the examination including motor function tests like cover test, versions, and ductions, and sensory tests like Worth 4-dot and Bagolini lenses. The document provides details on the order and components of a complete ocular examination for strabismus.
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.
1. The document discusses various causes and types of diplopia including monocular diplopia caused by refractive errors or macular disorders and binocular diplopia caused by cranial nerve palsies or muscle restrictions.
2. Evaluation of diplopia involves assessing head posture, eye movements, refractive error and neurological function through tests like the three-step test for fourth nerve palsy. Special tests like diplopia testing and cyclodeviation measurements localize the site of muscle weakness.
3. Causes of transient or intermittent diplopia include decompensated phoria, convergence insufficiency, myasthenia gravis or TIAs, while surgical procedures can also cause diplopia through restrictions
Convergence is the inward movement of the eyes to maintain single binocular vision. It can be symmetrical or asymmetrical depending on the position of the fixation point. The near point of convergence is the closest point an object can be focused on binocularly and is measured clinically. Convergence insufficiency is the most common convergence anomaly and causes eye strain. Other anomalies include convergence paralysis which is a total lack of convergence ability due to brain lesions. Convergence spasm involves intermittent periods of excessive convergence that can cause diplopia. Exercises are used to treat convergence insufficiency while prisms are used for convergence paralysis.
Concomitant and Incomitant, AHP and Hess chartTahseen Jawaid
This document discusses abnormal head posture, concomitant and incomitant strabismus, and Hess chart testing. It defines concomitant as having equal angle of deviation in all gazes, while incomitant deviation varies between gazes. Incomitant can be neurogenic from nerve palsies or mechanical from conditions like Brown syndrome. Abnormal head posture is a motor adaptation to maintain comfortable vision and includes face turns, chin elevation/depression, and head tilts. Hess chart testing uses red/green filters or mirrors to dissociate the eyes and identify muscle weaknesses or palsies.
3rd,4th, 6th nerves
Extraocular muscles
How to examine for ocular motility
Ophthalmoplegia
Diplopia and related disorders
Gaze pathway
How to examine for gaze
Gaze palsy
Types of eye movements
How to examine for EM
Nystagmus and non nystagmus ocular oscillation
This document defines the visual field and describes how it is examined. The visual field refers to the area that can be seen and has normal limits of 60 degrees superiorly, 60 degrees nasally, 75 degrees inferiorly, and 100 degrees temporally. The visual pathway involves the optic nerves transmitting signals from the retina to the brain. Visual field examinations assess central and peripheral vision using techniques like confrontation testing, Amsler grids, and perimetry. Common visual field defects include scotomas and hemianopias, which can be caused by conditions like glaucoma and optic neuropathies.
This document defines the visual field and describes how it is examined. The visual field refers to the total area visible to both eyes without moving the head or eyes. It is normally largest temporally and superiorly. The visual pathway involves the optic nerves transmitting signals from the retina to the brain. Common examination techniques include confrontation testing to check the peripheral field and Amsler grid for the central field. Static and kinetic perimetry provide quantitative assessments and can detect defects from various conditions. Visual field defects include scotomas and hemianopias that present as missing areas of the field.
The Hess screen test is used to evaluate eye muscle function and diagnose abnormalities. It involves the patient fixating on lights illuminated on a screen while wearing colored lenses over each eye. Patterns in how the lights are seen can reveal underaction or overaction of extraocular muscles, and determine if a deviation is comitant or incomitant. The test allows diagnosis of conditions like neurogenic or mechanical palsies, and helps evaluate their effects over time and before/after surgery. Interpretation involves analyzing features like the size and direction of any deviation, whether fields are similar between eyes, and if patterns indicate particular affected muscles or nerves.
