The document provides information on evaluating cases of orthoptics. It discusses evaluating a patient's history, visual acuity, eye movements, sensory status, and degree of strabismus. The evaluation includes assessing visual acuity, refraction, eye alignment using various objective tests like cover tests, assessing binocularity using stereopsis tests, and determining the presence of suppression or abnormal retinal correspondence. The document outlines the various tests used to evaluate motor and sensory functions in patients with strabismus.

1. EVALUATING THE CASES OF
ORTHOPTICS !
Optom. Ankit S. Varshney
B.Optom, M.Optom, Ph.D. in Optometry (pursuing) Fellow of IACLE (Aus.), Fellow of ASCO(Mum.)
Prof. at (Shree Bharatimaiya College of Optometry & Physiotherapy, Surat)
Life Member of Indian Optometric Association (IOA)
Associate Member of Association of Schools and Colleges of Optometry(ASCO)
Member of Optometry Council of India(OCI)
Educator Member of International Association of Contact lense Educators (Australia)(IACLE)
Mail id: ankitsvarshney@yahoo.com
Whatsapp no. +918155955820

2. ALWAYS REMEMBER !
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3. See how they works !
SURERIOR RECTUS
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Superior ObliqueInferior Oblique

4. EYE MOVEMENTS
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Ductions
Versions
Vergence

5. LAWS OF INNERVATION
Sherrington law of
reciprocal
innervation
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Hering’s law of
equal innervation

6. EVALUATION
INCLUDES
1. History
2. Visual acuity
3. General examination
4. Evaluation of the motor state
5. Evaluation of the sensory state
6. Anterior and Posterior segment
evaluation Optom. Ankit Varshney 6

7. ASK RELEVANT QUESTIONS ONLY!
Age of patient at onset.
Who noticed first
Mode of onset – sudden / gradual / intermittent
If intermittent – precipitating factors
Which eye deviates
Nature and direction of deviation
Any alternation with gazes & time
Amount of squint
Whether for near or distanceOptom. Ankit Varshney 7

8.  CHIEF C/O
 PERSONAL H/O
 FAMILY H/O
 TREATMENT H/O
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History

9. History- subjective ocular complaints
Blurred Or Double Vision
Headache, Asthenopia
Diplopia, Past Pointing, Vertigo
Presence Of Face Turn, Head Tilt, Abnormal Head
Movement
Closure Of One Eye In Bright Sunlight
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10. History - precipitating causes
History of head or face injury
History of recent illness
Any eye disease prior to onset
necessitating occlusion of one eye with
pad.
Maternal history and birth history
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11. PERSONAL HISTORY
 ANTENATAL- DRUGS, ILLNESS
 PERINATAL- TYPE OF DELIVERY
PREMATURITY
BIRTH WT.
NEONATAL JAUNDICE,
CONVULSIONS..
 DEVELOPMENTAL H/O- MOTOR, SPEECH, HEALTH,
HANDEDNESS
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12. History - previous treatment
Spectacle correction and its effect on squint
Occlusion or orthoptic treatment
Surgery
Response To Treatment
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13. FAMILY HISTORY
 PARENTS, GRANDPARENTS, UNCLE,
AUNTS…
 SQUINTING
 HIGH REFRACTIVE ERROR
 TREATMENT TAKEN FOR SQUINTS.
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14. 2. VISUAL ACUITY
Uniocular for distance and near, also
pinhole VA
With and without spectacles
Binocularly specially in patient
with nystagmus
Fixation pattern
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15. REFRACTION
 Refraction is a must for all patients with
strabismus
 Agent- <10yrs.- 1% Atropine sulphate
>10yrs.- 1% Cyclopentolate +
5% Homatropine
 Proper refractive error corrn. Reqd.
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16. FUNDUS EXAMINATION.
 MEDIA & FUNDUS EXAM. MUST BE DONE IN
ALL PATIENTS WITH STRABISMUS
 DIRECT OPHTHALMOSCOPE
ALSO USED IN BRUCKNER’S TEST
PUPILLARY REACTIONSOptom. Ankit Varshney 16

