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DIAGNOSTIC EVALUATION FOR STRABISMUS

Ms. JayaRajini Vasanth Mphil, B.S (opt) Assistant Professor Optometry Ophthalmology Department Sri Ramachandra University

Classification of strabismus
A.

Pseudostrabismus (false or apparent squint).

B. True strabismus: 1. Latent squint (heterophoria). 2. Manifest squint (heterotropia): - non- paralytic (concomitant). - paralytic (non- concomitant).

Axes of the eye

Visual axis: Line passes from the fovea to the point of fixation (object of regard). The normal visual axes (from both eyes) intersects at the point of fixation. Optical axis: It is the line passing through the centre of the cornea and meets the retina on the nasal side of the fovea Fixation axis: It is the line joining the fixation point and the centre of rotation

Angle kappa is the angle between visual (0ptical) axis and the anatomical (pupillary) axis.

As the fovea lies just temporal to the anatomical axis, a light shown into the cornea will cause reflex (on the visual axis) just nasal to the center of the cornea in both eyes (+ve angle kappa = 5).

In high myopia the, the fovea lies nasal to the optical axis. So, the corneal reflex lies temporal to the center of the cornea simulating esotropia. Negative angle kappa (myopia) leads to pseudoesotropia. Large positive angle kappa (hypermetropia) leads to pseudo-exotropia.

Pseudostrabismus

In young infants, strabismus must be differentiated from the more common pseudostrabismus

Pseudoesotropia as a result of a broad bridge of the nose. This is not a real eye crossing

Pseudo-deviations
Pseudo-esotropia Pseudo-exotropia

Epicanthic folds

Short interpupillary distance

Wide interpupillary distance

Positive angle kappa

Negative angle kappa

HISTORY

Age of onset of deviation Is the deviation constant or intermittent? Is the deviation present for distance, near or both? Is it unilateral or alternating? Is it present only when the patient is inattentive or fatigued? Is it associated with trauma or physical stress? Old photographs Birth history Is there a family history of strabismus?. Are there any other medical problems? Headaches Is there a history of toxin or medication exposure?

VISUAL ACUITY

Recognition acuity : Lea symbols, HOTV, Snellen Chart


Detection acuity : Stycar Ball test

Resolution acuity : Lea Paddles

SENSORY EVALUATION

Simultaneous macular perception


Worth four dot test Stereopsis

Tests for sensory anomalies


Worth four-dot test Bagolini striated glasses

a - Prior to use of glasses b - Normal c - Left suppression/ amblyopia d - Right suppression/ amblyopia e - Diplopia

a - Normal or ARC b- Diplopia c - Suppression d - Small suppression scotoma

Tests for Stereopsis


Tests on stereopsis can be based on two principles 1.Using targets which lie in two planes, but are so constructed that they stimulate disparate retinal elements and give a three dimensional effect, for example: Circular perspective diagram such as the concentric rings Titmus fly test, TNO test, Random dot stereograms, Polaroid test Langs stereo test Stereoscopic targets presented haploscopically in major amblyoscope 2.Using 3 dimensional targets (e.g. Langs two pencil test).

Qualitative tests for Stereopsis: Langs 2 pencil test Synoptophore Quantitative tests for Stereopsis: Random dot test TNO Test Langs stereo test

Tests for stereopsis


Titmus
TNO random dot test

Polaroid spectacles Figures seen in 3-D

Red-green spectacles Hidden shapes seen

Frisby

Lang

No spectacles Hidden circle seen

No spectacles Shapes seen

MOTOR EVALUATION

Extra ocular muscles Cover test Corneal reflex test Hirschberg Krimsky Bruckner Dissimilar image test Maddox rod

Evaluation of Motility

Two principle methods of evaluating ocular motility are: 1. Observation of ocular ductions, which are the actual monocular movements of the eye. 2. Observation of binocular ocular alignment, using cover/uncover and alternate cover testing.

Monocular eye movements

A- elevation d- adduction

B- depression Eextortion

C- adbuction F- intortion

Ocular movement examination

Right esotropia (RET) Right exotropia (RXT) Right hypertropia (RHT)right hypotropia
Left esotropia (LET) Left exotropia (LXT) Left hypertropia (LHT)left hypotropia Alternating esotropia (ALT ET) Alternating exotropia (ALT XT)

E esophoria X exophoria RH right hyperphoria LH left hyperphoria E(T) intermittent esotropia X(T) intermittent exotropia RH(T) intermittent right hypertropia LH(T) intermittent left hypertropia

Prism cover test measures total deviation

Cover test detects heterotropia


Uncover test detects heterophoria Alternate cover test detects total deviation

Motility tests Tests versions and ductions Grades under/overaction

Left inferior oblique overaction Left lateral rectus underaction

Hirschbergs test
Amount of deviation: note location of corneal light reflex 1 mm = 7 or 15

Reflex at border of pupil = 15

Reflex at limbus = 45

Hirschbergs Test
Normal

Used as an initial screen for strabismus How it works: Stand several feet in front of child with penlight shining at eyes Light reflection will be at the same point in each eye

Exotropia

Esotropi a

Krimsky Test

Modified Krimsky test

Asymmetric positions of the corneal reflex in the pupils of each eye are indicative of strabismus, which may be measured by placing a prism before the fixating eye until the reflection is similarly positioned in both eyes Base out prism for esotropia and Base in prism for exotropia This is the direct reading of the squint angle.

Bruckner Test

Is performed by using direct ophthalmoscope to obtain a red reflex simultaneously in both eyes. If there is strabismus , the deviated eye will have a lighter and brighter reflex than the fixing eye. Media opacities, Refractive errors, Strabismus

Dissimilar image tests


Maddox wing Maddox rod

Dissociates eyes for near fixation (1/3 m)


White spot converted into red streak

Measures heterophoria

Cannot differentiate tropia from phoria

Measurements of ocular misalignment


Measurement of squints/misalignments Synoptophore - picture test Measure - misalignments, sensory and motor fusion and stereopsis Predict BV post-surgery Measure misalignments 9 positions of gaze

Prism Cover Test

Measure squint/misalignment Single prism/prism bar Primary position or in all positions of gaze

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