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Motility > B10 > Flashcards

B10 Flashcards

1
Q

What is the purpose of external observations?

A

To identify gross abnormalities of the eye and adnexa

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2
Q

What 5 things do you need to observe when doing an external observation?

A
  • eye alignment
  • facial features
  • head position
  • posture
  • gait
  • carriage
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3
Q

What is the purpose of the cover test?

A

assess the presence and magnitude of a phoria or tropia

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4
Q

Do patients wear their glasses when doing cover test?

A

Yes

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5
Q

Present all the time in a cover test

A

Constant

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6
Q

Patient has moments of binocularity in cover test

A

Intermittent

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7
Q

When fixation may alternate between eyes or maintain fixation only with one eye

A

Eye preference

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8
Q

What do you need to record with cover test?

A
  • correction
  • magnitude
  • eye
  • phoria or tropia
  • constant or intermittent
  • distance or near
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9
Q

A test used to assess ability to perform conjugate eye movements

A

EOMs

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10
Q

Does the patient wear correction when doing EOMs?

A

No

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11
Q

What should you ask your patient when doing EOMs?

A

If they have any pain, see double, or eye strain

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12
Q

During EOMs what 6 things are you observing?

A 
-Fixation
• Pursuit of Eye Movements
• Vertical Movement of the Eyes and Lids
• Comitancy
• Monocular Motility
• Saccadic Movements
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13
Q

What is the purpose of hirschberg?

A

to determine the position of the visual axes, under binocular conditions at near

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14
Q

Do patients wear their glasses during hirschberg?

A

No

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15
Q

How far should you be from the patient when doing hirschberg?

A

50-100cm from patient

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16
Q

When doing hirschberg do you do it mono or bino?

A

First do it mono then do it bino

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17
Q

If the light is in the center of the pupil what is the angle lambda?

Deviation?

A

Angle lambda: 0

Deviation:ortho

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18
Q

If the light is nasal to the pupil what is the angle lambda?

Deviation?

A

AL: +
Deviation: exo

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19
Q

If the light is temporal to the pupil what is the angle lambda?

Deviation?

A

AL: -
Deviation: eso

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20
Q

If the light is above the center of the pupil what is the angle lambda?

Deviation?

A

AL: N/A
Deviation: hypo

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21
Q

If the light below the center of the pupil what is the angle lambda?

Deviation?

A

AL: N/A
Deviation: Hyper

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22
Q

If the corneal reflex if different mono vs bino during hirschberg, what does this mean?

A

There is a strabismus

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23
Q

When doing krimsky you place the prism over the ___ eye until the corneal reflex is in the same position as the deviating eye

A

Fixating

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24
Q

1mm of deviation= ___ D (Krimsky)

A

22D

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25
Q

If someone has an esotropia what kind of prism do you use?

A

BO

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26
Q

If someone has an esophoria what kind of prism do you use?

A

BO

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27
Q

If someone has an exotropia what kind of prism do you use?

A

BI

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28
Q

If someone has an exophoria what kind of prism do you use?

A

BI

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29
Q

What is the purpose of a bruckner test?

A

To evaluate the symmetry of bino fixation

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30
Q

What does bruckner test screen for?

A
  • Strabismus
  • Anisometropia
  • Media opacities
  • Posterior pole anomalies
  • Presence of refractive error
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31
Q

Do people wear their glasses for bruckner test?

A

No

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32
Q

When doing bruckner what instrument do you use?

A

Ophthalmoscope

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33
Q

How far do you need to be from the patient when doing Bruckners?

A

80-100cm illuminating both pupils

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34
Q

What does it mean when the reflexes are equally bright for bruckners?

A

Bino fixation

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35
Q

What does it mean when the the reflexes are not equally bright for bruckners?

A

There may be a Strabismus, media opacity, or retinoblastoma

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36
Q

When looking for a strabismus you would used Bruckners in conjunction with ____

A

Hirschberg

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37
Q

If you have an unequal reflex which eye is the fixating and which is the nonfixating eye? (Bruckners)

A

Non-fixating eye- brighter, lighter, or white reflex

Fixating eye- darker red reflex

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38
Q

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?

A

media opacity=dimmer eye

Retinoblastoma=brighter eye

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39
Q

When doing Bruckners and you see a crescent towards the head of the ophthalmoscope what does this mean?

A

That the patient is hyperopic

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40
Q

When doing Bruckners and you see a crescent towards the handle of the ophthalmoscope what does this mean?

A

The patient is myopic

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41
Q

How do you need to record bruckner?

A
  • 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)
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42
Q

vertical meridians of the retinas are rotated in the same direction and by the same amount

A

Conjugate movements

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43
Q

vertical meridians of the retinas are rotated in the opposite directions to maintain a single image

A

Disconjugate eye movements

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44
Q

Cyclovergence movements compensate for ___

A

Cyclophorias

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45
Q

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.

A

Cyclophoria

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46
Q

Is cycloversion considered conjugate or disconjugate?

A

Conjugate

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47
Q

Is cyclovergence considered conjugate or disconjugate

A

Disconjugate

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48
Q

What is the purpose of a double Maddox rod?

A
  • to detect a torsional misalignment

- Measures cyclodeviation BUT does not differentiate between phoria vs. tropia

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49
Q

Does the patient wear their correction during double Maddox rod?

