Diagnostic techniques and clinical cases Chantal Heiming Orthoptist
Orthoptist
Anne van den Berg
Diagnostic techniques and clinical cases
Detection of strabismus & Assessment of ocular movements Clinical cases www.gponline.com, www.eyedr.co.nz, www.cvcny.org, www.eyespecialistclinic.com, www.angeledipalma.blogspot.be
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Diagnostic techniques and clinical cases
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Detection of strabismus
Epicanthus Symmetric=corneal pseudostrabismus reflections
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Diagnostic techniques and clinical cases
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Our patiënt
Pim 4 years
Asymmetric corneal reflections Hirschberg’s test
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Diagnostic techniques and clinical cases
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Detection of strabismus Hirschberg’s test Good fixation Corneal reflections Symmetric / Asymmetric -
Pupillary margin: 15° (B) Close to limbus: 30° (C) Beyond limbus: 45° (D)
Uncooperative or very young patients
Ansons and Davis (2009), Gutter et al. (2009), www.one.aao.org
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Diagnostic techniques and clinical cases
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Detection of strabismus Who has a squint?
A
Positive angle kappa (no strabismus)
B
Micro-strabismus
C
Negative angle kappa (no strabismus)
www.lovelygirliebits.com
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Diagnostic techniques and clinical cases
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Detection of strabismus Angle kappa Positive angle kappa -
Physiological 3-5° Pseudo-exotropia
Negative angle kappa -
More rarely Pseudo-esotropia
Positive to nose
Hypermetropia
(Myopia)
Be aware: Anisometropia Ectopic macula Poor fixation Ansons and Davis (2009), Wright and Spiegel (2003), von Noorden and Campos (1983)
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Diagnostic techniques and clinical cases
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Detection of strabismus Covertest Detection, direction and angle of deviation 30 cm and 6 m Cover/uncovertest → manifest deviation Alternate covertest → latent deviation
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Diagnostic techniques and clinical cases
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Cover/uncovertest (manifest deviation) A Asymmetric corneal reflections B Cover the fixing eye Note by the uncovered eye: -
Direction, size and speed of the movement
C Uncover: -
Observe if the eye returns immediately to its original position
Ansons and Davis (2009), von Noorden and Campos (1983), www.aafp.org
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Diagnostic techniques and clinical cases
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Alternate covertest (latent deviation) Constantly shifting swiftly from eye to eye (breaks binocular fusion)
E
Symmetric corneal reflections
F
Cover either eye: -
Movement of the eye behind cover
G Switching cover to other eye: -
‘Refixation’ from a deviated to a normal position
-
Movement of other eye behind cover
Ansons and Davis (2009), von Noorden and Campos (1983), www.aafp.org
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Diagnostic techniques and clinical cases
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Detection of strabismus Cover/uncovertest:
Alternate covertest:
MANIFEST DEVIATION
LATENT DEVIATION
Specify: - Eye - Angle - Fixation
Specify: - Angle - Recovery
Exotropia
Exophoria
Estimation of size: -Minimal 20° Ansons and Davis (2009)
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Diagnostic techniques and clinical cases
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Our patiënt
Pim 4 years
Cover/uncovertest 30cm: moderate esotropia OS (does not maintain fixation) Cover/uncovertest 6m: moderate esotropie OS (does not maintain fixation)
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Diagnostic techniques and clinical cases
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Measurement of strabismus Prism and covertest Objective measurement of strabismus Prism bars or loose square prisms (^dpt) 30 cm and 6 m
Apex of prism in direction of deviation Base-out in esotropia ↔ Base-in in exotropia Base-up in hypotropia ↔ Base-down in hypertropia
Ansons and Davis (2009), von Noorden and Campos (1983)
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Diagnostic techniques and clinical cases
