SquintClinicSquintClinic
HyderabadHyderabad
L. V. Prasad Eye InstituteL. V. Prasad Eye Institute
Formal Orthoptic Diagnostic Aid:
Formal Orthoptic Diagnostic Aid:
1
2
3
1
2
3
management is traditional rather than rational
Orthoptic ReportOrthoptic Report
Getting an orthoptic report
is like kissing your own sister
It doesn’t lead anywhere
Getting an orthoptic report
is like kissing your own sister
It doesn’t lead anywhere
Practical
Approach
To
Strabismus
Practical
Approach
To
Strabismus
Definition of StrabismusDefinition of Strabismus
• When the two visual
axes do not intersect at
the object of attention
• When the two visual
axes do not intersect at
the object of attention
Aim of ExaminationAim of Examination
• To determine the normality or
abnormality of :
• The sensory apparatus
• The motor apparatus
• In a valid & repeatable manner
• To determine the normality or
abnormality of :
• The sensory apparatus
• The motor apparatus
• In a valid & repeatable manner
Information Required From ExamInformation Required From Exam
• Bifoveal Fusion
• Nature and degree of Deviation
• Fusional Vergences
• Measurements
• If Tropia – characteristics of Suppression scotoma
• Bifoveal Fusion
• Nature and degree of Deviation
• Fusional Vergences
• Measurements
• If Tropia – characteristics of Suppression scotoma
Factors to Be ControlledFactors to Be Controlled
• Accommodation
• Fixation
• Fusional vergences
• Accommodation
• Fixation
• Fusional vergences
All TestsAll Tests
• Cycloplegic
retinoscopy
• Refractive errors
corrected
• Accommodative
target for distance
and near
• Cycloplegic
retinoscopy
• Refractive errors
corrected
• Accommodative
target for distance
and near
Sequence of Clinical Tests Sequence of Clinical Tests
• Bi foveal fusion
• Fusional vergences
• Deviations & Measurements
• Rotations, A/V, Head tilt
• Limitation of movements • Restriction VS weakness
• Characteristics of suppression
• Bi foveal fusion
• Fusional vergences
• Deviations & Measurements
• Rotations, A/V, Head tilt
• Limitation of movements • Restriction VS weakness
• Characteristics of suppression
Doctor Must Do the Examination
Personally
Doctor Must Do the Examination
Personally
Cover TestCover Test
ExotropiaExotropia
EsotropiaEsotropia
Alternate Divergent SquintAlternate Divergent Squint
Un - Cover TestUn - Cover Test
Un - Cover TestUn - Cover Test
Exophoria – Fusional ReflexExophoria – Fusional Reflex
Exophoria – Fusion MovementExophoria – Fusion Movement
Intermittent Divergent SquintIntermittent Divergent Squint
Intermittent Divergent SquintIntermittent Divergent Squint
Prism Bar Cover TestPrism Bar Cover Test
Ocular MovementsOcular Movements
every limitation of movement must be checked uniocularly
every limitation of movement must be checked uniocularly
Patterns : Rising EyePatterns : Rising Eye
Patterns : Falling EyePatterns : Falling Eye
Testing For A-V PatternTesting For A-V Pattern
No A or VNo A or V
V PatternV Pattern
A PatternA Pattern
10 ET10 ET10 ET10 ET
10 RXT10 RXT10 RXT10 RXT
40 XT40 XT40 XT40 XT
+4+4+4+4 +4+4+4+4
L/R L/R ++3030L/R L/R ++3030
- 3- 3- 3- 3- 3- 3- 3- 3
R/L R/L ++3030R/L R/L ++3030
Recording ResultsRecording Results
10 ET10 ET10 ET10 ET
10 RXT10 RXT10 RXT10 RXT
40 XT40 XT40 XT40 XT
+4+4+4+4 +4+4+4+4
L/R L/R ++3030L/R L/R ++3030
{-3}{-3}{-3}{-3}- 3- 3- 3- 3
R/L =30R/L =30R/L =30R/L =30
Recording ResultsRecording Results
EXEXEX
Mild Face Turn
+EN
Globe RetractionGlobe Retraction
Exotropia with HypertropiaExotropia with Hypertropia
R.E. Fixing
R.E. Fixing
Suspect StrabismusSuspect Strabismus
• If abnormal head posture
• If closing one eye
• If abnormal head posture