A

Yes

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50
Q

What should the lighting conditions be for a double Maddox rod?

A

Dim

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51
Q

Do you test distance and near for a double Maddox rod?

A

Yes
Distance use a muscle light
Near use a penlight at 40cm

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52
Q

During a double Maddox rod the red filter should go over the ___ and the clear over the ___

A

Red-right

Clear-left

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53
Q

If you place the Maddox rods vertically the patient will see__ lines

A

Horizontal

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54
Q

How do you determine the degree of deviation of a double Maddox rod?

A

You rotate that orientation of the lenses until the two lines are parallel

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55
Q

If the patient only sees one line when you put the lenses on for a double Maddox rod what do you do?

A

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

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56
Q

For the double Maddox rod, the tilt of the line is ___ the tilt of the retinal image

A

Opposite

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57
Q

t/F: the line is perceived to the tilted in the direction in which the underacting muscle would rotate the eye

A

True

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58
Q

If the patients says line is tilted out then the eye is ____. And the underacting muscle is ___

A

The eye is intorted. And the underacting muscle is the IO (extorts)

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59
Q

If the patient says the line is tilted in then the eye is ____. And the underacting muscle is ___

A

Eye is extorted and the underacting muscle is the SO (intorts)

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60
Q

If the patient states the OD line is tilted towards the nose (intorted) there is a R ____ and the ___ is underacting

A

R excyclodeviation

SO underacting

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61
Q

How do you record a double Maddox rod?

A
  • eye
  • magnitude
  • direction
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62
Q

During amblyscope the fixating eye looks at the

A

More detailed image

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63
Q

What is the purpose of a parks 3 step?

A

To identify the muscle responsible for a vertical deviation

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64
Q

What is step 1 in a P3S?

A

Identify which eye is hyper in primary gaze

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65
Q

What is step 2 in a P3S?

A

Identify whether the vertical deviation increases on right or left gaze

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66
Q

What is step 3 in a P3S?

A

Identify whether the vertical deviation increases on right or left head tilt

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67
Q

What 3 tests do you used during P3S to evaluate deviation of eye?

A
  • cover test
  • Maddox rod
  • red lens
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68
Q

How do you determine the hyperdeviated eye in the primary gaze?

A
  • 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)
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69
Q

The paretic muscle is the muscle that is circled __ times (P3S)

A

3

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70
Q

A L hypertropia that increases with right gaze and left head tilt. what muscle is affected?

A

L SO

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71
Q

A right hypertropia that increases with L gaze and L head tilt what muscle is affected?

A

L SR

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72
Q

A right hypertropia that increases with R gaze and L head tilt. Which muscle is affected?

A

R IO

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73
Q

What is a + Bielschowsky sign Test (P3S)?

A

Increase in hyperdeviation on head tilt of one side versus the other

  • incomitant deviation
  • superior oblique paretic muscle of hyperdeviating eye
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74
Q

What is a - Bielschowsky sign?

A

Comitant deviation or incomitant deviation w/out SO involvement

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75
Q

When will you use a forced duction test?

A

When a restricted incomitant deviation is found (underacting muscle)

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76
Q

When doing an forced duction test you are looking to see if the underacting muscle is a ___ or a ___

A

Mechanical restriction (tumor, etc.) or a paretic muscle

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77
Q

When doing a forced duction test, the patient fixates towards the ____

A

Side of limited gaze

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78
Q

When doing a forced duction test, you move the eye in the direction of

A

Suspected restriction

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79
Q

When doing forced duction test, using forceps grasp the conj near the limbus on the side ___ the direction you want to move the eye

A

Opposite

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80
Q

If the eye is restricted and cant move, then we think its a ____ which is a ___ forced duction test

A

Restricted: mechanical restriction of muscle

+ FDT

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81
Q

If the eye moves then we think its a ____, so you have a ___ FDT

A

Paretic, - FDT

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82
Q

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?

A

Patient fixates: temporally
Forceps: medial limbus conj.
We move the muscle laterally

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83
Q

What is the purpose of a Hess-Lancaster test?

A

to evaluate the alignment of the eyes and their movements both individually and in tandem

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84
Q

Useful for spatial awareness assessment and mapping out a patient’s field of single binocular vision

A

Hess Lancaster test

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85
Q

For a Hess Lancaster test, the patient wears the red lens on the __ and the green lens on the ___.

A

Red: OD
Green:OS

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86
Q

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.

A

Doctor: red
Patient: green
Observing: OS

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87
Q

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

A

Doctor: green
Patient: red
Observing:OD

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88
Q

How do you determine a deviation for a HLT?

A

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

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89
Q

The Hess Lancaster test interprets what 3 things?

A

-position, size, shape

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90
Q

If the OD central point is out and down the patient has a ___

A

RXT with HypoT

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91
Q

If the patients OS central point is out and up then the patient has a

A

LXT with hyperT

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92
Q

What does a smaller field for a HLT mean?

A

Its the affected eye, eye with limited movement

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93
Q

If the displacement of the field for the HLT is interiorly then its an

A

Underaction of the muscle

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94
Q

T/F: the muscle with the greatest underaction is the affected muscle

A

True

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95
Q

The next greatest underacting muscle is going to be?

