B10 Flashcards
What is the purpose of external observations?
To identify gross abnormalities of the eye and adnexa
What 5 things do you need to observe when doing an external observation?
- eye alignment
- facial features
- head position
- posture
- gait
- carriage
What is the purpose of the cover test?
assess the presence and magnitude of a phoria or tropia
Do patients wear their glasses when doing cover test?
Yes
Present all the time in a cover test
Constant
Patient has moments of binocularity in cover test
Intermittent
When fixation may alternate between eyes or maintain fixation only with one eye
Eye preference
What do you need to record with cover test?
- correction
- magnitude
- eye
- phoria or tropia
- constant or intermittent
- distance or near
A test used to assess ability to perform conjugate eye movements
EOMs
Does the patient wear correction when doing EOMs?
No
What should you ask your patient when doing EOMs?
If they have any pain, see double, or eye strain
During EOMs what 6 things are you observing?
-Fixation • Pursuit of Eye Movements • Vertical Movement of the Eyes and Lids • Comitancy • Monocular Motility • Saccadic Movements
What is the purpose of hirschberg?
to determine the position of the visual axes, under binocular conditions at near
Do patients wear their glasses during hirschberg?
No
How far should you be from the patient when doing hirschberg?
50-100cm from patient
When doing hirschberg do you do it mono or bino?
First do it mono then do it bino
If the light is in the center of the pupil what is the angle lambda?
Deviation?
Angle lambda: 0
Deviation:ortho
If the light is nasal to the pupil what is the angle lambda?
Deviation?
AL: +
Deviation: exo
If the light is temporal to the pupil what is the angle lambda?
Deviation?
AL: -
Deviation: eso
If the light is above the center of the pupil what is the angle lambda?
Deviation?
AL: N/A
Deviation: hypo
If the light below the center of the pupil what is the angle lambda?
Deviation?
AL: N/A
Deviation: Hyper
If the corneal reflex if different mono vs bino during hirschberg, what does this mean?
There is a strabismus
When doing krimsky you place the prism over the ___ eye until the corneal reflex is in the same position as the deviating eye
Fixating
1mm of deviation= ___ D (Krimsky)
22D
If someone has an esotropia what kind of prism do you use?
BO
If someone has an esophoria what kind of prism do you use?
BO
If someone has an exotropia what kind of prism do you use?
BI
If someone has an exophoria what kind of prism do you use?
BI
What is the purpose of a bruckner test?
To evaluate the symmetry of bino fixation
What does bruckner test screen for?
- Strabismus
- Anisometropia
- Media opacities
- Posterior pole anomalies
- Presence of refractive error
Do people wear their glasses for bruckner test?
No
When doing bruckner what instrument do you use?
Ophthalmoscope
How far do you need to be from the patient when doing Bruckners?
80-100cm illuminating both pupils
What does it mean when the reflexes are equally bright for bruckners?
Bino fixation
What does it mean when the the reflexes are not equally bright for bruckners?
There may be a Strabismus, media opacity, or retinoblastoma
When looking for a strabismus you would used Bruckners in conjunction with ____
Hirschberg
If you have an unequal reflex which eye is the fixating and which is the nonfixating eye? (Bruckners)
Non-fixating eye- brighter, lighter, or white reflex
Fixating eye- darker red reflex
If you do hirschberg along with Bruckners and you see that there isnt a strabismus, then you know that there is a pathology. So the dimmer eye would mean? And a brighter eye would mean?
media opacity=dimmer eye
Retinoblastoma=brighter eye
When doing Bruckners and you see a crescent towards the head of the ophthalmoscope what does this mean?
That the patient is hyperopic
When doing Bruckners and you see a crescent towards the handle of the ophthalmoscope what does this mean?
The patient is myopic
How do you need to record bruckner?
- if the eyes appear equally bright
- present of any media opacities
- presence of refractive error and whether its equal size in both eyes
- which eye appears whiter and brighter (if applicable)
vertical meridians of the retinas are rotated in the same direction and by the same amount
Conjugate movements
vertical meridians of the retinas are rotated in the opposite directions to maintain a single image
Disconjugate eye movements
Cyclovergence movements compensate for ___
Cyclophorias
a tendency of the vertical meridians of the retinas to deviate from the straight ahead position in binocular vision, which becomes manifest in the absence of fusion.
Cyclophoria
Is cycloversion considered conjugate or disconjugate?
Conjugate
Is cyclovergence considered conjugate or disconjugate
Disconjugate
What is the purpose of a double Maddox rod?