• If closing one eye
Head Tilt TestHead Tilt Test
Head Tilt Test : OthersHead Tilt Test : Others
Head Tilt Test : OthersHead Tilt Test : Others
Head Tilt Test : OthersHead Tilt Test : Others
Head Tilt Test : OthersHead Tilt Test : Others
Sixth Nerve Paralysis & SaccadesSixth Nerve Paralysis & Saccades
Floating SaccadesFloating Saccades
Primary Versus Secondary Deviation
Primary Versus Secondary Deviation
Forced Duction TestForced Duction Test
Forced Duction TestForced Duction Test
Force Generation TestForce Generation Test
Force Generation TestForce Generation Test
Sensory System / TestsSensory System / Tests
The sensory system is of inestimable importance in the management
Valid inferences :
• Age of patient
• Type of squint
• Refraction correction H/O
• Motor examination
The sensory system is of inestimable importance in the management
Valid inferences :
• Age of patient
• Type of squint
• Refraction correction H/O
• Motor examination
Sensory / Suppression - InferenceSensory / Suppression - Inference
Early onset tropia Binocular suppression scotoma
Early onset exotropia Temporal hemiretinal suppression scotoma
Early onset esotropia Regional nasal hemiretinal suppression
Early onset tropia Binocular suppression scotoma
Early onset exotropia Temporal hemiretinal suppression scotoma
Early onset esotropia Regional nasal hemiretinal suppression
Visual AcuityVisual Acuity
Even in a Baby It Is Possible ToEven in a Baby It Is Possible To
• Test the quality of vision
• Refract and examination fundi
(with help of atropine)
• Test the quality of vision
• Refract and examination fundi
(with help of atropine)
Qualitative VisionQualitative Vision
Don’t Forget The FundusDon’t Forget The Fundus
Prism RE: LE moves outAnd comes back to refixatePrism RE: LE moves outAnd comes back to refixate
4 Prism Test : Normal4 Prism Test : Normal
Prism RE: LE moves outAnd stays outPrism RE: LE moves outAnd stays out
4 Prism Test : Abnormal4 Prism Test : Abnormal
After removal of prismAfter removal of prism
Prism LE : No movementsPrism LE : No movements
4 Prism Test: Abnormal4 Prism Test: Abnormal
4 Prism Test : Positive4 Prism Test : Positive
Sophisticated Tests Sophisticated Tests
Audience InteractionAudience InteractionAudience InteractionAudience Interaction
Aim of Strabismus ManagementAim of Strabismus Management
• Good vision in each eye
• Binocular vision
• Preferably stereopsis
• Normalise :
• Deviations
• Rotations
• Head position
• Good vision in each eye
• Binocular vision
• Preferably stereopsis
• Normalise :
• Deviations
• Rotations
• Head position
Rx of StrabismusRx of Strabismus
• Glasses
• Occlusion
• Prisms
• (Exercises)
• Surgery : minimum number of interventions
• Glasses
• Occlusion
• Prisms
• (Exercises)
• Surgery : minimum number of interventions
Pseudo StrabismusPseudo Strabismus
GlassesGlasses
OcclusionOcclusion
Cosmetic SurgeryCosmetic Surgery
Adjustable SuturesAdjustable Sutures
Superior Oblique ParalysisSuperior Oblique Paralysis
Key to StrabismusKey to Strabismus
If you master the physical examination and
disregard the mystique of orthoptics then
strabismus is no longer such a difficult subject
Even I can handle it ?
If you master the physical examination and
disregard the mystique of orthoptics then
strabismus is no longer such a difficult subject
Even I can handle it ?
If you are interested in doing things mechanically
Fix holes in the retina / do cataracts If you want to exercise those grey cells
Do squints
If you are interested in doing things mechanically
Fix holes in the retina / do cataracts If you want to exercise those grey cells
Do squints