A

The contralateral antagonist

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96
Q

The larger field for a HLT represents the ___ eye

A

Unaffected

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97
Q

A displacement of the field exteriorly for a HLT is an ___of the muscle

A

Overaction

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98
Q

The muscle with the greatest overaction is the ___ to the underacting muscle

A

Contralateral synergist

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99
Q

The next greatest overaction is the?

A

Ipsilateral antagonist

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100
Q

If the two fields are different then its a more __ condition

A

Recent

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101
Q

If the two fields are similar then its a more ___ condition

A

Long standing

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102
Q

When the deviation is the same in all positions of gaze

A

Comitancy

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103
Q

Narrowing fields in opposing directions for a HLT

A

Mechanical restrictions

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104
Q

If the red line is above the clear line doing DMR what does this mean?

A

That the patient has a hypodeviation

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105
Q

What does the NSUCO oculomotor test assess?

A

Pursuits and saccades

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106
Q

How far should you hold the red and white sticks for a NOT test?

A

40cm

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107
Q

During a NSUCO O test what 3 movements are you observing?

A
  • eye movements
  • head movements
  • body movements
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108
Q

The score for a NSUCO Oculomotor test is based on?

A

Patients

  • ability
  • accuracy
  • head movement
  • body movement
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109
Q

How many rounds for you do for saccades (NOT)?

A

5 rounds

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110
Q

How many rotations do you do for pursuits (NOT)?

A

2 clockwise rotations

2 counter clockwise rotations

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111
Q

Describe the scoring for ability for saccades (NOT)

A
  1. ) no attempt is made to perform the task to 1 round trip
  2. Completes 2 round trips
  3. Completes 3
  4. Completes 4
  5. Completes 5 (best)
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112
Q

Describe the scoring for ability for pursuits (NOT)

A
  1. No attempt is made to perform the task to 1/2rotation
  2. Completes 1/2 rotation but not one full
  3. Completes 1 rotation not 2
  4. Completes 2 in one direction but not in the other direction
  5. Completes2 in both directions
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113
Q

Describe the scoring for accuracy for pursuits (NOT)

A
  1. No attempt to follow the target to 10 refixations
  2. Refixated 4-10 times
  3. Refixated 2-4 times
  4. Refixated 2 or less times
  5. No refixations
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114
Q

Describe the scoring for ability for saccades (NOT)

A
  1. Gross overshooting or undershooting
  2. Large to moderate
  3. Constant slight
  4. Intermittent slight
  5. No overshooting (best)
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115
Q

What are you looking for for accuracy

A
  • to make sure there is no noticeable correction needed in the case of saccades
  • to make sure the patient is not refixating
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116
Q

What is the scoring for head and body movement (NOT)

A
  1. Gross movement of head/body
  2. Large to moderate
  3. Consistent slight
  4. Intermittent slight
  5. No movement
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117
Q

Visible-verbal ocular motor assessment tool that accounts for difficulties in naming numbers and checks on VT progress

A

Developmental eye movement test (DEM)

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118
Q

What kind of correction do you wear during a DEM?

A

Habitual near correction

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119
Q

What should the lighting conditions be for a DEM?

A

Normal lighting

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120
Q

How far away from the patient should you be when doing a DEM test?

A

Harmon distance (elbow to middle knuckle)

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121
Q

During a DEM test does the patient point to the numbers?

A

No

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122
Q

What is the purpose of a pre-test for DEM?

A

To ensure the child knows their numbers

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123
Q

Do you want the patient to red the numbers fast or slow when doing a DEM test?

A

As fast as they can

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124
Q

The child must complete the pre-test within ___ secs. (DEM)

A

12 seconds

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125
Q

Should you administer a DEM if a child fails a pre-test?

A

NO

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126
Q

What does subtlest A and B test for?

A

Vertical saccades

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127
Q

How many numbers do Sub A and B have? (DEM)

A

40

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128
Q

What does subtest C test for? (DEM)

A

Horizontal saccades

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129
Q

How many numbers does a C test have?

A

80 single-digit numbers

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130
Q

This error you cross out the number with a / if there is a problem naming

A

Substitutions

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131
Q

This error you place an arrow where a number has been read out of sequence

A

Transposition

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132
Q

This error you circle the number if it is omitted

A

Omissions

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133
Q

This error you place a cross when the extra number has been added or a number as been repeated

A

Additions

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134
Q

What is the DEM ratio?

A

Horizontal adj time/ vertical adj time

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135
Q

What does a type 1 ratio mean (DEM)

A

Average performance in all subset values

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136
Q

What does a type 2 ratio mean (DEM)

A

High horizontal time, normal vertical time

- oculomotor dysfunction

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137
Q

If the patient got a type 2 ratio the patient has a ___

A

Oculomotor dysfunction

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138
Q

What does a type 3 ratio mean (DEM)

A

High horizontal and vertical times, normal ratio

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139
Q

If the patient got a type 3 ratio the patient has a difficulty in ___

A

Automaticity of number naming

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140
Q

What does a type 4 ratio mean (DEM)

A

Horizontal time, vertical time, and ratio are all abnormal

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141
Q

If the patient got a type 4 ratio the patient has a ___

A

Deficiency in oculomotor skills AND in automaticity

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142
Q

When determining the adjusted horizontal time what errors you use in the equation?