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Measurement of strabismus Prism and covertest
OD
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O S
Diagnostic techniques and clinical cases
OD
O S
OD
O S
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Measurement of strabismus Simultaneous prism and covertest Manifest deviation Estimate angle (cover/uncover test) Simultaneous: - Prism before deviating eye - Occlude fixing eye Correctly chosen prism neutralizes the shift of the deviating eye
Ansons and Davis (2009), Harley et al. (2005), von Noorden and Campos (1983)
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Diagnostic techniques and clinical cases
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Our patiënt
Pim 4 years
Manifest deviation
Simultaneous prism and covertest 30cm: 25^ ET -0Simultaneous prism and covertest 6m: 20^ ET -0-
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Diagnostic techniques and clinical cases
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Measurement of strabismus Alternate prism and covertest Manifest + latent deviation = total deviation Estimate angle (alternate covertest) Prism before either eye Constantly shifting swiftly from eye to eye Increase strength of prisms until no more movement is seen
Ansons and Davis (2009), von Noorden and Campos (1983)
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Diagnostic techniques and clinical cases
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Our patiënt
Pim 4 years
Manifest + latent deviation
Alternate prism and covertest 30cm: 35^ ET -0Alternate prism and covertest 6m: 30^ ET -0-
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Diagnostic techniques and clinical cases
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Detection of strabismus
Moderate exotropia + minimal hypotropia OS
Moderate esotropia OS
N. III palsy OS
Limitation of abduction OS: N. VI palsy OS www.sboportal.org.br, www.12cranialnerves.wordpress.com
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Diagnostic techniques and clinical cases
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Assessment of ocular movements 9 cardinal positions of gaze Versions - Alternate covertest Ductions - Occluding one eye - Extent and quality of ocular movement - Grade and direction of the abnormability - Presence of pattern (V or A) - Change in position of eyelids, position of globe or palpebral fissure size - Presence of nystagmus and its direction
Ansons and Davis (2009), von Noorden and Campos (1983)
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Diagnostic techniques and clinical cases
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Assessment of ocular movements
www.droualb.faculty.mjc.edu, www.answersingenesis.or
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Diagnostic techniques and clinical cases
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Assessment of ocular movements
Vertical recti Vertical ductions max. in abduction
Obliqui Vertical ductions max. in adduction Cycloductions max. in abduction
www.revophth.com
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Diagnostic techniques and clinical cases
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Case 1
4 years
Sudden onset right esotropia Mother would like to have the squint corrected Hirschberg: 15° esotropia OD Cover/uncover test 30cm: moderate esotropia OD (dnmf) Cover/uncover test 6m: small esotropia OD (dnmf) Cardinal positions of gaze: full Alternate prism and covertest 30cm: 36^ ET Alternate prism and covertest 6m: 18^ ET
Would you operate or not?
VOD 1.0 // VOS 1.0 Cycloplegic refraction: OD S+3.50 // OS S+3.50
www.mypedeyedr.com
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Diagnostic techniques and clinical cases
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Case 1 Glasses:
4 years
OD S+3.00 OS S+3.00
Hirschberg: symmetric corneal reflections Stereopsis cc: 60 arcsec. Cover/uncover test cc 30cm: small esophoria (rr) Cover/uncover test cc 6m: orthophoria
Diagnosis: Fully accommodative esotropia OD
No strabismus surgery indicated Always look for a accommodative component!
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Diagnostic techniques and clinical cases
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Case 2
12 years
Complains about intermittent exotropia OS Hirschberg: symmetric corneal reflections Stereopsis: 60 arcsec. Cover/uncover test 30cm: small exophoria (rr) Cover/uncover test 6m: moderate exotropia OS (mf) Alternate prism and covertest 30cm: 2^ XF Alternate prism and covertest 6m: 30^ XT
Would you operate or not?
