8.1.4

Question 1

What is heterotropia?

Answer 1

A condition where the eyes are misaligned and cannot maintain proper binocular fixation.

Question 2

What are the types of onset for heterotropia?

Answer 2

• Congenital/longstanding
• Acquired (sudden or gradual onset)

Question 3

What are common symptoms of heterotropia?

Answer 3

• Diplopia (monocular or binocular)
• Asthenopia (eye strain, headaches)
• Cosmesis concerns
• Suppression or adaptation (if longstanding)

Question 4

What triggers or associations are linked to heterotropia?

Answer 4

• Trauma
• Vascular disease
• Neurological conditions
• Recent illnesses or stress
• Medication history

Question 5

What is the purpose of the Cover Test in diagnosing heterotropia?

Answer 5

Determines manifest deviation (constant or intermittent).

Question 6

What does the Alternate Cover Test identify?

Answer 6

Direction and size of deviation.

Question 7

What does the Prism Cover Test quantify?

Answer 7

Deviation in prism diopters.

Question 8

What is assessed during an ocular motility assessment?

Answer 8

• Versions (binocular movements)
• Ductions (monocular movements)
• Identifies incomitance (e.g., paralytic squint)

Question 9

What tests are used for sensory evaluation in heterotropia?

Answer 9

• Worth 4-dot test
• Bagolini lenses
• Refraction

Question 10

What conditions are ruled out by Slit Lamp Examination & Fundoscopy?

Answer 10

Ocular pathology.

Question 11

What neurological aspects are evaluated if indicated?

Answer 11

Cranial nerves (III, IV, VI).

Question 12

What is the management approach for longstanding or decompensated tropia?

Answer 12

• Spectacle Correction
• Prisms
• Occlusion Therapy
• Orthoptic Exercises

Question 13

What corrections are made with spectacle correction?

Answer 13

Fully correct refractive error, particularly in accommodative esotropia.

Question 14

What type of prisms are prescribed for mild deviations?

Answer 14

• Fresnel prisms (temporary)
• Ground-in prisms (permanent)

Question 15

What is the primary action for acquired (sudden-onset) tropia?

Answer 15

Urgent referral if neurological, vascular, or orbital causes are suspected.

Question 16

What temporary management options are available for acquired tropia?

Answer 16

• Occlusion
• Prisms
• Monitor spontaneous recovery

Question 17

What is the focus of management for incomitant tropia?

Answer 17

• Monitor for spontaneous recovery
• Address underlying causes
• Orthoptic therapy & prisms

Question 18

What are the potential benefits of squint surgery?

Answer 18

• Improves ocular alignment and cosmesis
• Reduces or eliminates diplopia
• Enhances binocular function in some cases

Question 19

What are the limitations and risks associated with squint surgery?

Answer 19

• Success is not guaranteed
• Over- or under-correction may occur
• Risks of general anesthesia, infection, or scarring

Question 20

What are the driving regulations according to DVLA guidelines for patients with diplopia?

Answer 20

Driving is not permitted unless managed (e.g., prism, occlusion).

Question 21

What adaptations may be needed for work and daily activities?

Answer 21

Adaptations in tasks requiring depth perception.

Question 22

What should be discussed with patients regarding prognosis and treatment expectations?

Answer 22

Regular follow-up and realistic outcomes of treatments.

Question 23

What are the referral criteria for sudden-onset tropia?

Answer 23

Urgent referral to neurology/ophthalmology.

Question 24

What should be done in primary care before referring a patient with heterotropia?

Answer 24

Fully assess to ensure appropriate urgency.

Question 25

What aspects of patient-centered care should be discussed?

Answer 25

* Discuss treatment options transparently * Provide psychological support for cosmetic concerns

Question 26

What is a key characteristic of a paralytic squint?

Answer 26

Sudden onset due to neurological or mechanical causes ## Footnote Examples include cranial nerve palsy, stroke, trauma, or myasthenia gravis.

Question 27

What are the signs of a non-paralytic (concomitant) squint?

Answer 27

Longstanding onset, no diplopia, comitant deviation, normal ocular motility ## Footnote Often associated with refractive error or decompensating heterophoria.

Question 28

What test can differentiate between paralytic and non-paralytic squints?

Answer 28

Hess Chart & Maddox Rod ## Footnote Paralytic squints show incomitant deviations.

Question 29

What is a common differential diagnosis for horizontal diplopia?

Answer 29

Sixth Nerve (Abducens) Palsy, Third Nerve (Oculomotor) Palsy, Myasthenia Gravis, Thyroid Eye Disease ## Footnote These conditions may present with varying degrees of ocular misalignment.

Question 30

What is the next step in management for a patient presenting with diplopia?

Answer 30

Perform a cover test and ocular motility assessment ## Footnote This helps identify comitant vs. incomitant deviation.

Question 31

What are surgical options for exotropia?

Answer 31

Bilateral Lateral Rectus Recession, Unilateral Resection & Recession, Medial Rectus Advancement, Adjustable Suture Surgery ## Footnote The choice depends on the type and severity of exotropia.

Question 32

What should be assessed in a patient with long-standing esotropia concerned about cosmesis?

Answer 32

Sensory Adaptation, Treatment Options (glasses, prisms, surgery), Risks of surgery ## Footnote Surgery is elective if the patient is asymptomatic.

Question 33

What are the limitations of using prisms in heterotropia management?

Answer 33

Limited to small deviations, does not treat underlying cause, cosmetic concerns ## Footnote Prism adaptation may occur over time.

Question 34

What are key signs of a third nerve (oculomotor) palsy?

Answer 34

Eye position 'down and out', ptosis, diplopia, accommodation deficit, pupil involvement ## Footnote Pupil involvement suggests a potentially serious cause.

Question 35

What is the significance of pupil involvement in third nerve palsy?

Answer 35

Suggests a compressive cause, requires emergency referral for neuroimaging ## Footnote Pupil-sparing palsy is more likely due to microvascular ischemia.

Question 36

What tests are used to assess cranial nerve IV palsy? 4

Answer 36

Cover Test, Parks-Bielschowsky Three-Step Test, Maddox Rod Test, ocular motility assessment ## Footnote Systemic workup is needed if bilateral or progressive.

Question 37

What tests assess binocular function in heterotropia?

Answer 37

Worth 4-Dot Test, Bagolini Striated Lenses, Synoptophore, Stereopsis Tests, Hess Chart, Prism Adaptation Test ## Footnote These tests help evaluate suppression and angle of anomaly.

Question 38

What is the management plan for a patient with recent-onset esotropia and a history of hypertension?

Answer 38

Differentiate causes, assess cranial nerves, urgent referral if red flags, monitor microvascular cases, temporary management with prisms ## Footnote Address underlying hypertension.

Question 39

What are the indications for botulinum toxin injections in strabismus?

Answer 39

Acute paralytic strabismus, small-angle deviations, post-surgical residual deviations, alternative for high-risk patients ## Footnote It is not suitable for chronic deviations.

Question 40

When should an adult with heterotropia be referred to an ophthalmologist?

Answer 40

Urgent referral for sudden-onset heterotropia, neurological signs; routine for symptomatic diplopia ## Footnote No referral needed for stable, asymptomatic strabismus.

Question 41

What factors determine the success of squint surgery?

Answer 41

Type of tropia, angle of deviation, binocular function, surgical technique ## Footnote Intermittent strabismus has better outcomes than constant.