A

Omissions and additions

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143
Q

A test that can be used for concussion detection

A

King-devick test

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144
Q

What type of neuro functions does the king devick test (KDT) assess

A
  • visual process
  • concentration
  • attention
  • speech
  • language
  • other correlates of brain function
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145
Q

Does the KDT assess saccadic eye movements?

A

Sure does

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146
Q

What type of correction does the patient wear for a KDT?

A

Habitual near correction

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147
Q

What kind of lighting conditions do you need for a KDT?

A

Normal lighting

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148
Q

How far is the testing distance for KDT?

A

Harmon distance. The patient holds the booklet as they would a book while reading

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149
Q

Does the patient point to the numbers for a KDT?

A

No! Get that finger away

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150
Q

For a KDT do you want the patient to read slow or fast?

A

As fast as they can.

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151
Q

Scoring for a KDT is based on?

A

Time and number of errors

152
Q

If the patient reads Test card 1 and its greater than 50 seconds what do you do?

A

Stop at test card 1

153
Q

If the total time of test card 1 and 2 for a KDT is greater than 100 seconds what do you do?

A

Stop at test card 2

154
Q

If the patient is < or = to 10 years old and unable to complete card 3 what do you do?

A

Take the same of test cards 1 and 2 time and errors

155
Q

If a patient quickly corrects an error do you count it for a KDT?

A

Nope

156
Q

How do you determine if a KDT is normal?

A

Compare the patients value with expected age-matched normative data

157
Q

This test assesses pursuit eye moments, detects reading disability, and requires little cognitive ability

A

Groffman tracings

158
Q

What 3 things does reading require for a groffman tracing?

A
  • ability to make accurate ocular fixations
  • smoothly follow the stationary continuous lines of prints
  • change direction with precision and accuracy
159
Q

What kind of correction is used for groffman?

A

Habitual near correction

160
Q

What does the lighting conditions need to be for groffman?

A

Normal

161
Q

What is the testing distance for groffman?

A

Harmon distance

162
Q

Can the patient use their finger to trace the line for groffman?

A

No dammit

163
Q

What do you tell the patient to do for a groffman?

A

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

164
Q

For groffman, each letter is scored _____

A

Individually

165
Q

If the patient reached the incorrect number for groffman they get ___ points for that letter

A

ZERO!

166
Q

If they used their finger to trace the line they get ___ points

A

ZERO!I TOLD YOU NOT TO USE THAT FINGER

167
Q

How do you determine the norm for Groffman?

A

You add all the points up and compare to the age-matched norm data

168
Q

What is the normal findings for a NCT?

A

2.5 cm break/5cm recovery or TTN

169
Q

If someone has a abnormal NCT with a light what do you do next?

A
  • NPC with red green glasses

- NPC with accommodative target

170
Q

Patient DE has a Left hypertropia that increases with left gaze and right head tilt. What muscle is paretic?

A

LIR

171
Q

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?

A

Towards the nose

A palsy

172
Q

What is the most common sign of a neuromuscular problem?

A

Deviation of the visual axes (tropia or phoria)

173
Q

Abnormalities with sensory function can lead to

A

Disruption in motor fusion then a deviation of the visual axes

174
Q

Proper alignment of the eyes needs

A

Good sensory and motor fusion

175
Q

A latent tendency for the eyes to deviate when fusion is broken.

A

Phoria

176
Q

Name 3 reasons fusions is needed?

A
  • for bino vision
  • to prevent diplopia
  • suppression
177
Q

Name 4 things that can disrupt fusion

A
  • alternating cover test
  • fatigue
  • illness
  • stress
178
Q

A manifest deviation of the eyes

A

Tropia

179
Q

A tropia is seen on a ___ cover test

A

Unilateral

180
Q

A tropia can result in___, ___, and/ or ___

A
  • amblyopia
  • diplopia
  • suppression
181
Q

When the patient fixated with the other eye

A

Unilateral tropia

182
Q

Fusion inadequate to keep eye aligned is a ___ tropia

A

Constant tropia

183
Q

Fusion functions sometimes, but not always

A

Intermittent tropia

184
Q

Can a patient have a tropia at a certain distance and/or gaze, but a phoria at another distance and/or gaze?

A

Yes

185
Q

What is the norm for a distance cover test?

A

1 XP (+/- 2pd) so….ortho to 3pd

186
Q

What is the norm for near cover test?

A

3 XP (+/- 3pd) so….ortho to 6 Pd

187
Q

If someone is ortho for a cover test what should you do to verify it?

A

Use a BI and then BO to

188
Q

Anytime you neutralize what should you do to confirm your result?

A

Go a bit more till you see a reversal.

189
Q

If both eyes have BU or BD and the value isn’t split, the prism will produce

A

A version

190
Q

By splitting the vertical prism, the deviation is treated with the _____

A

The resultant and net bino effect (the absolute sum of the prism)

191
Q

If someone has a 8 BD what would we give them

A

4 BU in OD and 4BD in OS

192
Q

If someone has a 4 BU OD and 4BD OS what is the resultant

A

8BU OD or 8 BD OS

193
Q

If someone has a 2 BU OD and 3 BD OS what is the resultant

A

5 BU OD or 5 BD OS

194
Q

If you give someone a BI and BO what happens?

