Exam sequence in strabismus Flashcards
This allows you to develop a hypothesis and guide the management plan
Case history
What do you need to address in case history
CC FOLDAR Medical Hx Birth Hx Family Hx Meds Allergies
Attention to chiefs complaints
- asthenopia
- Poor cosmesis
- failed screening
- second opinion (confirm a dx)
- family history of strabismus
- birth defects
- signs of asthenopia (rubbing)
- developmental concerns
FOLDAR questions specific to ocular motility problems
- frequency of deviation or symptom
- onset of deviation or symptom
Why do we need to ask about frequency or deviation or symptom for motility problems
- Constant or intermittent can predict presence of amblyopia and sensory adaptations
- worse during a time of day, AC/A problems, decompensations, when inattentive
What do we need to ask about onset of deviation or symptom for ocular motility problems
- age of onset (infantile/congenital or acquired)
- mode of onset- sudden or gradual
Location and laterality during FOLDAR during case history
At distance or near in a particular gaze unilateral or alternating
Duration during FOLDAR in case history
Onset to first treatment
Associated signs and symptoms in case history for ocular motility problems
double vision, eye strain, trauma, illness, medication use, numbness and dizziness, no symptoms
Relieve in FOLDAR in case history for motility problems
Treatments that have helped: glasses, occlusions, vision therapy, surgery
Systemic history in ocular motility problems
Childhood diseases, medications, neurologic, problems, developmental milestones
Birth history
Birth weight, prematurity, complications, prenatal and perinatal care
Family history for ocular motility problem exam
History of strabismus, history of binocular dysfunctions or amblyopia
Direct observation of patietns experience in ocular motility exam
Head positioning, head movements, attentiveness, motor control
Head posture
Head tilt, turn or tip to avoid diplopia ( or to keep double images far apart)
-common in non-comitant deviations-face placed in the affected muscles diagnostic action field
Facial assymetry in ocular motility problems
Down syndrome
Cerebral palsy
Hydrocephaly
Craniofacial abnormalities
Lid position
Ptosis
Exophthalmos (graves, Duane’s)
Lagophthalmos
Prominent epicanthal folds
Nose bridge in ocular motility problems
Can make the appearance of strabismus not correct
Wide nose bridge
Makes XT less obvious
Narrow nose bridge
Makes ET less obvious
Wide face
Makes XT less obvious
Narrow face
Makes ET less obvious
Hypertelorism
Eyes wide apart
Positive angle lambda
Reflex nasal to pupil
Makes XT more obvious
Negative angle lambda
Temporal reflex to pupil
Makes ET more obvious
Normal hircschbirg
Reflex is about 0.5mm nasal to the center of the pupil (slightly exo)
What to consider when looking at presence of deviation
Constant or intermittent Unilateral or alternating Size and direction of the deviation Cosmesis Constancy
Motor fusion tests done on ocular motility exam
Pertinent entrance tests, eye and head tilt CT (in all gazes), ductions and versions Hirsh/Krimsky Bruckner test Test of torsion-double Maddox Parks three step test Red glass Hess Lancaster, major amblyoscope
What types of refractions are pertinent in an ocular motility exam
Keratometry
Dry ret
Subjective refraction
Cylcoplegic refraction
What ocular health tests are pertinent in an ocular motility exam
Biomicroscopy
90D, BIO with 20D