Fusion range 30cm: -20^ until +20^ Suppression 6m: until -40^ no double vision VOD 1.0 // VOS 1.0 Cycloplegic refraction: OD S+0.50 // OS S+0.25
www,telemedicine.orbis.org
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Diagnostic techniques and clinical cases
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Case 2
12 years
Marlow 48 hours Breaks fusion between the eyes by patching one eye for over two days Examination after 48 hours: Alternate prism and covertest 30cm: 30^ exo Alternate prism and covertest 6m: 30^ XT
Orthoptic diagnosis: Exotropia type simulated divergence excess After Marlow the deviation is the same for near and distance
So yes, there is a good indication for surgery
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Diagnostic techniques and clinical cases
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Case 3
36 years
Operated for strabismus at 3 years of age, unknown of it was for esotropia or exotropia Would like to have a re-operation Glasses: Hirschberg: 15° exotropia OD Bimedial small conjunctival vertical scars
OD S+4.50 C-0.50 x 178 OS S+3.25 C-0.50 x 174
Covertest 30cm cc: moderate exotropia OD (dnmf) Covertest 6m cc: moderate exotropia OD (dnmf) Alternate prism and covertest 30cm cc: 25^ XT Alternate prism and covertest 6m cc: 30^ XT Prism suppression 30cm cc: -18^ double vision (base-in) Prism suppression 6m cc: -20^ double vision (base-in) Cardinal positions of gaze: slighty limited adduction OD VOD cc 0.7 // VOS cc 1.0
www,eyespecialistclinic.com
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Diagnostic techniques and clinical cases
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Case 3
36 years
Operated for strabismus at 3 years of age, unknown of it was for esotropia or exotropia Would like to have a re-operation Glasses: Hirschberg: 15° exotropia OD Bimedial small conjunctival vertical scars Covertest 30cm cc: moderate exotropia OD (dnmf) Covertest 6m cc: moderate exotropia OD (dnmf) Alternate prism and covertest 30cm cc: 25^ XT Alternate prism and covertest 6m cc: 30^ XT
OD S+4.50 C-0.50 x 178 OS S+3.25 C-0.50 x 174
What is likely to be the pre-op deviation: Esotropia / Exotropia? Why?
Prism suppression 30cm cc: -18^ double vision (base-in) Prism suppression 6m cc: -20^ double vision (base-in) Cardinal positions of gaze: slighty limited adduction OD VOD cc 0.7 // VOS cc 1.0
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Diagnostic techniques and clinical cases
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Case 3
36 years
Operated for strabismus at 3 years of age, unknown of it was for esotropia or exotropia Would like to have a re-operation Glasses: Hirschberg: 15° exotropia OD Bimedial small conjunctival vertical scars
OD S+4.50 C-0.50 x 178 OS S+3.25 C-0.50 x 174
Covertest 30cm cc: moderate exotropia OD (dnmf) Covertest 6m cc: moderate exotropia OD (dnmf) Alternate prism and covertest 30cm cc: 25^ XT Alternate prism and covertest 6m cc: 30^ XT Prism suppression 30cm cc: -18^ double vision (base-in) Prism suppression 6m cc: -20^ double vision (base-in) Cardinal positions of gaze: slighty limited adduction OD VOD cc 0.7 // VOS cc 1.0
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Diagnostic techniques and clinical cases
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Case 3
36 years
Operated for strabismus at 3 years of age, unknown of it was for esotropia or exotropia Would like to have a re-operation Glasses: Hirschberg: 15° exotropia OD Bimedial small conjunctival vertical scars Covertest 30cm cc: moderate exotropia OD (dnmf) Covertest 6m cc: moderate exotropia OD (dnmf) Alternate prism and covertest 30cm cc: 25^ XT Alternate prism and covertest 6m cc: 30^ XT
OD S+4.50 C-0.50 x 178 OS S+3.25 C-0.50 x 174
Is it safe to operate the exotropia? Yes / No? Why?
Prism suppression 30cm cc: -18^ double vision (base-in) Prism suppression 6m cc: -20^ double vision (base-in) Cardinal positions of gaze: slighty limited adduction OD VOD cc 0.7 // VOS cc 1.0
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Diagnostic techniques and clinical cases
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Case 3
36 years
You can operate up to 18^ XT
Strabismus angle: 25^ XT Suppression area: from -18^ double vision
Take home message Hirschberg
Observe
Covertest
Detect
Manifest deviation: Cover/uncovertest
Latent or total deviation: Alternate covertest
Prism and covertest
Manifest deviation: Simultaneous prism and covertest
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Diagnostic techniques and clinical cases
Measure Latent or total deviation: Alternate prism and covertest
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