- to detect a torsional misalignment
- Measures cyclodeviation BUT does not differentiate between phoria vs. tropia
Does the patient wear their correction during double Maddox rod?
Yes
What should the lighting conditions be for a double Maddox rod?
Dim
Do you test distance and near for a double Maddox rod?
Yes
Distance use a muscle light
Near use a penlight at 40cm
During a double Maddox rod the red filter should go over the ___ and the clear over the ___
Red-right
Clear-left
If you place the Maddox rods vertically the patient will see__ lines
Horizontal
How do you determine the degree of deviation of a double Maddox rod?
You rotate that orientation of the lenses until the two lines are parallel
If the patient only sees one line when you put the lenses on for a double Maddox rod what do you do?
Place a prism over one of the eyes so you can separate it and see a red line with the OD and a clear with the OS
For the double Maddox rod, the tilt of the line is ___ the tilt of the retinal image
Opposite
t/F: the line is perceived to the tilted in the direction in which the underacting muscle would rotate the eye
True
If the patients says line is tilted out then the eye is ____. And the underacting muscle is ___
The eye is intorted. And the underacting muscle is the IO (extorts)
If the patient says the line is tilted in then the eye is ____. And the underacting muscle is ___
Eye is extorted and the underacting muscle is the SO (intorts)
If the patient states the OD line is tilted towards the nose (intorted) there is a R ____ and the ___ is underacting
R excyclodeviation
SO underacting
How do you record a double Maddox rod?
- eye
- magnitude
- direction
During amblyscope the fixating eye looks at the
More detailed image
What is the purpose of a parks 3 step?
To identify the muscle responsible for a vertical deviation
What is step 1 in a P3S?
Identify which eye is hyper in primary gaze
What is step 2 in a P3S?
Identify whether the vertical deviation increases on right or left gaze
What is step 3 in a P3S?
Identify whether the vertical deviation increases on right or left head tilt
What 3 tests do you used during P3S to evaluate deviation of eye?
- cover test
- Maddox rod
- red lens
How do you determine the hyperdeviated eye in the primary gaze?
- use alternate cover test (hyper is the eye that moves down when uncovered)
- Maddox rod/red lens (target see will be lower that image seen by other eye)
The paretic muscle is the muscle that is circled __ times (P3S)
3
A L hypertropia that increases with right gaze and left head tilt. what muscle is affected?
L SO
A right hypertropia that increases with L gaze and L head tilt what muscle is affected?
L SR
A right hypertropia that increases with R gaze and L head tilt. Which muscle is affected?
R IO
What is a + Bielschowsky sign Test (P3S)?
Increase in hyperdeviation on head tilt of one side versus the other
- incomitant deviation
- superior oblique paretic muscle of hyperdeviating eye
What is a - Bielschowsky sign?
Comitant deviation or incomitant deviation w/out SO involvement
When will you use a forced duction test?
When a restricted incomitant deviation is found (underacting muscle)
When doing an forced duction test you are looking to see if the underacting muscle is a ___ or a ___
Mechanical restriction (tumor, etc.) or a paretic muscle
When doing a forced duction test, the patient fixates towards the ____
Side of limited gaze
When doing a forced duction test, you move the eye in the direction of
Suspected restriction
When doing forced duction test, using forceps grasp the conj near the limbus on the side ___ the direction you want to move the eye
Opposite
If the eye is restricted and cant move, then we think its a ____ which is a ___ forced duction test
Restricted: mechanical restriction of muscle
+ FDT
If the eye moves then we think its a ____, so you have a ___ FDT
Paretic, - FDT
For a FDT if the suspected muscle is the LR (limited gaze temporally) then how would the patient fixate? Where would we use the forceps? How would we move the muscle?
Patient fixates: temporally
Forceps: medial limbus conj.
We move the muscle laterally
What is the purpose of a Hess-Lancaster test?
to evaluate the alignment of the eyes and their movements both individually and in tandem
Useful for spatial awareness assessment and mapping out a patient’s field of single binocular vision
Hess Lancaster test
For a Hess Lancaster test, the patient wears the red lens on the __ and the green lens on the ___.
Red: OD
Green:OS
During a Hess Lancaster, when the OD is fixating the doctor holds the __ light and the patient holds the ___ light and we are observing the ____ eye.
Doctor: red
Patient: green
Observing: OS
During a Hess Lancaster, when the OS is fixating the doctor holds the __ light and the patient holds the ___ light and we are observing the ___ eye
Doctor: green
Patient: red
Observing:OD
How do you determine a deviation for a HLT?
Ask the patient to superimpose their light upon the projected light from the examiner and if there is any difference then there’s a deviation
The Hess Lancaster test interprets what 3 things?