A

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.

195
Q

If someone is a 8PD ESO then you would give them

A

4BO OD and 4BO OS

196
Q

An abnormal head posture

A

Torticollis

197
Q

What are the 3 types of torticollis?

A
  • head turn
  • head tilt
  • chin up or down
198
Q

If someone has a prolonged toricollis what can this lead to

A

Permanent facial asymmetry and contracture of neck muscles

199
Q

T/F: Toricollis is mostly see in kids

A

True

200
Q

A compensatory response to an ocular problem

A

Ocular torticollis

201
Q

Someone with ocular torticollis attempts to maintain ___, ___, or use of limited____

A

Binocularity, VA, or limited VF

202
Q

A patient with non-comitant strabismus to improve alignment is an example of

A

Ocular torticollis

203
Q

Will parents be aware that their child have a torticollis?

A

Probably not

204
Q

With ocular torticollis you want to rule out ___

A

Nystagmus. Because some people will tilt their head a certain way to keep the nystagmus under control

205
Q

What are some abnormalities that can cause an ocular torticollis?

A
  • nystagmus
  • paretic strabismus
  • restrictive strabismus
  • supranuclear disorder
  • monocular blindness
  • A or V pattern strabismus
  • ptosis
  • refractive error
  • visual field defect
206
Q

What are some abnormalities that people use a torticollis to better their VA?

A
  • nystagmus
  • ptosis
  • refractive error
  • VF defect
207
Q

When the deviation size remains the same or (within 5pd) in all positions of gaze

A

Comitant

208
Q

This comitancy implies no muscles are underacting or overacting

A

Comitant

209
Q

Deviation size is different in different positions of gaze.

A

Non-comitant

210
Q

This comitancy is due to an over action or under action of one or multiple muscles.

A

Non-comitant

211
Q

How do you determine comitancy

A

CT is done in all positions of gaze

212
Q

Non-comitant can be due to

A
  • Innervation problems (paralytic)

- Mechanical restrictions

213
Q

Do vergences play a role in some neuromuscular anomalies?

A

Yes

214
Q

When someone puts their book in their lap in order to read is an example of

A

Convergence insufficiency

215
Q

If someone has convergence insufficiency they are ___ at near

A

Exo

216
Q

When someone converges too much

A

Convergence excess

217
Q

If someone has convergence excess they are ___ at near

A

Eso

218
Q

If someone has a divergence insufficiency they are ___ at distance

A

Eso

219
Q

If someone has a divergence excess they are ___ at distance

A

Exo

220
Q

Name the 4 sites of lesions

A
  • supranuclear
  • nuclear
  • infranuclear
  • myogenic (disease at the muscle)
221
Q

Any strabismus that developed after 6 months

A

Acquired

222
Q

Onset at birth or during the 1st 6 months of life

A

Congenital onset

223
Q

Acquired deviations are

A
  • acute
  • longstanding
  • consecutive
224
Q

Time of onset for a neuromuscular abnormality from surgical overcorrection

A

Consecutive (acquired)

225
Q

Time of onset for a neuromuscular abnormality from trauma, infection, inflammation, or vascular disease

A

Acute (acquired)

226
Q

action of muscle or group of muscles completely eliminated (no movement seen)

A

Paralysis

227
Q

action of muscle or muscles is impaired (some movement seen)

A

Paresis

228
Q

general term for paralysis or paresis (since could be difficult to differentiate)

A

Palsy

229
Q

If there is difficulty moving the eye in a certain direction we can think its probably a __

A

Mechanical restriction

230
Q

A palsy also cause ___ deviations. And why?

A

Non-comitant deviations

-because of the over action or under action of the involved muscles

231
Q

What are some etiologies of neuromuscular deviations

A
  • 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
232
Q

What are some neurological defects that can cause neuro deviations?

A
  • birth injuries
  • cerebral palsy
  • developmental/special needs
  • retinopathy of prematurity
233
Q

If someone is suppressing and you put in a prism what will happen?

A

Nothing!

234
Q

What are some mechanical restrictions for neuro deviations

A
  • agenesis or abnormal insertion of the extraocular muscles
  • abnormal adhesions at tissue or fibrosis of the muscles
  • tumor metastases
  • sarcoidosis
235
Q

Poor fusion can be associated with

A
  • Fatigue
  • Asthenopia - eye strain, heaviness, soreness
  • Headaches – frontal
  • Avoidance
  • Diplopia
  • Suppression
236
Q

Why may a patient with a small phoria have no symptoms?

A

Because the sensorimotor system is able to cope with the deviation

237
Q

T/F: Vertical deviations are likely to cause symptoms because vertical fusional amplitudes are naturally limited.

A

True

238
Q

History: Uncertain of onset; only intermittent diplopia and may be asymptomatic

C or A?

A

Congenital

239
Q

History: Diplopia; exact time of onset is known; symptomatic

C or a?

A

Acquired

240
Q

Head posture: Aware of the head posture, needs to adopt intermittently because of symptoms; obvious

C or A?

A

Acquired

241
Q

Head posture: Patient/family unaware of posture; some facial asymmetry may be possible; deviation may now be comitant

C or A?

