Squint Clinic Hyderabad L. V. Prasad Eye Institute

Formal Orthoptic Diagnostic Aid: management is traditional rather than rational

Orthoptic Report Getting an orthoptic report is like kissing your own sister It doesn’t lead anywhere Getting an orthoptic report is like kissing your own sister It doesn’t lead anywhere

Practical Approach To Strabismus

Definition of Strabismus When the two visual axes do not intersect at the object of attention

Aim of Examination To determine the normality or abnormality of : The sensory apparatus The motor apparatus In a valid & repeatable manner To determine the normality or abnormality of : The sensory apparatus The motor apparatus In a valid & repeatable manner

Information Required From Exam Bifoveal Fusion Nature and degree of Deviation Fusional Vergences Measurements If Tropia – characteristics of Suppression scotoma Bifoveal Fusion Nature and degree of Deviation Fusional Vergences Measurements If Tropia – characteristics of Suppression scotoma

Factors to Be Controlled Accommodation Fixation Fusional vergences Accommodation Fixation Fusional vergences

All Tests Cycloplegic retinoscopy Refractive errors corrected Accommodative target for distance and near Cycloplegic retinoscopy Refractive errors corrected Accommodative target for distance and near

Sequence of Clinical Tests Bi foveal fusion Fusional vergences Deviations & Measurements Rotations, A/V, Head tilt Limitation of movements Restriction VS weakness Characteristics of suppression Bi foveal fusion Fusional vergences Deviations & Measurements Rotations, A/V, Head tilt Limitation of movements Restriction VS weakness Characteristics of suppression

Doctor Must Do the Examination Personally

Cover Test

Exotropia

Esotropia

Alternate Divergent Squint

Un - Cover Test

Exophoria – Fusional Reflex

Exophoria – Fusion Movement

Intermittent Divergent Squint

Prism Bar Cover Test

Ocular Movements

every limitation of movement must be checked uniocularly

Patterns : Rising Eye

Patterns : Falling Eye

Testing For A-V Pattern

No A or V

V Pattern

A Pattern

10 ET 10 RXT 40 XT L/R R/L +30 Recording Results

10 ET 10 RXT 40 XT L/R +30 {-3}{-3} - 3 R/L =30 Recording Results

Globe Retraction

Exotropia with Hypertropia R.E. Fixing

Suspect Strabismus If abnormal head posture If closing one eye If abnormal head posture If closing one eye

Head Tilt Test

Head Tilt Test : Others

Sixth Nerve Paralysis & Saccades

Floating Saccades

Primary Versus Secondary Deviation

Forced Duction Test

Force Generation Test

Sensory System / Tests The sensory system is of inestimable importance in the management Valid inferences : Age of patient Type of squint Refraction correction H/O Motor examination The sensory system is of inestimable importance in the management Valid inferences : Age of patient Type of squint Refraction correction H/O Motor examination

Sensory / Suppression - Inference Early onset tropia Binocular suppression scotoma Early onset exotropia Temporal hemiretinal suppression scotoma Early onset esotropia Regional nasal hemiretinal suppression Early onset tropia Binocular suppression scotoma Early onset exotropia Temporal hemiretinal suppression scotoma Early onset esotropia Regional nasal hemiretinal suppression

Visual Acuity

Even in a Baby It Is Possible To Test the quality of vision Refract and examination fundi (with help of atropine) Test the quality of vision Refract and examination fundi (with help of atropine)

Qualitative Vision

Don’t Forget The Fundus

Prism RE: LE moves out And comes back to refixate Prism RE: LE moves out And comes back to refixate 4 Prism Test : Normal

Prism RE: LE moves out And stays out Prism RE: LE moves out And stays out 4 Prism Test : Abnormal After removal of prism

Prism LE : No movements 4 Prism Test: Abnormal

4 Prism Test : Positive

Sophisticated Tests

Audience Interaction

Aim of Strabismus Management Good vision in each eye Binocular vision Preferably stereopsis Normalise : Deviations Rotations Head position Good vision in each eye Binocular vision Preferably stereopsis Normalise : Deviations Rotations Head position

Rx of Strabismus Glasses Occlusion Prisms (Exercises) Surgery : minimum number of interventions Glasses Occlusion Prisms (Exercises) Surgery : minimum number of interventions

Pseudo Strabismus

Glasses

Occlusion

Cosmetic Surgery

Adjustable Sutures

Superior Oblique Paralysis

Key to Strabismus If you master the physical examination and disregard the mystique of orthoptics then strabismus is no longer such a difficult subject Even I can handle it ? If you master the physical examination and disregard the mystique of orthoptics then strabismus is no longer such a difficult subject Even I can handle it ?

If you are interested in doing things mechanically Fix holes in the retina / do cataracts If you want to exercise those grey cells Do squints