-position, size, shape
If the OD central point is out and down the patient has a ___
RXT with HypoT
If the patients OS central point is out and up then the patient has a
LXT with hyperT
What does a smaller field for a HLT mean?
Its the affected eye, eye with limited movement
If the displacement of the field for the HLT is interiorly then its an
Underaction of the muscle
T/F: the muscle with the greatest underaction is the affected muscle
True
The next greatest underacting muscle is going to be?
The contralateral antagonist
The larger field for a HLT represents the ___ eye
Unaffected
A displacement of the field exteriorly for a HLT is an ___of the muscle
Overaction
The muscle with the greatest overaction is the ___ to the underacting muscle
Contralateral synergist
The next greatest overaction is the?
Ipsilateral antagonist
If the two fields are different then its a more __ condition
Recent
If the two fields are similar then its a more ___ condition
Long standing
When the deviation is the same in all positions of gaze
Comitancy
Narrowing fields in opposing directions for a HLT
Mechanical restrictions
If the red line is above the clear line doing DMR what does this mean?
That the patient has a hypodeviation
What does the NSUCO oculomotor test assess?
Pursuits and saccades
How far should you hold the red and white sticks for a NOT test?
40cm
During a NSUCO O test what 3 movements are you observing?
- eye movements
- head movements
- body movements
The score for a NSUCO Oculomotor test is based on?
Patients
- ability
- accuracy
- head movement
- body movement
How many rounds for you do for saccades (NOT)?
5 rounds
How many rotations do you do for pursuits (NOT)?
2 clockwise rotations
2 counter clockwise rotations
Describe the scoring for ability for saccades (NOT)
- ) no attempt is made to perform the task to 1 round trip
- Completes 2 round trips
- Completes 3
- Completes 4
- Completes 5 (best)
Describe the scoring for ability for pursuits (NOT)
- No attempt is made to perform the task to 1/2rotation
- Completes 1/2 rotation but not one full
- Completes 1 rotation not 2
- Completes 2 in one direction but not in the other direction
- Completes2 in both directions
Describe the scoring for accuracy for pursuits (NOT)
- No attempt to follow the target to 10 refixations
- Refixated 4-10 times
- Refixated 2-4 times
- Refixated 2 or less times
- No refixations
Describe the scoring for ability for saccades (NOT)
- Gross overshooting or undershooting
- Large to moderate
- Constant slight
- Intermittent slight
- No overshooting (best)
What are you looking for for accuracy
- to make sure there is no noticeable correction needed in the case of saccades
- to make sure the patient is not refixating
What is the scoring for head and body movement (NOT)
- Gross movement of head/body
- Large to moderate
- Consistent slight
- Intermittent slight
- No movement
Visible-verbal ocular motor assessment tool that accounts for difficulties in naming numbers and checks on VT progress
Developmental eye movement test (DEM)
What kind of correction do you wear during a DEM?
Habitual near correction
What should the lighting conditions be for a DEM?
Normal lighting
How far away from the patient should you be when doing a DEM test?
Harmon distance (elbow to middle knuckle)
During a DEM test does the patient point to the numbers?
No
What is the purpose of a pre-test for DEM?
To ensure the child knows their numbers
Do you want the patient to red the numbers fast or slow when doing a DEM test?
As fast as they can
The child must complete the pre-test within ___ secs. (DEM)
12 seconds
Should you administer a DEM if a child fails a pre-test?
NO
What does subtlest A and B test for?
Vertical saccades
How many numbers do Sub A and B have? (DEM)
40
What does subtest C test for? (DEM)
Horizontal saccades
How many numbers does a C test have?
80 single-digit numbers
This error you cross out the number with a / if there is a problem naming
Substitutions
This error you place an arrow where a number has been read out of sequence
Transposition
This error you circle the number if it is omitted
Omissions
This error you place a cross when the extra number has been added or a number as been repeated
Additions
What is the DEM ratio?
Horizontal adj time/ vertical adj time
What does a type 1 ratio mean (DEM)
Average performance in all subset values
What does a type 2 ratio mean (DEM)
High horizontal time, normal vertical time
- oculomotor dysfunction
If the patient got a type 2 ratio the patient has a ___
Oculomotor dysfunction
What does a type 3 ratio mean (DEM)
High horizontal and vertical times, normal ratio
If the patient got a type 3 ratio the patient has a difficulty in ___
Automaticity of number naming
What does a type 4 ratio mean (DEM)
Horizontal time, vertical time, and ratio are all abnormal
If the patient got a type 4 ratio the patient has a ___
Deficiency in oculomotor skills AND in automaticity
When determining the adjusted horizontal time what errors you use in the equation?