17. NEAR POINT OF CONVERGENCE
 PRINCE RULE, RAF RULE
 BREAK POINT
 NORMAL – 5 TO 10 cm
 CONVERGENCE
MAINTAINANCE
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• <5 EXCESSIVE
• >10 DEFECTIVE
• ACCOM.TARGETWITH SUBJECTIVE
AND OBJECTIVE METHODS

18. Near Point Of Convergence
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•The RAF Rule is used for measurement of distances from the spectacle plane to the
target.
•To measure NPC the slide is moved closer to the patient until diplopia is reported (break),
then pushed back until single vision is regained (recovery)

19. 3. General examination
 Facial characteristics
facial asymmetry
Mongoloid / Anti mongoloid slant
slant
Epicanthus
Hypertelorism
Searching movements
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20. Head Posture
Head
tilt to right or left shoulder
Face
turn to right or left side
Chin
elevation or depressionOptom. Ankit Varshney 20

21. Optom. Ankit Varshney 21

22. MEASUREMENT OF DEVIATION
 OBJECTIVE TESTS :
MINIMAL COOPERATION REQUIRED
ONLY STEADY FIXATION
 SUBJECTIVE TESTS :
PT’S RESPONSE DETERMINES THE
RESULTS
CLINICAL EVALUATION OF SENSORY
STATUS Optom. Ankit Varshney 22

23. HIRSCHBERG CORNEAL REFLECTION TEST
 ROUGH BUT HANDY METHOD :
 ESTIMATE APPROXIMATE ANGLE OF
MANIFEST SQUINT
 MORE IMPORTANT FOR
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1. BLIND EYE
2. DEEP AMBLYOPIC EYE WITH LOW VA
3. UNABLE TO MAINTAIN FIXATION FOR
LONGER TIME e.g. YOUNG CHILDREN

24. Optom. Ankit Varshney 24

25. PSEUDO ESOTROPIA :IN PROMINENT
EPICANTHAL FOLD
PSEUDO EXOTROPIA: WIDE INTERPUPILLARY
DISTANCE: +VE ANGLE KAPPA
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26. COVER TEST
I. DISSOCIATION OF BINOCULAR VISION BY COVER
II. ALWAYS BE DONE FOR NEAR AND DISTANCE FIXATION
TO ESTABLISH ANY DIFFERENCE WITH ACCOMODATION
III. SHOULD BE DONE WITH GLASSES AND WITHOUT
IV. AND IN ALL NINE GAZES FOR INCOMITANT SQUINT.
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Three observations:
1. Watching one eye as the other eye is covered.
2. Watching the uncovered eye when the cover is removed.
3. Watching the covered eye when its cover is removed.

27. BEFORE TEST
NO MOVEMENT AFTER COVER
ESOTROPIA
EXOTROPIA
HYPERTROPIA
HYPOTROPIA
DIRECT COVER TEST
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28. RIGHT ESOTROPIA RIGHT EXOTROPIA
DEMONSTRATION
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29. UNI LATERAL RE ESOTROPIA:
AFTER UNCOVER, LE AGAIN
TAKE FIXATION
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30. Cover-uncover test
Detects phorias
Deviation of eye under cover noted; fusional
movement on removal of the cover noted
Test is repeated covering the other eye;
performed for distance as well as near.
Disadvantage  small phorias may be
missed
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31. ESOPHORIAEXOPHORIA.
DEMONSTRATION
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EXOPHORIA

32. ALTERNATE-COVER TEST
 COVER EACH EYE ALTERNATELY TO BREAK
COMPLETE FUSION AND WATCH BEHAVIOR OF
EACH EYE WHEN COVER IS REMOVED AND
TRANFERED TO OTHER EYE.
 FOR, BASIC DEVIATION, INTTERMITANT
TROPIAS, PHORIAS WITH STRONG FUSION
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• Patient should fixate with each eye
• Detects total strabismus
(manifest + latent )