This document discusses esotropia, which is an inward turning of one or both eyes. It defines esotropia and describes the different types including accommodative esotropia, congenital esotropia, and microtropia. It outlines the causes, characteristics, diagnosis, and management of each type of esotropia. Some key points covered include the role of accommodation and refractive error in accommodative esotropia, the importance of early treatment for congenital esotropia to prevent amblyopia, and the use of occlusion therapy, refractive correction, surgery, and botulinum toxin injection in the management of esotropia.
The document discusses various types of diplopia (double vision) and visual field defects, their causes and treatments. It describes defects that can occur due to cranial nerve palsies or strokes affecting the third, fourth, sixth or optic nerves. Treatments mentioned include Fresnel prisms, eye patching, Botox injections, eye muscle surgery, visual field testing, and vision therapy. The orthoptist aims to restore binocular single vision through various orthoptic treatments and management strategies for visual defects.
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.
The document discusses paralytic strabismus, including:
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.
1. Monocular elevation deficiency (MED), also known as double elevator palsy, is characterized by an inability to elevate one eye in all fields of gaze, resulting in hypotropia of the affected eye.
2. The condition can be congenital or acquired, with causes including superior rectus palsy, inferior rectus restriction, and supranuclear lesions.
3. Surgical management of MED depends on forced duction test results and may include inferior rectus recession, superior rectus resection, or Knapp's procedure to transpose the horizontal rectus muscles. The goal is to improve eye position and increase binocular vision.
This document provides an overview of evaluating a patient presenting with diplopia (double vision). It discusses taking a thorough history and performing a physical exam to determine if the diplopia is monocular or binocular. A variety of tests are described to localize the cause and characterize the deviation, such as which muscles are affected and how the diplopia changes with different gazes or head positions. Causes can be supranuclear, nuclear, internuclear, infranuclear or myogenic/restrictive. Imaging may be needed to identify structural lesions.
This document discusses strabismus, which is a misalignment of the visual axes of the eyes. It defines key terms like phoria, tropia, intermittent tropia, and provides details on the anatomical and visual axes. It describes various types of strabismus like concomitant, incomitant, horizontal, vertical, and torsional deviations. It also discusses the mechanisms, causes, adaptations, and evaluations of strabismus, including cover tests, versions, ductions, fusional amplitudes, stereopsis tests, and diplopia evaluation methods.
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.
It is one of the most viewed document from Pgblaster India website: Disorders of ocular motility with an emphasis on squint. In this document I have tried to give some important concepts of the different types of squints in simple words.At a glance, it is a much harder and complex topic of ophthalmology but I had made it as simpler as I could. Hope it will help you..
This document discusses congenital infantile esotropia. It defines esotropia as eyes turning inward and provides background on types. Congenital infantile esotropia is characterized by a large-angle esotropia present before 6 months of age. It may be associated with cerebral palsy or low birth weight. Treatment involves correcting refractive errors, amblyopia therapy, and bilateral medial rectus recession surgery between 6 months to 2 years of age. Post-surgical outcomes include orthophoria, small residual deviations managed with observation, or large residual deviations requiring repeat surgery.
The document provides an overview of eye anatomy and examination procedures. It describes the external structures of the eye including the eyelids, muscles, and lacrimal apparatus. Internally, it outlines the three layers of the eye - sclera, choroid, and retina. Examination steps are detailed including visual acuity tests, pupil examination, eye muscle function, ophthalmoscopy, and visual field testing. Common eye signs and conditions like strabismus, cataracts, and hemorrhages are also summarized.
The document provides information about performing and interpreting a Hess screen test. It describes the test setup which uses a metal plate with grids to plot eye movements. Each eye is tested separately by having the patient fixate while wearing colored glasses. Abnormal findings may indicate underacting or overacting muscles, the degree of deviation, and whether the condition is congenital or acquired. Examples of plotted Hess charts are presented and analyzed to diagnose specific conditions like Duane's retraction syndrome or third nerve palsy.