Omissions and additions
A test that can be used for concussion detection
King-devick test
What type of neuro functions does the king devick test (KDT) assess
- visual process
- concentration
- attention
- speech
- language
- other correlates of brain function
Does the KDT assess saccadic eye movements?
Sure does
What type of correction does the patient wear for a KDT?
Habitual near correction
What kind of lighting conditions do you need for a KDT?
Normal lighting
How far is the testing distance for KDT?
Harmon distance. The patient holds the booklet as they would a book while reading
Does the patient point to the numbers for a KDT?
No! Get that finger away
For a KDT do you want the patient to read slow or fast?
As fast as they can.
Scoring for a KDT is based on?
Time and number of errors
If the patient reads Test card 1 and its greater than 50 seconds what do you do?
Stop at test card 1
If the total time of test card 1 and 2 for a KDT is greater than 100 seconds what do you do?
Stop at test card 2
If the patient is < or = to 10 years old and unable to complete card 3 what do you do?
Take the same of test cards 1 and 2 time and errors
If a patient quickly corrects an error do you count it for a KDT?
Nope
How do you determine if a KDT is normal?
Compare the patients value with expected age-matched normative data
This test assesses pursuit eye moments, detects reading disability, and requires little cognitive ability
Groffman tracings
What 3 things does reading require for a groffman tracing?
- ability to make accurate ocular fixations
- smoothly follow the stationary continuous lines of prints
- change direction with precision and accuracy
What kind of correction is used for groffman?
Habitual near correction
What does the lighting conditions need to be for groffman?
Normal
What is the testing distance for groffman?
Harmon distance
Can the patient use their finger to trace the line for groffman?
No dammit
What do you tell the patient to do for a groffman?
Tell them to start at a letter and follow the line and tell you what number it ends at at the bottom of the page
For groffman, each letter is scored _____
Individually
If the patient reached the incorrect number for groffman they get ___ points for that letter
ZERO!
If they used their finger to trace the line they get ___ points
ZERO!I TOLD YOU NOT TO USE THAT FINGER
How do you determine the norm for Groffman?
You add all the points up and compare to the age-matched norm data
What is the normal findings for a NCT?
2.5 cm break/5cm recovery or TTN
If someone has a abnormal NCT with a light what do you do next?
- NPC with red green glasses
- NPC with accommodative target
Patient DE has a Left hypertropia that increases with left gaze and right head tilt. What muscle is paretic?
LIR
If your patients OD does not turn in the patient will look for a FDT?
Would this be mechanical or a palsy if the eye moves?
Towards the nose
A palsy
What is the most common sign of a neuromuscular problem?
Deviation of the visual axes (tropia or phoria)
Abnormalities with sensory function can lead to
Disruption in motor fusion then a deviation of the visual axes
Proper alignment of the eyes needs
Good sensory and motor fusion
A latent tendency for the eyes to deviate when fusion is broken.
Phoria
Name 3 reasons fusions is needed?
- for bino vision
- to prevent diplopia
- suppression
Name 4 things that can disrupt fusion
- alternating cover test
- fatigue
- illness
- stress
A manifest deviation of the eyes
Tropia
A tropia is seen on a ___ cover test
Unilateral
A tropia can result in___, ___, and/ or ___
- amblyopia
- diplopia
- suppression
When the patient fixated with the other eye
Unilateral tropia
Fusion inadequate to keep eye aligned is a ___ tropia
Constant tropia
Fusion functions sometimes, but not always
Intermittent tropia
Can a patient have a tropia at a certain distance and/or gaze, but a phoria at another distance and/or gaze?
Yes
What is the norm for a distance cover test?
1 XP (+/- 2pd) so….ortho to 3pd
What is the norm for near cover test?
3 XP (+/- 3pd) so….ortho to 6 Pd
If someone is ortho for a cover test what should you do to verify it?
Use a BI and then BO to
Anytime you neutralize what should you do to confirm your result?
Go a bit more till you see a reversal.
If both eyes have BU or BD and the value isn’t split, the prism will produce
A version
By splitting the vertical prism, the deviation is treated with the _____
The resultant and net bino effect (the absolute sum of the prism)
If someone has a 8 BD what would we give them
4 BU in OD and 4BD in OS
If someone has a 4 BU OD and 4BD OS what is the resultant
8BU OD or 8 BD OS
If someone has a 2 BU OD and 3 BD OS what is the resultant
5 BU OD or 5 BD OS
If you give someone a BI and BO what happens?