33. LEFT EXOTROPIA
DEMONSTRATION
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34. ALTERNATE ESOTROPIA :
RE MAINTAIN FIXATION
AFTER REMOVING COVER
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35. RE ECCENTRIC FIXATION
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36. MADDOX ROD TEST
 PRINCIPLE
 INSTRUMENT
 METHOD
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37. Maddox Rod
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H: Ortho ESOphoria or
ESOtropia
EXOphoria or
EXOtropia
V: Ortho
R hyper
or
L hypo (phoria or tropia)
R hypo deviation
or
L hyper
(phoria or tropia)
Patient’s view with
Maddox Rod
over right eye.
Appearance is
reversed if the
Maddox Rod is
over the left eye.
Maddox Rod axis horizontal: vertical streak
Maddox Rod axis vertical : horizontal streak

38. MADDOX WING TEST
 PRINCIPLE
 INSTRUMENT
 METHOD
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39. PRISM BAR COVER TEST
 PRINCIPLE :
– AFTER COVERING FIXATING EYE, MOVEMENT OF OTHER EYE IS
DIRECTLY PROPORTIONAL TO DISTANCE OF FOVEA FROM
PERIPHERAL STIMULATED AREA.
– PLACING PRISM WITH INCREASING DIOPTRE BRINGS IMAGE
CLOSER TO FOVEA, WHEN PRISM STRENGTH EQUALS TO
DEVIATION, (IMAGE ON FOVEA) NO MOVEMENT
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40. -ACCO. TARGET
-APEX TOWARDS
DEVIATION
-END POINT :
NO MOVEMENT
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41. LOOSE
PRISMS
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42. RE ESO
ALT. COVER EYES
PRISM BASE OUT PLACED
COVER TRANSFERRED TO
PRISM
NO MOVEMENT
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43. Prism-cover test
Advantages
 Accurate to within 2 prism diopters
 Provides complete dissociation thus
measure maximum deviation
 Gives comparison of angle at different
distance
Disadvantages
 Inaccurate in large deviation
 Cyclotropia can’t be measured
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44. KRIMSKY PRISM TEST
 BASED ON HERING’S LAW
 VALUABLE IN PATIENT WITH BLIND OR DEEPLY
AMBLYOPIC EYE OR ECC FIXATION.
 PRECISE THEN HIRSCHBERG’S TEST
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45. RE ESO WITH POOR VISION
PRISM ON FIXING EYE
K’REFLEX IN CENTRE IN
DEVIATED EYE
OPTICAL PRINCIPLE
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46. SYNOPTOPHORE
 DIVISION OF “ PHYSICAL SPACE INTO TWO SEPARATE AREAS OF VISUAL SPACE”
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• FOR DISTANCE & NEARVISION:
– NEAR MEASUREMENTWITH MINUS LENSES (IPD 6 cms)
• MEASUREMENTOF SUBJECTIVE & OBJECTIVEANGLE OF DEVIATION
FOCAL PLANE AT OPTICAL INFINITY
ROLE OF PROXIMAL CONVERGENCE
EXAMINATION IN EXTREME
POSITION OF GAZE
ADJUSTMENT FOR NEAR
IMPORTANT CONSIDERATION