This document summarizes key concepts in binocular vision and ocular motility. It discusses two theories of binocular vision development: correspondence and disparity theory, and the neurophysiologic theory. It describes sensory adaptations that develop binocular vision such as Worth's three levels of fusion. Common motility problems are reviewed like esotropia, exotropia, and cranial nerve palsies. The extraocular muscles are defined including origin, insertion and action. Laws of ocular motility like Hering's law and Sherrington's law are also outlined.
The document discusses the evaluation of strabismus. It defines strabismus and the different types such as phoria, tropia, comitant, and incomitant. It describes the history to obtain and various tests used in the examination including motor function tests like cover test, versions, and ductions, and sensory tests like Worth 4-dot and Bagolini lenses. The document provides details on the order and components of a complete ocular examination for strabismus.
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.
1. The document discusses various causes and types of diplopia including monocular diplopia caused by refractive errors or macular disorders and binocular diplopia caused by cranial nerve palsies or muscle restrictions.
2. Evaluation of diplopia involves assessing head posture, eye movements, refractive error and neurological function through tests like the three-step test for fourth nerve palsy. Special tests like diplopia testing and cyclodeviation measurements localize the site of muscle weakness.
3. Causes of transient or intermittent diplopia include decompensated phoria, convergence insufficiency, myasthenia gravis or TIAs, while surgical procedures can also cause diplopia through restrictions
Convergence is the inward movement of the eyes to maintain single binocular vision. It can be symmetrical or asymmetrical depending on the position of the fixation point. The near point of convergence is the closest point an object can be focused on binocularly and is measured clinically. Convergence insufficiency is the most common convergence anomaly and causes eye strain. Other anomalies include convergence paralysis which is a total lack of convergence ability due to brain lesions. Convergence spasm involves intermittent periods of excessive convergence that can cause diplopia. Exercises are used to treat convergence insufficiency while prisms are used for convergence paralysis.
Concomitant and Incomitant, AHP and Hess chartTahseen Jawaid
This document discusses abnormal head posture, concomitant and incomitant strabismus, and Hess chart testing. It defines concomitant as having equal angle of deviation in all gazes, while incomitant deviation varies between gazes. Incomitant can be neurogenic from nerve palsies or mechanical from conditions like Brown syndrome. Abnormal head posture is a motor adaptation to maintain comfortable vision and includes face turns, chin elevation/depression, and head tilts. Hess chart testing uses red/green filters or mirrors to dissociate the eyes and identify muscle weaknesses or palsies.
3rd,4th, 6th nerves
Extraocular muscles
How to examine for ocular motility
Ophthalmoplegia
Diplopia and related disorders
Gaze pathway
How to examine for gaze
Gaze palsy
Types of eye movements
How to examine for EM
Nystagmus and non nystagmus ocular oscillation
This document defines the visual field and describes how it is examined. The visual field refers to the area that can be seen and has normal limits of 60 degrees superiorly, 60 degrees nasally, 75 degrees inferiorly, and 100 degrees temporally. The visual pathway involves the optic nerves transmitting signals from the retina to the brain. Visual field examinations assess central and peripheral vision using techniques like confrontation testing, Amsler grids, and perimetry. Common visual field defects include scotomas and hemianopias, which can be caused by conditions like glaucoma and optic neuropathies.
This document defines the visual field and describes how it is examined. The visual field refers to the total area visible to both eyes without moving the head or eyes. It is normally largest temporally and superiorly. The visual pathway involves the optic nerves transmitting signals from the retina to the brain. Common examination techniques include confrontation testing to check the peripheral field and Amsler grid for the central field. Static and kinetic perimetry provide quantitative assessments and can detect defects from various conditions. Visual field defects include scotomas and hemianopias that present as missing areas of the field.
This document outlines the procedures and assessments for a comprehensive eye examination. It includes collecting the patient's history, testing visual acuity with a Snellen chart, examining the external eye structures, assessing eye movements and cranial nerves, performing diagnostic tests like ophthalmoscopy and slit lamp examination, and using additional tools like tonometry, perimetry, and imaging tests. The goal is to gather all relevant information on the patient's ocular and medical history, examine the eyes, and determine if any further testing is needed to diagnose any underlying conditions.