A

Congenital

242
Q

Comitancy: May appear comitant because of developed muscle sequalea – primary and secondary angles appear similar.

C or A?

A

Congenital

243
Q

Comitancy: Over action of the yoked muscle seen; secondary deviation larger than primary deviation. Hess chart of affected eye is smaller.

C or A?

A

Acquired

244
Q

Facial Amplitude: Patient have large vertical fusional amplitude (>10pd)

C or A?

A

Congenital

245
Q

Facial amplitude: Only have normal vertical fusional amplitudes of 2-3pd

C or A?

A

Acquired

246
Q

Suppression: Occurs in young children in the critical period (unless prevented); rare in adults

C or A?

A

Acquired

247
Q

Suppression: often present

C or A?

A

Congenital

248
Q

Torsion: rarely seen

C or A?

A

Congenital

249
Q

Torsion: seen

C or A?

A

Acquired

250
Q

Deviation: marked as deviation in primary

Neurogenic or Mechanical?

A

Neurogenic

251
Q

Deviation: Little deviation seen in primary, e.g. Brown’s, Duane’s, fractures

Neurogenic or Mechanical?

A

Mechanical

252
Q

Diplopia: same in different gazes. Hyper remains a hyper

Neurogenic or Mechanical?

A

Neurogenic

253
Q

Diplopia: may reverse

Neurogenic or Mechanical?

A

Mechanical

254
Q

Head posture: Head tilt rare; chin down or up may
be seen for vertical deviations

Neurogenic or Mechanical?

A

Mechanical

255
Q

Head posture: Head tilt seen with vertical palsies

Neurogenic or Mechanical?

A

Neurogenic

256
Q

Ocular Movement: duction > versions

Neurogenic or Mechanical?

A

Neurogenic

257
Q

Ocular Movement: Duction and version movements
equally limited

Neurogenic or Mechanical?

A

Mechanical

258
Q

Hess Lancaster: Field of affected eye is smaller; but both fields are displaced according to the deviation

Neurogenic or Mechanical?

A

Neurogenic

259
Q

Hess Lancaster:The fields are irregular and close to each other, can look flat

Neurogenic or Mechanical?

A

Mechanical

260
Q

Retraction of globe: Retracts when turned in direction opposite the restriction

Neurogenic or Mechanical?

A

Mechanical

261
Q

Retraction of globe: None

Neurogenic or Mechanical?

A

Neurogenic

262
Q

Pain on movement: none

Neurogenic or Mechanical?

A

Neurogenic

263
Q

Pain on movement: could be present

Neurogenic or Mechanical?

A

Mechanical

264
Q

Forced duction: able to move

Neurogenic or Mechanical?

A

Neurogenic

265
Q

Forced duction: limited movement

Neurogenic or Mechanical?

A

Mechanical

266
Q

A normal variable, transient, intermittent angle strabismus (exo or eso) seen in 2-3 months of life that often resolves by 4 months

A

Infancy ocular instability (split)

267
Q

A latent esodeviation controlled by fusional vergences

A

Esophoria

268
Q

manifest deviation not properly controlled by fusional vergences where the eye is turned in

A

Esotropia

269
Q

Deviations from neuromuscular abnormalities can be due to what 6 problems?

A
  • innervation
  • anatomical
  • mechanical
  • refractive
  • accommodative
  • genetic
270
Q

T/F: fusional vergences allow fusion and alignment

A

True

271
Q

Appearance of ET when eyes are actually straight.

A

Pseudoesotropia

272
Q

If someone has pseudoesotropia will they have a normal hirschberg and cover test?

A

Yes

273
Q

Pseudoesotropia is seen in children with ____ nose bridges, _____folds, and ____ interpupillary distance

A
  • wide, flat nose bridge
  • prominent epicanthal folds
  • small interpupillary distance
274
Q

An onset of an ET that appears between birth and 6 months

A

Infantile (congenital) ET

275
Q

Someone with infantile ET will have a ___ constant esotropia and will have a family history of a ET

A

Large

276
Q

What neurological or developmental conditions will many children with infantile ET have

A
  • cerebral palsy
  • hydrocephalus
  • prematurity
277
Q

When a patient uses the adducted eye to look in the contralateral view (uses RET to look in the left field)

A

Cross fixation

278
Q

Can people with infantile ET develop amblyopia? If so in what eye?

A

Yes. In the constantly deviated eye

279
Q

People with infantile ET may have ____ hyperopia

A

Low

280
Q

The patients will have an apparent large, constant angle (>30pd)

A

Infantile (congenital) ET

281
Q

Accounts for about 30-50% of all esotropes

A

Infantile esotropia

282
Q

What are 6 other variables you can see with infantile esotropia?

A
  • Amblyopia
  • A or V pattern
  • DVD – Dissociated vertical deviation
  • OIO – over action of inferior oblique
  • Nystagmus
  • AHP- anomalous head posture
283
Q

Name the management considerations in strabismus

A
  • correction of refractive error
  • added lenses (bifocal)
  • prism
  • occlusion (for amblyopia or suppression treatment)
  • VT
  • Botox
  • surgery (for larger angles)
284
Q

Management in infantile ET

A
  • comprehensive evaluation (birth history, pregnancy complications)
  • full cycloplegic refraction
  • surgery
285
Q

Why do you want to do a full cycloplegic refraction in infantile ET patients?