47. ADAPTATION TO STRABISMUS
SUPPRESSION
AMBLYOPIA
ECCENTRIC FIXATION
ANOMALOUS RETINAL CORRESPONDENCE
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48. Sensory Evaluation
Goals: to establish
 Presence of diplopia or suppression
 Presence and degree of amblyopia
 Type of retinal correspondence
 Stereopsis
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49. TEST FOR
STEREOPSIS
Titmus test: fly  3000 sec of arc
circles  800-40 sec of arc
animals  400-100 sec of arc
TNO test: 480-15sec of arc.
No monocular clues are given.
Lang’s test:1200-550 sec of arc
Frisby test: 600-15 sec of arc
Synaptophore
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50. MAJOR AMBLYOSCOPE
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51. TITMUS FLY TESTS
 TITMUS :- POLAROID VECTO GRAPH OF
2 PLATES ,VIEWED THROUGH
POLAROID SPECTACLES
 1) FLY :-GROSS STEREOPSIS (3000 SEC
OF ARC)
 2)CIRCLES :-FINE DEPTH PERCEPTION
(DISPARITY 800-40 SECS OF ARC)
 3)ANIMAL :-DEGREE OF DISPARITY 400-
100SECS OF ARC
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52. TNO
 TRUE MEASUREMENT
 CONSISTS OF 7 PLATES
 RED –GREEN SPECTS
 FIRST 3 PLATES :PRESENCE OF
STEREOPSIS
 OTHERS :-TO QUANTIFY
 NO MONOCULAR CLUES
 DEGREE OF DISPERITY :-480 -15
SECS OF ARC
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53. The Random Dot “E” Test
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54. LANG
 YOUNG CHILDREN
 NOT REQ. SPECIAL SPECTS
 TARGETS SEEN BY EACH EYE
THROUGH BUILT IN
CYLINDRICAL LENS ELEMENT
 D.D.1200 -600SECS OF ARC
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55. FRISBY
 THREE TRANSPARENT PLASTIC
PLATES
OF VARYING THICKNESS
 EACH PLATE :- 4 SQUARES OF
SMALL RANDOM SHAPES --1
WITH HIDDEN CIRCLE
 D.D. 600 -15SECS OF ARC
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56. TWO PENCIL TESTS
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57. TESTs FOR SUPPRESSION
Worth’s 4 dot test
Bagolini Striated Glass Test
4 diopter base out prism test
Major amblyoscope
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58. TEST FOR ARC
WFDT
After image test
Bagolini’s striated glasses
Synoptophore
Red Filter Test
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59. THE WORTH FOUR DOT TEST
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•LOOKING THROUGH RED – GREEN
GLASSES RT-RED, LT-GREEN
•TO FOUR DOTS(1RED, 2 GREEN,1 WHITE)

60.  PERIPHERAL FUSION WITH ORTHOPHORIA
OR TROPIA WITH ARC.
 SUPPRESSION OF LEFT EYE
 SUPPRESSION OF RIGHT EYE
 UNCROSSED DIPLOPIA WITH ESOTROPIA
 CROSSED DIPLOPIA WITH EXOTROPIA..
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WFDT : INTERPRETATIONS

61. STRIATED GLASSES TEST
OF BAGOLINI
 STRIATED GLASSES PLACED AT
45 AND 135 DEGREE
 (AS OBLIQUE MERIDIAN IS LESS
LIKELY TO SUPPRESS)
 PT. FIXATES A SMALL LIGHT AT
NEAR & DIST. LIGHT PERCIVED
TO EACH EYE PERPENDICULAR
TO STRIATION.
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62. ORTHOPHORIA WITH NRC OR
TROPIA WITH ARC.
FIXATION POINT SCOTOMA (WITH
TROPIA; ARC) OR FOVEAL SCOTOMA
(ORTHOPHORIA ; NRC) OF RT EYE.
SUPPRESSION OF RIGHT EYE
 DIPLOPIA WITH TROPIA.Optom. Ankit Varshney 62

63. 4 Diopter Base - Out
Prism Test
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64. AFTER IMAGE TEST
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65. DIPLOPIA CHARTING
 PRINCIPLE
 PROCEDURE-
* RED-GREEN GOGGLES
* HEAD POSITION
* LIGHT SOURCE
* CLOSE EACH EYE ONEBYONE
* NINE DIAGNOSTIC POSITIONS OF GAZE
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66. HESS CHARTING
PRINCIPLE
- foveal projection
- laws of innervation
- dissociation of eyes by means of complementary colors.
 ARCHITECTURE OF THE SCREEN :-DIAGNOSIS OF POSSIBLE
PARESIS OR PARALYSIS WITH NRC
– 3X31/2 FT. SCREEN LINES 50 ANGLE
– RED DOTS AT 150 AND 300
– EXAMINATION AT ½ METER DISTANCE
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67. Optom. Ankit Varshney 67

68. LEES SCREEN
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69. Thank You
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