The document discusses various techniques for examining the interior of the eye including ophthalmoscopy. It describes the indirect ophthalmoscopy technique where a convex lens is used to make the eye highly myopic, allowing examination of the retina. The key steps of the technique are outlined including using a dark room, convex lens, illumination source and obtaining an inverted, magnified view of the retina between the lens and examiner's eye. Advantages of indirect ophthalmoscopy are also provided.
Ophthalmoscopy allows examination of the inside of the eye. It is done using an ophthalmoscope to view the retina and optic disc. It was invented in 1851 and has since improved. During the exam, the pupil is dilated and the ophthalmologist views the retina through different aperture settings and filters on the ophthalmoscope. They examine the optic disc, retina, blood vessels and look for any abnormalities. Common findings include signs of diabetes, hypertension, glaucoma, or other eye conditions. The ophthalmoscopy exam is important for evaluating eye health and detecting underlying diseases.
The document discusses the Hess chart, which is used to map eye movements and diagnose extraocular muscle palsies. It describes how Hess developed the chart in 1908 and won a Nobel Prize for his work mapping the brain's control of internal organs. The document outlines how the Hess chart is performed and interpreted, including identifying underacting and overacting muscles, differentiating comitant from incomitant strabismus, and aiding in surgical planning. Several examples of Hess chart interpretations are provided to demonstrate identifying affected muscles and diagnosing conditions like third nerve palsy and Brown's syndrome.
1. Monocular elevation deficiency (MED), also known as double elevator palsy, is characterized by an inability to elevate one eye in all fields of gaze, resulting in hypotropia of the affected eye.
2. The condition can be congenital or acquired, with causes including superior rectus palsy, inferior rectus restriction, and supranuclear lesions.
3. Surgical management of MED depends on forced duction testing and may include inferior rectus recession, superior rectus resection, or Knapp's procedure to improve eye alignment and increase binocular vision.
This document discusses suppression, which is one of the three mechanisms of sensory adaptation that occurs in patients with strabismus. Suppression refers to the active inhibition of the image from the deviated eye to avoid diplopia. There are different types of suppression depending on factors such as etiology, retinal area involved, constancy, and the eye affected. Several tests are used to diagnose suppression including the Worth four dot test, Bagolini striated glass test, and visual acuity testing. Treatment involves refractive correction, occlusion therapy, eye alignment procedures, and anti-suppression exercises.
The pupil is a circular opening in the iris that controls the amount of light entering the eye. It constricts (miosis) and dilates (mydriasis) under autonomic nervous system influence. The iris contains two muscle groups - the sphincter pupillae and dilator pupillae - that regulate pupil size. Abnormal pupils may be unequal in size (anisocoria), irregularly shaped, or have abnormal reactions to light or accommodation. Various diseases and drugs can cause pupil abnormalities.
The pupil is a circular opening located in the center of the iris that controls the amount of light entering the eye. The size of the pupil is regulated by two sets of muscles - the sphincter pupillae constricts the pupil in response to parasympathetic stimulation while the dilator pupillae dilates the pupil under sympathetic influence. Abnormalities in pupil size, shape, reaction to light and accommodation can provide clues to underlying ocular and neurological diseases. Common causes of an abnormal pupil include trauma, inflammation, drugs and disorders of the autonomic nervous system.
This document provides information on examining the 12 cranial nerves, beginning with a overview of their origins and locations. It then examines each cranial nerve individually, describing their function, relevant examination techniques, and ways to interpret the results. For cranial nerves I-II (olfactory and optic), it discusses testing smell identification and visual acuity/fields. For cranial nerves III-VI (oculomotor, trochlear, abducens), it outlines how to examine the pupils, accommodation reflex, and eye movements. The summary provides a high-level view of examining the main cranial nerves and evaluating sensory and motor functions.