It will create a version eye movement and not correct the deviation because they are yoked prisms and the effect will be canceled out in a version movement.
If someone is a 8PD ESO then you would give them
4BO OD and 4BO OS
An abnormal head posture
Torticollis
What are the 3 types of torticollis?
- head turn
- head tilt
- chin up or down
If someone has a prolonged toricollis what can this lead to
Permanent facial asymmetry and contracture of neck muscles
T/F: Toricollis is mostly see in kids
True
A compensatory response to an ocular problem
Ocular torticollis
Someone with ocular torticollis attempts to maintain ___, ___, or use of limited____
Binocularity, VA, or limited VF
A patient with non-comitant strabismus to improve alignment is an example of
Ocular torticollis
Will parents be aware that their child have a torticollis?
Probably not
With ocular torticollis you want to rule out ___
Nystagmus. Because some people will tilt their head a certain way to keep the nystagmus under control
What are some abnormalities that can cause an ocular torticollis?
- nystagmus
- paretic strabismus
- restrictive strabismus
- supranuclear disorder
- monocular blindness
- A or V pattern strabismus
- ptosis
- refractive error
- visual field defect
What are some abnormalities that people use a torticollis to better their VA?
- nystagmus
- ptosis
- refractive error
- VF defect
When the deviation size remains the same or (within 5pd) in all positions of gaze
Comitant
This comitancy implies no muscles are underacting or overacting
Comitant
Deviation size is different in different positions of gaze.
Non-comitant
This comitancy is due to an over action or under action of one or multiple muscles.
Non-comitant
How do you determine comitancy
CT is done in all positions of gaze
Non-comitant can be due to
- Innervation problems (paralytic)
- Mechanical restrictions
Do vergences play a role in some neuromuscular anomalies?
Yes
When someone puts their book in their lap in order to read is an example of
Convergence insufficiency
If someone has convergence insufficiency they are ___ at near
Exo
When someone converges too much
Convergence excess
If someone has convergence excess they are ___ at near
Eso
If someone has a divergence insufficiency they are ___ at distance
Eso
If someone has a divergence excess they are ___ at distance
Exo
Name the 4 sites of lesions
- supranuclear
- nuclear
- infranuclear
- myogenic (disease at the muscle)
Any strabismus that developed after 6 months
Acquired
Onset at birth or during the 1st 6 months of life
Congenital onset
Acquired deviations are
- acute
- longstanding
- consecutive
Time of onset for a neuromuscular abnormality from surgical overcorrection
Consecutive (acquired)
Time of onset for a neuromuscular abnormality from trauma, infection, inflammation, or vascular disease
Acute (acquired)
action of muscle or group of muscles completely eliminated (no movement seen)
Paralysis
action of muscle or muscles is impaired (some movement seen)
Paresis
general term for paralysis or paresis (since could be difficult to differentiate)
Palsy
If there is difficulty moving the eye in a certain direction we can think its probably a __
Mechanical restriction
A palsy also cause ___ deviations. And why?
Non-comitant deviations
-because of the over action or under action of the involved muscles
What are some etiologies of neuromuscular deviations
- fusion disrupted
- mechanical restrictions
- uncorrected refractive error (EP in hyperopes)
- tropia
- brainstem abnormalities
- paresis or paralysis
- neuro defects
- vestibular abnormalities (VOR)
- abnormalities along the visual pathway
- assault during gestation
What are some neurological defects that can cause neuro deviations?
- birth injuries
- cerebral palsy
- developmental/special needs
- retinopathy of prematurity
If someone is suppressing and you put in a prism what will happen?
Nothing!
What are some mechanical restrictions for neuro deviations
- agenesis or abnormal insertion of the extraocular muscles
- abnormal adhesions at tissue or fibrosis of the muscles
- tumor metastases
- sarcoidosis
Poor fusion can be associated with
- Fatigue
- Asthenopia - eye strain, heaviness, soreness
- Headaches – frontal
- Avoidance
- Diplopia
- Suppression
Why may a patient with a small phoria have no symptoms?
Because the sensorimotor system is able to cope with the deviation
T/F: Vertical deviations are likely to cause symptoms because vertical fusional amplitudes are naturally limited.
True
History: Uncertain of onset; only intermittent diplopia and may be asymptomatic
C or A?
Congenital
History: Diplopia; exact time of onset is known; symptomatic
C or a?
Acquired
Head posture: Aware of the head posture, needs to adopt intermittently because of symptoms; obvious
C or A?
