By pd examination of a squint
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Transcript of By pd examination of a squint
DR.VARSHINI SHANKARMODERATOR
DR.PUSHKAR DHIRPRESENTOR
HISTORY
INSPECTION
VISUAL ACUITY
EVALUATION OF MOTOR STATUS
HBCT/KRIMSKY/CT
EVALUATION OF SENSORY STATUS (STEROPSIS/ SUPPRESSION /ARC OR RC)
MEASUREMENT OF DEVIATION
ANT.& POST.SEGMENT
SPECIAL TEST TO IDENTIFY PARESIS & RESTRICTION
HISTORY• Age of Patient
• Complaint & HOPC:-o Age of Squint onset (early onset/ long
duration / constant angle / previous photos)
o Is it Sudden Or Gradual ?
o Direction of deviation patient / parent noted
o Is it Constant? Or Sometimes (INTERMITTENT)
o Noticed in One Eye or Both?
(U/L OR ALTERNATE)
o Diplopia? Asthenopia? Abn.Head Posture
• Birth Historyo Regarding Pregnancy & Delivery
o Developmental Milestones(Delay)
• Family History o Squint/ Refractive Error / Lazy eye
• Personal History o DM /HTN / Thyroid
• Treatment Historyo Glasses /Occlusion Therapy /Orthoptic
Exercise / Prev. Surgery
.….Looks can b really Deceptive
• Lid Fissure:-• Ptosis
• Mongoloid/Anti mongoloid
• Exophthalmos / enophthalmos
• Nasal Bridge
• Closure of one eye in bright light
• Epicanthal folds
• Head Posture (AHP)• Face Turn (Right/Left)
• Head Tilt (Right/Left Shoulder)
• Chin (Elevation/Depression)
• Facial Asymmetry
• Fixation Preference
• Nystagmus
INSPECTION
PTOSIS
Meri Refraction kon karega
VISUAL ACUITY
Infants (Birth-14 months)
Pre-Verbal Children
Toddlers ( 14 months – 21/2
years)
Preschoolers (21/2 years – 5years)
School going children (5years- 15 years)
1.Fixation preference test.
•Does he have a central/steady & mantained fixation.?
•Does he follow target?
•Does he get upset when u close one eye?
2.Optokinetic Nystagmus (OKN)
3.Force Choice Preferential looking test (FCPL)
4.Visual Evoked Potential (VEP)
1.Hundred & thousand sweet test
2. The Cardiff acuity Test
3.Dott Visual Acuity Testing.
1.LEA Symbols
2.Allen Picture Card
3.Broken Wheel Test
4.Tumbling E chart
5.Landolt C chart
6.Sjogren hand test
7.HOTV test
1.Tumbling E chart
2.Landolt C chart
3.Sjogren hand chart
4.Snellen’s chart
5.LogMAR chart.
FIXATION PREFERENTIAL TEST (CSM METHOD)
There are 2 types fixations are present:-
1.Centric 2.Eccentric
Component of Fixation
C= location of Corneal Reflex (Central/Uncentral)
S= Steady
M= Ability to maintain alignment first with one eye then with other
If Nystagmoid movements , VA ACUITY IN PATIENTS WITH NYSTAGMUS IS BINOCULAR
UC= uncentral
US= unsteady
UM= unmantained
MOTOR EXAMINATION
Extra-Ocular Movements
EOM
MONOOCULAR BINOCULAR
VERSIONS
(Conjugate Movements)
VERGENCES ( DisconjugateMovements)
???? ANGRY ?????
OR
????B/L MR OVER-ACTION
???
Points to Remember for EOM
• To check if all eye muscles r working together.
• Patient and examiner positioned at same level
• Correct any anomalous head position
• Room should be properly illuminated.
• Sit in front of the patient so that BE eyes can be seen simultaneously.
• Remove any Spectacles.( to remove prismatic effect)
• USE A PENLIGHT.
• 40 CM DISTANCE,SHINE ON FOREHEAD
• Move in 6 diagnostic/H position.
When Test Marks come
DEXTRO-ELEVATION LEVO-ELEVATION
DEXTRO-DEPRESSION LEVO-DEPRESSION
• ADDUCTION:- is normal when NASAL 1/3RD CORNEA crosses nasal punctum
• ABDUCTION:- is normal when TEMPORAL LIMBUS touches lateral canthus.
• INFERIOR OBLIQUES:- on lateral version , upwards deviation from the
horizontal line passing through centre of pupil
• SUPERIOR OBLIQUES :- on lateral version, downwards deviation from
the horizontal line.
• ELEVATION :-
• DEPRESSION :-
.
VergenceMovement
NPC NPA
NPC = role of DOT CARDNPA= role of FLIPPERSFusional Convergence= = role of CAT CARD/SYNAPTOPHOREFusional Divergence= =
!!D FORGOTTEN REFLEX!!
Bruckner Reflex
• Done with DO
• Distance of 3fts
• Power of DO is 0
• Helps to Detect:-Squint
Anisometropia
Leukocoria
Anisocoria
BRUCKNER REFLEX
Hirschberg Corneal Reflex (HBCT)• 1mm shift = 7° or 15 *Uses 1st Purkinje Image
00ºº
1515ºº
4545ºº
2828ºº
SQUINT
Apperent squint
(Pseudo-squint)
Latent squint
(Hetro-phoria)
Comitant
Paralytic/Paresis Ristrictive Spastic
Incomitant
Manifest squint
(Hetro-tropia)
Squint
PRE-REQUISTE FOR CT/CUT/ALT
• Vision More than 6/60 in BE to see the target
• Central fixation in BE
• If Bifocals are worn, near deviation measured through reading segment
SQUINT
TERMINOLOGIES
• IDS-RXT
• IDS-AXT
• LET
• ICS-RET
• ACCOMODATIVE ESOTROPIA
!!!!! KYA LOCHA HAI YE!!!!