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.
This document summarizes information about the anatomy and physiology of the eye, eye movements, amblyopia, and strabismus. It describes the three layers of the eye (fibrous, vascular, and neural), the extraocular muscles that control eye movement, and the cranial nerves involved (3rd, 4th, 6th). It defines amblyopia as reduced vision in one eye due to lack of coordination between the eyes and brain. Strabismus is described as misalignment of the eyes that can be constant or intermittent. Treatment options for amblyopia and strabismus include glasses, patching, and sometimes surgery to correct muscle imbalance.
This document discusses various tests used to evaluate binocular vision, including cover tests, Hess charting, and diplopia charting. Cover tests are used to detect manifest or latent strabismus and determine deviation direction. Hess charting maps eye positions in 9 gazes using colored lenses to dissociate vision between eyes. It identifies muscle under or overaction. Diplopia charting records double vision separation in 9 gazes to localize affected muscles. These objective tests evaluate binocular function and strabismus type and localization.
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3. Diplopia
Our two eyes work mutually; the images
that hit the fovea are processed by the
brain. Thus the term Binocular single
vision is used. In the absence of
simultaneous perception of light from the
same object, the binocular single image is
not formed. It is the result of impaired
function of Extraocular Muscles. Problem
with the extraocular muscle could be
Mechanical(Trauma & Injury), Disorder of
Motor neuron- Muscle
junction(myoneural junction), Disorders
of trochlear, Abducens, & Oculomotor
cranial Nerve.
8. Diplopia Charting
Diplopia chart is the record of subjective separation of double images in the
nine positions of gaze.
Two methods
1. Simple method
2. Electronic devices(Hess n Lees screens )
9. Simple Method
-Patient comfortable with his head erect and should preferably be still throughout
the examination.
-Carried out in a dark room.
-A red glass is put in front of one of the eyes (red in front of right, R for R, is a
convention). It is desirable to use Armstrong goggles since these are shaped to fit
the orbital margin.
-Examiner holds the torch at around ½ m or 1 m (It is important to mention the
distance on the chart).The light is held directly in front of the patient at first. If the
patient notes a double image, the relative position of these images is noted.
10. -The light is then carried to the other 8 positions of gaze.
-If there is no double vision in primary position, the position in which double
vision appears and is maximal is to be noted.
-In each gaze position the patient must be asked whether the images are,
parallel , distance between two images & tilt if present.
-Colored pencils can be given to patient to show the separation.
11.
12. Analysis of diplopia
Rules governing the relationship of two images
RULE 1.Displacement of the false image may be horizontal or vertical or both.
RULE 2 : Separation of the 2 images is greatest in the direction in which the weak
muscle has its purest action.
RULE 3: False image is displaced furthest in the direction in which the weak muscle
should move the eye.
RULE 4: The distal image ( image that is farthest away ) belongs to the paretic eye
RULE 5: If the images are exactly side by side it will be only the lateral or medial recti
that are involved.
RULE 6: If they are one above the other, either of the obliques, or the superior and
inferior recti, may be defective.
13. Hess Screen
-Walter Hess,1908.
-Principle is haploscopic – based on Burian principle – that in presence of normal
retinal correspondence, the two test objects presented to the two eyes will be
superimposed if they stimulate foveae of the two eyes, irrespective of the position
of the two eyes.
-Chart is plotted based on the Hering’s and Sherrington’s law of innervation.
-Dissociation of two eyes is by the means of colors.
-Haploscopic principle: two targets, one target pointed and patient has to
superimpose it with other target.
14. -Herings law of equal innervation: an equal and simultaneous innervation flows from
the brain to pair of muscles of both eyes (yoke muscle) which contract simultaneously
in different binocular movements.
-Sherrington's law of reciprocal innervation states that: When a muscle contracts, its
direct antagonist relaxes to an equal extent allowing smooth movement.