Acquired
Head posture: Patient/family unaware of posture; some facial asymmetry may be possible; deviation may now be comitant
C or A?
Congenital
Comitancy: May appear comitant because of developed muscle sequalea – primary and secondary angles appear similar.
C or A?
Congenital
Comitancy: Over action of the yoked muscle seen; secondary deviation larger than primary deviation. Hess chart of affected eye is smaller.
C or A?
Acquired
Facial Amplitude: Patient have large vertical fusional amplitude (>10pd)
C or A?
Congenital
Facial amplitude: Only have normal vertical fusional amplitudes of 2-3pd
C or A?
Acquired
Suppression: Occurs in young children in the critical period (unless prevented); rare in adults
C or A?
Acquired
Suppression: often present
C or A?
Congenital
Torsion: rarely seen
C or A?
Congenital
Torsion: seen
C or A?
Acquired
Deviation: marked as deviation in primary
Neurogenic or Mechanical?
Neurogenic
Deviation: Little deviation seen in primary, e.g. Brown’s, Duane’s, fractures
Neurogenic or Mechanical?
Mechanical
Diplopia: same in different gazes. Hyper remains a hyper
Neurogenic or Mechanical?
Neurogenic
Diplopia: may reverse
Neurogenic or Mechanical?
Mechanical
Head posture: Head tilt rare; chin down or up may
be seen for vertical deviations
Neurogenic or Mechanical?
Mechanical
Head posture: Head tilt seen with vertical palsies
Neurogenic or Mechanical?
Neurogenic
Ocular Movement: duction > versions
Neurogenic or Mechanical?
Neurogenic
Ocular Movement: Duction and version movements
equally limited
Neurogenic or Mechanical?
Mechanical
Hess Lancaster: Field of affected eye is smaller; but both fields are displaced according to the deviation
Neurogenic or Mechanical?
Neurogenic
Hess Lancaster:The fields are irregular and close to each other, can look flat
Neurogenic or Mechanical?
Mechanical
Retraction of globe: Retracts when turned in direction opposite the restriction
Neurogenic or Mechanical?
Mechanical
Retraction of globe: None
Neurogenic or Mechanical?
Neurogenic
Pain on movement: none
Neurogenic or Mechanical?
Neurogenic
Pain on movement: could be present
Neurogenic or Mechanical?
Mechanical
Forced duction: able to move
Neurogenic or Mechanical?
Neurogenic
Forced duction: limited movement
Neurogenic or Mechanical?
Mechanical
A normal variable, transient, intermittent angle strabismus (exo or eso) seen in 2-3 months of life that often resolves by 4 months
Infancy ocular instability (split)
A latent esodeviation controlled by fusional vergences
Esophoria
manifest deviation not properly controlled by fusional vergences where the eye is turned in
Esotropia
Deviations from neuromuscular abnormalities can be due to what 6 problems?
- innervation
- anatomical
- mechanical
- refractive
- accommodative
- genetic
T/F: fusional vergences allow fusion and alignment
True
Appearance of ET when eyes are actually straight.
Pseudoesotropia
If someone has pseudoesotropia will they have a normal hirschberg and cover test?
Yes
Pseudoesotropia is seen in children with ____ nose bridges, _____folds, and ____ interpupillary distance
- wide, flat nose bridge
- prominent epicanthal folds
- small interpupillary distance
An onset of an ET that appears between birth and 6 months
Infantile (congenital) ET
Someone with infantile ET will have a ___ constant esotropia and will have a family history of a ET
Large
What neurological or developmental conditions will many children with infantile ET have
- cerebral palsy
- hydrocephalus
- prematurity
When a patient uses the adducted eye to look in the contralateral view (uses RET to look in the left field)
Cross fixation
Can people with infantile ET develop amblyopia? If so in what eye?
Yes. In the constantly deviated eye
People with infantile ET may have ____ hyperopia
Low
The patients will have an apparent large, constant angle (>30pd)
Infantile (congenital) ET
Accounts for about 30-50% of all esotropes
Infantile esotropia
What are 6 other variables you can see with infantile esotropia?
- Amblyopia
- A or V pattern
- DVD – Dissociated vertical deviation
- OIO – over action of inferior oblique
- Nystagmus
- AHP- anomalous head posture
Name the management considerations in strabismus
- correction of refractive error
- added lenses (bifocal)
- prism
- occlusion (for amblyopia or suppression treatment)
- VT
- Botox
- surgery (for larger angles)
Management in infantile ET
- comprehensive evaluation (birth history, pregnancy complications)
- full cycloplegic refraction
- surgery
Why do you want to do a full cycloplegic refraction in infantile ET patients?