A

To rule out early onset accommodative ET

286
Q

Will smaller, variable intermittent ET respond to a full cycloplegic refraction?

A

Yeah

287
Q

Deviation associated with the accommodative reflex

A

Accommodative esotropia

288
Q

What is the onset of accommodative ET?

Average?

A

Between 6 months-7 yrs. (average 2.5)

289
Q

T/F: accommodative ET is often hereditary

A

True

290
Q

Accommodative ET starts ___ and then may become ___

A

Starts intermittently and then may become constant

291
Q

This is often present with large, constant, and unilateral angles

A

Amblyopia

292
Q

What are the 3 types of accommodative ETs?

A
  • refractive accommodative ET
  • non-refractive accommodative ET
  • mixed accommodative ET
293
Q

About ___% of all ET have an accommodative component

A

50%

294
Q

Due to uncorrected hyperopia and insufficient fusional vergence to diverge (high hyperopia)

A

Refractive accommodative ET

295
Q

A _____develops if the patient doesn’t have enough fusional divergence to counter the increased convergence

A

ET

296
Q

Refractive Accommodative ET could be about ___ pd

A

20-35pd

297
Q

Will someone with a refractive accommodative ET have different or similar deviations at distance and near?

A

Similar

298
Q

An average hyperopia that can cause a refractive accommodative ET is ____ but can honestly vary.

A

+4.00

299
Q

If hyperopia is greater than ___, isometropic amblyopia develops because patient has too much blur and will be unable to try to accommodate

A

6

300
Q

How would you manage refractive accommodative ET?

A
  • comprehensive exam
  • cycloplegic refraction
  • can reduce plus later to aid in emmetropization
  • start amblyopia treatment if VA doesnt fully improve with Rx
301
Q

Do you offer the full cycloplegic hyperopic correction for refractive accommodative ET patients?

A

Yes. They should ward it full time ASAP

302
Q

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?

A

Refractive accommodative due to similar D and N deviations

RX: +6.50

303
Q

ET due to high AC/A ratio

A

Non-refractive accommodative ET

304
Q

Non-refractive accommodative ET patients will have ___hyperopia to myopia

A

Moderate

305
Q

This type of ET will have a ET greater at N due to need for accommodation at N

A

Non-refractive accommodative ET

306
Q

amount of convergence induced by a change in accommodation

A

AC/A

307
Q

A change in accommodation is accompanied by a change in ____

A

Vergence

308
Q

helps evaluate the strength between the accommodative and vergences systems

A

AC/A ratio

309
Q

How do you calculate AC/A (equation)?

A

Absolute change/ absolute change in accommodation

310
Q

How do you manage non-refractive accommodative ET?

A
  • treat underlying refractive error
  • bifocal to reduce accommodation and accommodative convergence
  • repeat cyclo yearly for any changes
311
Q

Would you do surgery on a patient with non-refractive accommodative ET?

A

No. Because you know what the problem is

312
Q

Where should the seg height be for a child?

A

Must bisect the pupil. This forces the child to use it

313
Q

If a patient has ortho at D, but has a 30 CAET @ N what type of ET is this?

A

Non-refractive accommodative ET

314
Q

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?

A

+1.25 sph with a +3.00 add OU

315
Q

An ET with a combination of refractive accommodative and non refractive accommodative findings

A

Mixed accommodative ET

316
Q

These patient will have a ET with high hyperopic and a high AC/A ratio

A

Mixed-accommodative ET patients

317
Q

How would you manage a mixed accommodative ET patient?

A
  • give full hyperopic correction

- bifocal (based on AC/A ratio)

318
Q

Would you do surgery on someone with a mixed accommodative ET?

A

Nope

319
Q

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?

A

-mixed accommodative ET

Rx: +3.00/+3.00 add OU

320
Q

When accommodation contributes to, but does not account for the entire deviation

A

Partially accommodative ET

321
Q

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

A

Partially accommodative ET

322
Q

Will a partially accommodative ET be constant or intermittent ?

How about unilateral or bilateral?

A

Constant and unilateral

323
Q

Is suppression common in patients with partially accommodative ET?

A

Yes

324
Q

What are 2 types of Non-accommodative ETs?

A
  • early onset non-accommodative ET

- acute acquired ET

325
Q

When does early onset non-accommodative ET begin?

A

After about age 6 months-before age 2

326
Q

In Early Onset Non Accommodative Esotropia is ET the same or different at D and N?

Comitant?

A

The same

Its comitant

327
Q

How would you manage early onset non Accommodative ET

A
  • Correct refractive error, consider prisms or bifocals
  • Amblyopia treatment
  • Vision Therapy to improve ranges
  • Consider surgery
328
Q

Is an acute acquired ET non-comitant or comitant?

A

Comitant

329
Q

A sudden ET onset in a 3-5 year old

A

Acute acquired ET

330
Q

Do you want to do a neuro evaluation on someone with an acute acquired ET?

A

Yes. Do it ASAP

331
Q

How would you manage a acute acquired ET?