-Original Hess screen is a single tangent screen made up of a black cloth 3 feet height
and 3 feet long, marked by horizontal and vertical lines.
-Chart includes horizontal and vertical lines that subtend a visual angle of 5 degree.
-Fixation points are indicated at the centre of the screen and at the intersections of 15
deg and 30 deg lines by red dots. The screen is used to map/ chart the relative
positions of each eye in 9 gazes
Inner 15 degree field – 8 dots ( testing points )
Outer 30 degree field- 16 dots ( testing points )
After all the points are plotted – dots are joined by lines to identify inner and outer
field.
15.
16. -Test is performed with each eye fixating in turn.
-It is done at 50cm.
-Patient wears red and green glasses
-Eye to be tested should have green glass in front of it.
-The chart has electronically operated board with small red lights. Patient is asked to
place green light in each of points on red light as illuminated.
-When red light controlled by the examiner
• Eye under RED goggle acts as the Fixing Eye
• Eye under GREEN goggle acts as the Indicator Eye
17. -The patient wears red-green goggles and is seated 50
cm from the screen, preferably with his or her head
fixed in a headrest.
-The patient now sees the red dots with one eye (fixing
eye) and the green cords with the other (charted eye).
-The patient is instructed to place the three green cords
over each of the red dots in screen.
-It is advisable to start from point A then go to above
point B then proceed clockwise from C to I.
-The points found by the patient are connected by
straight lines and permit the examiner to determine
which, if any, muscles react abnormally.
-To change fixation, the red green goggles are reversed
with the red filter now in front of the left eye.
18. Hess Chart(Position)
-The basic principle of Hess
chart is foveal projection
therefore the higher field
belongs to the higher eye.
-Position of the central dot
indicates whether the deviation
is in primary position or not.
19. Hess Chart(Size)
-The variation in the size of the Hess
chart of each eye is due to the
Hering’s law.
-Small field belongs to the eye with
primary limitation of movement.
-Underaction can be seen with the
inward movement of the dots and
therefore the whole curve.
-Overaction can be seen by noting
the outward displacement of the
dots.
20. Hess Chart(Shape)
-Each small square on the grid subtends
5 degree at the working distance of 50
cm. Therefore the amount of deviation
can be calculated.
-In primary position, the amount could
be calculated by fixing either eye by the
displacement of the pointer from the
centre dots.
-The amount of underaction and
overaction can be calculated in the
various positions and hence the amount
of excursions can also be calculated.
21. Causes of III, IV and VI nerve palsies
Site Common causes
Brain stem • Stroke Superior orbital fissure • Tumor
• Demyelination
Meningeal • Meningitis Orbit • Infection
• Raised ICT • Tumor
• Aneurysms • Trauma
• Cerebellopontine angle tumor
• Trauma
Cavernous sinus • Infection
• Thrombosis
22. 3rd nerve palsy
-Complete 3rd nerve lesion causes total paralysis
of the eye lid, so diplopia occurs only when the lid
is held up.
-When the lid is lifted the eye will be found
deviated outwards and downwards.
4th nerve palsy
-Principal action of the muscle is depress and
intort globe– palsy of it causes hypertropia
and excyclotorsion.
-Head Tilt test : Vertical diplopia is seen upon
reading or looking down– exacerbated by
tilting the head towards the side with muscle
palsy and alleviated by tilting away.
( Cardinal diagnostic feature)
23. 6th nerve palsy
-Abducens nuclear lesion produces a
complete lateral gaze palsy from
weakness of both ipsilateral lateral
rectus and contralateral medial rectus.
-UL/BL abducens palsy is a classic sign
of raised intracranial pressure.
-Diagnosis is confirmed by papilladema
(Fundus).
24.
25. Management
Patching ( occlusive ) therapy
Identify and treat the underlying cause of the problem
Eye exercises
Wearing an eye patch on alternative eyes
Prism correction
Surgery
Botulinum toxin
27. Enophthalmos
Retro positioning of the globe in its three dimensional relationship in the orbit.