To rule out early onset accommodative ET
Will smaller, variable intermittent ET respond to a full cycloplegic refraction?
Yeah
Deviation associated with the accommodative reflex
Accommodative esotropia
What is the onset of accommodative ET?
Average?
Between 6 months-7 yrs. (average 2.5)
T/F: accommodative ET is often hereditary
True
Accommodative ET starts ___ and then may become ___
Starts intermittently and then may become constant
This is often present with large, constant, and unilateral angles
Amblyopia
What are the 3 types of accommodative ETs?
- refractive accommodative ET
- non-refractive accommodative ET
- mixed accommodative ET
About ___% of all ET have an accommodative component
50%
Due to uncorrected hyperopia and insufficient fusional vergence to diverge (high hyperopia)
Refractive accommodative ET
A _____develops if the patient doesn’t have enough fusional divergence to counter the increased convergence
ET
Refractive Accommodative ET could be about ___ pd
20-35pd
Will someone with a refractive accommodative ET have different or similar deviations at distance and near?
Similar
An average hyperopia that can cause a refractive accommodative ET is ____ but can honestly vary.
+4.00
If hyperopia is greater than ___, isometropic amblyopia develops because patient has too much blur and will be unable to try to accommodate
6
How would you manage refractive accommodative ET?
- comprehensive exam
- cycloplegic refraction
- can reduce plus later to aid in emmetropization
- start amblyopia treatment if VA doesnt fully improve with Rx
Do you offer the full cycloplegic hyperopic correction for refractive accommodative ET patients?
Yes. They should ward it full time ASAP
If someone has a CT sc: 30 CAET @ D and N with a +6.50 correction what type of ET is this?
What would you rx them?
Refractive accommodative due to similar D and N deviations
RX: +6.50
ET due to high AC/A ratio
Non-refractive accommodative ET
Non-refractive accommodative ET patients will have ___hyperopia to myopia
Moderate
This type of ET will have a ET greater at N due to need for accommodation at N
Non-refractive accommodative ET
amount of convergence induced by a change in accommodation
AC/A
A change in accommodation is accompanied by a change in ____
Vergence
helps evaluate the strength between the accommodative and vergences systems
AC/A ratio
How do you calculate AC/A (equation)?
Absolute change/ absolute change in accommodation
How do you manage non-refractive accommodative ET?
- treat underlying refractive error
- bifocal to reduce accommodation and accommodative convergence
- repeat cyclo yearly for any changes
Would you do surgery on a patient with non-refractive accommodative ET?
No. Because you know what the problem is
Where should the seg height be for a child?
Must bisect the pupil. This forces the child to use it
If a patient has ortho at D, but has a 30 CAET @ N what type of ET is this?
Non-refractive accommodative ET
If a patient non-refractive accommodative ET patient was cyclopleged at +1.25 and a +3.00D brought the ET to ortho what would you rx?
+1.25 sph with a +3.00 add OU
An ET with a combination of refractive accommodative and non refractive accommodative findings
Mixed accommodative ET
These patient will have a ET with high hyperopic and a high AC/A ratio
Mixed-accommodative ET patients
How would you manage a mixed accommodative ET patient?
- give full hyperopic correction
- bifocal (based on AC/A ratio)
Would you do surgery on someone with a mixed accommodative ET?
Nope
Patients CT sc: 15 IAET @ D, 35 CAET @ N
Cycloplegic refraction: +3.00sph OU
CT with correction: ortho @ D, 20 IAET @ N
3EP @ N with +3.00D
What do they have and what would you prescribe?
-mixed accommodative ET
Rx: +3.00/+3.00 add OU
When accommodation contributes to, but does not account for the entire deviation
Partially accommodative ET
When there is a reduction in the angle, but there is still a residual ET after treatment. Due to waiting to long to get glasses to fix problem
Partially accommodative ET
Will a partially accommodative ET be constant or intermittent ?
How about unilateral or bilateral?
Constant and unilateral
Is suppression common in patients with partially accommodative ET?
Yes
What are 2 types of Non-accommodative ETs?
- early onset non-accommodative ET
- acute acquired ET
When does early onset non-accommodative ET begin?
After about age 6 months-before age 2
In Early Onset Non Accommodative Esotropia is ET the same or different at D and N?
Comitant?
The same
Its comitant
How would you manage early onset non Accommodative ET
- Correct refractive error, consider prisms or bifocals
- Amblyopia treatment
- Vision Therapy to improve ranges
- Consider surgery
Is an acute acquired ET non-comitant or comitant?