Cover Test / Cover-Uncover/
Alternate Cover Test
• Helps to establish Ortho-tropic or not.
• Is Squint Latent= Phoria
• Is Squint Manifested = Tropia
• Direction of Deviation
• Fixation Behavior
• Check for Distance & Near
Cover test in all gazes for distance and near
Cover Test
• Done for distance & near
• Covering one eye of patient with normal binocular vision interrupts fusion.
• See for the movement OF OTHER EYE
• When eye is uncovered ,it will reestablish binocular fixation
• Imp. of Test:- Detects & Confirms
Tropias
Cover- Uncover Test
• Examiner OBSERVE THE COVERED EYE AS COVER IS REMOVED.
• In Hetrophoria,covered eye will deviate toward hetrophoricposition.
• When eye uncovered Reestablish Binocular Vision.
• Imp.of Test:- used to find out
PHORIAS
Alternate Cover Test
• Identify (Tropia + Phoria)
• Hold occluder over one eye for
several seconds
o Dissociates binocular vision
• Rapidly move occluder to other
eye
• Observe Refixation shift of
unoccluded eye
Objective Test
• Hirshberg Test
• Prism Alt.Cover Test(PACT)
• Krimsky Test
• Synaptophore Test
Subjective Test
• Maddox Rod
• Hess Screen Test
• Synaptophore Test
Krimsky Test /Modified HBCT
• Angle of strabismus is evaluated,
when the light is projected straight
ahead, and subsequent prisms
(prism bar) are placed
• Based on HERRING LAW of
equal innervation
BEFORE THE FIXING EYE
until symmetrical light reflexes are
seen on the cornea of both eyes.
Prism Alt.Cover Test
1.Maximum Deviation of eyes to be achieved to bring out full amt. of deviation ( can be done by patching one eye for 45/60mins)
2.Place Neutralizing prism over one eye.
3.Repeat Alternate testing
4.Cover should be placed alternatively over each other for some time.
5.NEVER NEVER NEVER allow patient to regain Fusion while cover is transferred.
6. Check for Distant & Near Vision
SENORY
EXAMINATION
STEREOPSIS
SUPPRESSION & DIPLOPIA
RETINAL CORRESPONDANCE
TO BE DONE WITH FULL OPTICAL
CORRECTION
TO BE DONE PRIOR TO ANY
DISSOCIATION
STEREOPSIS
TITMUS FLY TEST
(Based on Vectographic Principle)
RANDOM DOT TESTS
• RANDOM DOT E TEST
• TNO TEST (Based on Anaglph mehtod)
LANG TEST
(L-sterotest1 & 2)
LANG 2 Pencil Test
SYNAPTOPHORE
(Based on Haploscopic Principle)
SUPPRESSION
WORTH 4 DOT TEST
4D/20D BASE OUT TEST
BAGOLINIS FILTER TEST
MADDOX ROD TEST
AFTER IMAGE TE4ST
Gross Stereoacuity
Top of Upper Wings:2000seconds
Bottom of Lower Wings:1150 sec
Tip of Abdomen:700 sec
Fine Stereoacuity
Circles
1-3:800-200sec
4-6:140-80 sec
7-9:60-40 sec
Animals
A row:400sec
B row:200sec
C row:100sec
• Graded from 15-480 arc sec
• 8 plates; 480/240/120/60/30/15
• 1ST 3 plates to check for presence of stereopsis
• 4 is SUPPRESSION TEST PLATE
• If a child see 2 circle ask for larger circle
• 5,6,7for degree of steropsis
• Special Glasses Required
• Kept at distance of approx 30 cms
• Cost around 20,000!!!!!!!!!
• Checks NEAR STEROPSIS ONLY
FRISBY DAVIS DISTANCE TEST(FD2)
• Red / Green glasses
(Red over right eye)
• Dark Room
• Illuminated Target
• VARY TESTING DISTANCE TO IDENTIFY
SIZE OF SUPPRESSION SCOTOMA.
• White light is only binocular fusion target
• Done with a Projector/Chart
(6m)
• Test for Macular Scotoma
• Done with a Flashlight
• At Near (1/3m)-subtends 6
degree arc
• Tests for Extramacular
Suppression
W4dt interpretations• Distant W4DT means fusion occurs at macular
level
• Near W4DT means fusion occur at extramacular/peripheral retina.
• Narrow striation running in
one principal meridian.
• Lenses oriented at 45o and
135o
• Evaluation of DISTANCE
AND NEAR retinal
correspondence with minimal
dissociations.
R L
F
FL FR
BG LBG R
Multiple cylindrical high plus lenses stacked ontop of eachother.
Converts point source to streak Streak is perpendicular to cylinders!
Dissociative Blocks fusion (measures phoria) No control of
accommodative convergence Less useful for horizontal deviations
Uncrossed : Rt EsoCrossed : Rt Exo
STIMULATOR
• DEMONSTARTE
Patient is asked to comment on
–Position
–Brightness
–Separation between images
Diplopia Test