• Should always be assessed in relation to the contralateral eye
• It is an unsightly deformity which can be impossible to correct completely
• Regarded as the most common and serious sequalae of complex orbital
trauma.
28. Signs And Symptoms
• Sunken eye
• Narrowing of palpebral width with pseudo-ptosis of the upper lid
• Supra tarsal hollowing
• Hooding of the eye
• Decreased anterior projection of the globe
• Paresthesia of the infraorbital nerve
30. Causes
• Increased orbital volume
• Herniation of orbital fat
• Orbital fat atrophy
• Loss of ligamentary support
• Trochlear dislocation
• Entrapment of tissues in blow outs pulls the whole system downwards and backwards
• Action of gravity on orbital contents in an enlarged cavity
31. Relationship With Orbital
Volume
• 1mm medial displacement of the medial wall results in a 0.4 ml increase in orbital
volume.
• 1mm inferior displacement of the floor results in a 0.8 ml increase in orbital volume.
• An increase in orbital volume of approximately 1.25 ml will result in 1mm enophthalmos.
• 10% (2.5ml) increase in volume would be expected to result in clinically significant
enophthalmos.
• This is roughly equivalent to 3mm inferior displacement of the orbital floor.
32. Clinical Examination
ASSESS
• Visual acuity
• Eyelids and periorbital regions
• Extra-ocular movements
• Pupillary light reactivity
• Globe projection
• Measure enophthalmos with Hertel’s or Naugle’s exophthalmometer
• Paraesthesia
• Canthal positions
• Eye and ZMC symmetry in all three planes
33. HERTEL EXOPHTHALMOMETER NAUGLE EXOPHTHALMOMETER
Among adults, the usual
distance from the lateral
orbital
rim to the corneal apex is
approximately 16-21mm.
35. Surgical Approaches
• Subciliary / Subtarsal
• Transconjunctival with / without lateral canthotomy
• Infra orbital
• Lateral nasal approach for medial wall
• Coronal
• Endoscopic Intra sinus
36. Indications For Surgery
• Enophthalmos of 2mm or more present for 2 weeks
• Positive forced duction test (FDT)
• Volume expansion on CT scan
• Herniation of orbital contents in the maxillary antrum
• Combined medial and inferior wall fracture
• Isolated medial wall fracture with displacement >3- 5mm
• Isolated floor fracture with displacement > 3mm
Early intervention is always beneficial as late intervention gives poor results
because of extensive scarring and muscle shortening.
37. Aims Of Surgery
• Restore anatomy
• Restore orbital volume
• Preserve vision
• Improve eye movements
• Restore esthetics
38. Management
ENOPHTHALMOS WITH ISOLATED ORBITAL FRACTURES
• Expose the fracture site
• Free all the entrapped and herniated tissue
• Wide subperiosteal exposure
• Find a fixed base posterior to the globe
• Reconstruct the defect with graft or plate
• Graft or plate should fit passively and must be fixed to the base or rim with
plates/screws
• Graft must be placed behind the globe axis to push it forward
• Assess with FDT again before closure
• Close in layers
39. ASSOCIATED ZMC FRACTURES
• Expose the fracture sites
• Reduce the displaced ZMC and the fractured rims to their accurate anatomical
positions
• Rigidly fix ZMC (3 point fixation)
• Free any herniated tissue
• Graft/plate any defects
• Perform FDT before closure
• Close in layers
40. Complications
• Failure to correct properly in the initial setting thus requiring secondary repair
• Iatrogenic damage to the globe
• Optic nerve compression
• Graft resorption and recurrence of enophthalmos
• Infection/extrusion of the graft/plate
• Foreign body reaction
• Tissue sagging owing to inadequate closure
• Scarring, ectropion or scleral show
42. Massive retrobulbar hemorrhage in the posterior region of the muscle cone, triggered
by vessel disruption, leads to progressive exophthalmos with concurrent pupil
dilatation, reduced vision and increased intraocular pressure. (Ord 1981; Ord and El
Altar 1982)
Retrobulbar hemorrhage may occur spontaneously or as a result of trauma, peribulbar
or retrobulbar injections, or surgery.