A
  • neuro evaluation
  • correction
  • prism or surgery since they probably had BV before the ET
  • amblyopia treatment if needed
332
Q

An ultra small ET

A

Microtropia

333
Q

An esotropia that develops due to vision loss in one eye

A

Sensory ET

334
Q

Will someone with a sensory ET have a clear image/good VA?

A

No. The pathology prevents the clear, focused retinal image and they will have a poor VA in the affected eye

335
Q

Someone with a sensory ET will have ___VA in affected eye, ____deviation,____pd, and ___cosmesis

A
  • poor VA in affected eye
  • constant unilateral deviation
  • 10-45pd
  • poor cosmesis
336
Q

How would you manage a sensory ET?

A
  • eliminate the pathology is possible
  • polycarbonate lens for full time wear
  • treat secondary amblyopia
  • surgery (for cosmesis or residual deviation)
337
Q

A non accommodative esodeviation greater at distance than near

A

Divergence insufficiency ET

338
Q

Do you want to do a neuro referral on someone with a divergence insufficiency ET?

A

YESSSS!

339
Q

How would you manage a divergence insufficiency ET?

A
  • correct the refractive error
  • BO for diplopia at D
  • VT
  • Botox
340
Q

Esodeviation after exo strabismus surgery.

A

Consecutive ET

341
Q

Why would you not want to surgery on a divergence insufficiency ET patient?

A

Because the deviation is only at distance

342
Q

How would you manage a consecutive ET?

A
  • treat refractive error
  • try BO prism or plus lens
  • repeat surgery for very large of symptomatic consecutive deviations
343
Q

What are 2 types of non comitant Eso deviations?

A
  • 6th nerve palsy

- Duanes syndrome

344
Q

A latent exodeviation controlled by fusional vergences

A

Exophoria

345
Q

A manifest deviation where the eye is turned out

A

Exotropia

346
Q

T/F: in exodeviations prevalence varies by ethnic groups

A

True

347
Q

Someone with a wide interpupillary distance that looks like a exodeviation

A

Pseudoesotropia

348
Q

What could happen if fusional vergences are not adequate in an exodeviation?

A

XT could result or XP becomes symptomatic

349
Q

When is treatment of an exophoria needed?

A

When there is asthenopia (eye strain) or diplopia

350
Q

The most common XT

A

Intermittent XT

351
Q

A type of XT in children where the XT is larger at disance and is seen prominently when the target is at a distance

A

Divergence excess XT

352
Q

A XT in adults that’s the same at distance and near

A

Basic XT

353
Q

A XT in adults where the XT is larger at near

A

Convergence insufficiency XT

354
Q

A XT where the deviation is latent at times and becomes manifest that occurs before age 5

A

Intermittent XT

355
Q

____light may cause reflex closure of one eye in an intermittent XT

A

Bright

356
Q

This XT could occurs late in the day, with fatigue, when daydreaming, when drowsy.

A

Intermittent XT

357
Q

This XT can be associated with small hypers and/or A/V pattern

A

Intermittent XT

358
Q

T/F: Untreated intermittent XT can lead to constant XT

A

True

359
Q

What type of intermittent control describes XT only manifest on CT and then resumes fusion rapidly

A

Good control

360
Q

What type of intermittent control describes XT on CT, fusion regained after blinking or refixating

A

Fair control

361
Q

What type of intermittent control describes XT manifest spontaneously and for an extended period of time.

A

Poor control

362
Q

IXT may be ______ at distance because of some fusion at near keeping eyes straight.

A

Greater

363
Q

Is diplopia common with good control?

A

No

364
Q

How would you manage a intermittent XT?

A
  • correct significant hyperopia, myopia, and astigmatism
  • patching for amblyopia
  • VT
  • prisms
  • surgery
  • Botox
365
Q

T/F: Mild myopia correction could make deviation better (IXT) and mild hyper could make it worse

A

True

366
Q

Why does moderate hyperopia (>+4.00) need to be corrected in someone with intermittent XT?

A

Because the child be unable to accommodate through this, resulting in blur and a manifest XT

367
Q

XT that is common post surgery

A

Consecutive XT

368
Q

Exotropia greater at near than distance

A

Convergence insufficiency XT

369
Q

Someone with a convergence insufficiency XT has a ____deviation at N, ___AC/A, and ____near fusion convergence amplitudes

A
  • intermittent alternating deviation
  • low AC/A
  • poor near fusion
370
Q

If someone has convergence insufficiency XT what may be some symptoms they will have when reading?

A
  • asthenopia
  • diplopia
  • blurred vision at near
371
Q

Commonly seen in older patients with a sensory XT or patients with a longstanding XT that has decompensated (decompensating XP).

A

Constant XT

372
Q

What are 2 examples of constant XT?

A
  • infantile XT

- sensory XT

373
Q

Large exo, constant angle that is present before 6 months

A

Infantile XT

374
Q

T/F: Children with Infantile XT will most likely have neuro issue and craniofacial disorders

A

True

375
Q

Would you do surgery for a child with infantile XT?

A

Yes

376
Q

In sensory XT, if VA is improved, what can be useful for better alignment

A

Surgery

377
Q

In sensory XT, if VA is not corrected , what could happen

A

Misalignment could occur again after surgery

Motility (6 decks)

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