Comitant
A sudden ET onset in a 3-5 year old
Acute acquired ET
Do you want to do a neuro evaluation on someone with an acute acquired ET?
Yes. Do it ASAP
How would you manage a acute acquired ET?
- neuro evaluation
- correction
- prism or surgery since they probably had BV before the ET
- amblyopia treatment if needed
An ultra small ET
Microtropia
An esotropia that develops due to vision loss in one eye
Sensory ET
Will someone with a sensory ET have a clear image/good VA?
No. The pathology prevents the clear, focused retinal image and they will have a poor VA in the affected eye
Someone with a sensory ET will have ___VA in affected eye, ____deviation,____pd, and ___cosmesis
- poor VA in affected eye
- constant unilateral deviation
- 10-45pd
- poor cosmesis
How would you manage a sensory ET?
- eliminate the pathology is possible
- polycarbonate lens for full time wear
- treat secondary amblyopia
- surgery (for cosmesis or residual deviation)
A non accommodative esodeviation greater at distance than near
Divergence insufficiency ET
Do you want to do a neuro referral on someone with a divergence insufficiency ET?
YESSSS!
How would you manage a divergence insufficiency ET?
- correct the refractive error
- BO for diplopia at D
- VT
- Botox
Esodeviation after exo strabismus surgery.
Consecutive ET
Why would you not want to surgery on a divergence insufficiency ET patient?
Because the deviation is only at distance
How would you manage a consecutive ET?
- treat refractive error
- try BO prism or plus lens
- repeat surgery for very large of symptomatic consecutive deviations
What are 2 types of non comitant Eso deviations?
- 6th nerve palsy
- Duanes syndrome
A latent exodeviation controlled by fusional vergences
Exophoria
A manifest deviation where the eye is turned out
Exotropia
T/F: in exodeviations prevalence varies by ethnic groups
True
Someone with a wide interpupillary distance that looks like a exodeviation
Pseudoesotropia
What could happen if fusional vergences are not adequate in an exodeviation?
XT could result or XP becomes symptomatic
When is treatment of an exophoria needed?
When there is asthenopia (eye strain) or diplopia
The most common XT
Intermittent XT
A type of XT in children where the XT is larger at disance and is seen prominently when the target is at a distance
Divergence excess XT
A XT in adults that’s the same at distance and near
Basic XT
A XT in adults where the XT is larger at near
Convergence insufficiency XT
A XT where the deviation is latent at times and becomes manifest that occurs before age 5
Intermittent XT
____light may cause reflex closure of one eye in an intermittent XT
Bright
This XT could occurs late in the day, with fatigue, when daydreaming, when drowsy.
Intermittent XT
This XT can be associated with small hypers and/or A/V pattern
Intermittent XT
T/F: Untreated intermittent XT can lead to constant XT
True
What type of intermittent control describes XT only manifest on CT and then resumes fusion rapidly
Good control
What type of intermittent control describes XT on CT, fusion regained after blinking or refixating
Fair control
What type of intermittent control describes XT manifest spontaneously and for an extended period of time.
Poor control
IXT may be ______ at distance because of some fusion at near keeping eyes straight.
Greater
Is diplopia common with good control?
No
How would you manage a intermittent XT?
- correct significant hyperopia, myopia, and astigmatism
- patching for amblyopia
- VT
- prisms
- surgery
- Botox
T/F: Mild myopia correction could make deviation better (IXT) and mild hyper could make it worse
True
Why does moderate hyperopia (>+4.00) need to be corrected in someone with intermittent XT?
Because the child be unable to accommodate through this, resulting in blur and a manifest XT
XT that is common post surgery
Consecutive XT
Exotropia greater at near than distance
Convergence insufficiency XT
Someone with a convergence insufficiency XT has a ____deviation at N, ___AC/A, and ____near fusion convergence amplitudes
- intermittent alternating deviation
- low AC/A
- poor near fusion
If someone has convergence insufficiency XT what may be some symptoms they will have when reading?
- asthenopia
- diplopia
- blurred vision at near
Commonly seen in older patients with a sensory XT or patients with a longstanding XT that has decompensated (decompensating XP).
Constant XT
What are 2 examples of constant XT?
- infantile XT
- sensory XT
Large exo, constant angle that is present before 6 months
Infantile XT
T/F: Children with Infantile XT will most likely have neuro issue and craniofacial disorders
True
Would you do surgery for a child with infantile XT?
Yes
In sensory XT, if VA is improved, what can be useful for better alignment
Surgery
In sensory XT, if VA is not corrected , what could happen
Misalignment could occur again after surgery