A Retrobulbar hemorrhage is a space-occupying lesion of the orbit leading to forward
displacement of these structures as intraorbital volume and pressure increases.
Neurological damage is caused by direct compression, by bony fragments or by an
indirect compression of the nerves caused by hemorrhage (Rowe and Williams 1985)
43. Etiology
Spontaneous : Orbital vascular abnormality Arteriovenous malformation
Uncontrolled hypertension Scuba diving, weightlifting, sneezing
Post Traumatic : Orbital Fractures
High Level Midfacial Fracture
Le Fort III Fracture
Post Anaesthesia : Retrobulbar injection
Peribulbar injection
Sub-Tenon’s injection(episcleral)
Post Operative : Facial /Orbital Fracture Repair
Endoscopic Sinus Surgery
44.
45. Soft Tissue Considerations
The orbit is lined by periosteum that attaches firmly at the foramina, fissures, suture
lines and the posterior lacrimal crest. Between these firm attachments the
periosteum is loosely adherent, creating a potential space for accumulation of blood.
The characteristic CT appearance of an acute subperiosteal hematoma is a broad-
based extraconal mass that abuts the bony orbit and displaces orbital contents
centrally. Radiographically, the mass is high-density, sharply defined and
homogeneous.
46. All mechanisms relate to increased intraorbital pressure and volume leading to:
:Ischemic optic neuropathy from compression or stretching of the small nutrient vessels
:Direct compressive optic neuropathy
:Central retinal artery occlusion
:Retinal vascular ischemia
47. Signs And Symptoms
-Protrusion of the globe (up to 10 mm)
-Increased intra-ocular pressure more than 80 mmHg
-Ischemia of the optic disk and retina with clearly reduced vision
-Pain
-Reduced vision
-Diplopia
48. -MRI scans provide better visualization of the soft tissues of the orbit.
-CT scans are preferred because of their fast acquisition time and better visualization
of the bony anatomy.
Investigations
49. Treatment Options
-Once the diagnosis is made, therapy should begin immediately.
-Optic nerve damage was proportional to the duration of occlusion of Central Retinal
Artery.
-Treatment is aimed at lowering intraorbital or intraocular pressure and protecting the
optic nerve from damage.
-Rapid surgical intervention remains the mainstay of treatment.
50. Medical Treatment Options
Include
Oxygen therapy: May decrease the ischemic insult by dilating intraocular vessels.
Mannitol 20% IV: The hyperosmotic agent, rapid IV infusion of 1.5 - 2 g/kg over 30 min,
with the first 12.5 g over the first 3 min. Reduces intraocular pressure.
Acetazolamide: The carbonic anhydrase inhibitor. Given 500 mg IV. Lowers intraocular
pressure.
Steroids: Methylprednisolone, 100 mg, decrease inflammation and edema.
Topical β-blockers: Decrease intraocular pressure by lowering aqueous humor
secretion.
52. -Relieve orbital compression primarily.
-Can often be achieved via a lateral canthotomy and inferior cantholysis.
-If further decompression is needed, a lateral anterior orbitotomy may be required to
break the fibrous septa of the orbital fat compartments.
-Pterional orbital decompression:A neurosurgical approach.
Removal of the bony lateral and superolateral orbital walls to maximally decompress the
orbit
53. Post-operative Care
-The patient must be closely followed with serial examinations:
Pupillary light reflexes
Visual acuity
Intraocular pressure
Fundoscopy
-The head of the bed may be elevated to decrease arterial pressure.
-The lateral canthotomy and cantholysis may be repaired days later to allow for
further drainage in the event of additional hemorrhage or it may be allowed to heal
spontaneously.