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SENSORY & MOTORSENSORY & MOTOR
EVALUATION IN STRABISMUSEVALUATION IN STRABISMUS
DR. DEVDUTTA NAYAKDR. DEVDUTTA NAYAK
Classification of strabismusClassification of strabismus
A.A. Pseudostrabismus (false orPseudostrabismus (false or
apparen...
CLASSIFICATIONCLASSIFICATION
1. Direction of deviation:1. Direction of deviation:
- convergent (esotropia)- convergent (es...
3. Constancy:3. Constancy:
- intermittent- intermittent
- constant- constant
4. Onset:4. Onset:
- childhood (congenital)- ...
6. Apparent (psuedostrabismus)6. Apparent (psuedostrabismus)
Manifest (tropias)Manifest (tropias)
Latent (phorias)Latent (...
Axes of the eyeAxes of the eye
 Visual axis:Visual axis:
Line passes from the fovea to the point ofLine passes from the f...
Angle kappa is the angle between visual axis and theAngle kappa is the angle between visual axis and the
anatomical (pupil...
•In high myopia the, the fovea lies nasal to theIn high myopia the, the fovea lies nasal to the
optical axis. So, the corn...
PseudostrabismusPseudostrabismus
 In young infants,In young infants,
strabismus must bestrabismus must be
differentiated ...
Pseudo-deviationsPseudo-deviations
Pseudo-esotropiaPseudo-esotropia Pseudo-exotropiaPseudo-exotropia
•Epicanthic folds
Sho...
HISTORYHISTORY
 Age of onset of deviationAge of onset of deviation
 Is the deviation constant or intermittent?Is the dev...
GOALSGOALS
The goals of strabismus examination are to:The goals of strabismus examination are to:
 Establishing a cause f...
VISUAL ACUITYVISUAL ACUITY
 Visual acuity is evaluated for each eye separately andVisual acuity is evaluated for each eye...
VISUAL ACUITYVISUAL ACUITY
 Recognition acuity : Lea symbols, HOTV, Snellen ChartRecognition acuity : Lea symbols, HOTV, ...
Assessment of VisionAssessment of Vision
Birth to 12 months – forced choice preferentialBirth to 12 months – forced choice...
Assessment of visionAssessment of vision
12 months – 2 years Cardiff Cards12 months – 2 years Cardiff Cards
Assessment of Vision - Cardiff CardsAssessment of Vision - Cardiff Cards
Assessment of Vision – occludingAssessment of Vision – occluding
glassesglasses
Assessment of VisionAssessment of Vision
2 – 4 years Kay Pictures2 – 4 years Kay Pictures
Assessment of VisionAssessment of Vision
4 – 6 years Crowded logMAR4 – 6 years Crowded logMAR
MOTOR EVALUATIONMOTOR EVALUATION
 Extra ocular musclesExtra ocular muscles
 Cover testCover test
 Corneal reflex test –...
Evaluation of MotilityEvaluation of Motility
 Two principle methods of evaluating ocular motilityTwo principle methods of...
Monocular movementsMonocular movements
(Ductions)(Ductions)
A- elevation B- depression C- abduction
D- adduction E–extorti...
Binocular movements (Versions)Binocular movements (Versions)
 Range of eye movements examined to find out, whether concom...
Motility testsMotility tests
Tests versions and ductionsTests versions and ductions
Grades under/overactionGrades under/ov...
Measurement of DeviationMeasurement of Deviation
 Hirschberg corneal reflex testHirschberg corneal reflex test
 Krimsky’...
Hirschberg’s testHirschberg’s test
Amount of deviation: note location of corneal light reflexAmount of deviation: note loc...
Hirschberg’s TestHirschberg’s Test
 Used as an initial screen forUsed as an initial screen for
strabismus.strabismus.
 R...
Krimsky TestKrimsky Test
This test is used to
centralize the corneal
reflection in squinting
eye as compared to the
reflex...
Bruckner TestBruckner Test
 Performed by usingPerformed by using
direct ophthalmoscopedirect ophthalmoscope
to obtain a r...
Prism Cover TestPrism Cover Test
 MeasuresMeasures
squint/misalignmentsquint/misalignment
 Single prism/prism barSingle ...
•Cover test detects heterotropia.
•Uncover test detects heterophoria.
•Alternate cover test detects total deviation.
•Pris...
Dissimilar image testsDissimilar image tests
Maddox wing
Maddox rod
•Dissociates eyes for near
fixation (1/3 m)
•Measures ...
Double Maddox Rod TestDouble Maddox Rod Test
 Torsional deviations can be measured withTorsional deviations can be measur...
Measurements of ocularMeasurements of ocular
misalignmentmisalignment
Synoptophore:Synoptophore:
 Measures angle ofMeasur...
SENSORY EVALUATIONSENSORY EVALUATION
 Normal binocular vision comprises of simultaneousNormal binocular vision comprises ...
Synoptophore:Synoptophore:
 Examination of the simultaneousExamination of the simultaneous
perception means determination...
Tests for sensory anomalies
Bagolini striated glasses
a - Normal or ARC
b- Diplopia
c - Suppression
d - Small suppression ...
Tests for sensory anomalies
Worth four-dot test
a - Prior to use of glasses
b - Normal
c - Left suppression/ amblyopia
d -...
4 Prism Test4 Prism Test
 A 4 diopter prism placed in front of one eye andA 4 diopter prism placed in front of one eye an...
STEREOPSISSTEREOPSIS
 Qualitative tests forQualitative tests for
StereopsisStereopsis::
 Lang’s 2 pencil testLang’s 2 pencil test
 Synoptoph...
Tests for stereopsis
Titmus
• Red-green spectacles
TNO random dot test
• ‘Hidden’ shapes seen
• Polaroid spectacles
• Figu...
Titmus Fly Test:Titmus Fly Test:
 A stereo-test.A stereo-test.
 Measures stereoacuity from 3000Measures stereoacuity fro...
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
Sensory & motor evaluation of strabismus
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Sensory & motor evaluation of strabismus

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Sensory & motor evaluation of strabismus

  1. 1. SENSORY & MOTORSENSORY & MOTOR EVALUATION IN STRABISMUSEVALUATION IN STRABISMUS DR. DEVDUTTA NAYAKDR. DEVDUTTA NAYAK
  2. 2. Classification of strabismusClassification of strabismus A.A. Pseudostrabismus (false orPseudostrabismus (false or apparent squint).apparent squint). B. True strabismus:B. True strabismus: 1. Latent squint (heterophoria).1. Latent squint (heterophoria). 2. Manifest squint (heterotropia):2. Manifest squint (heterotropia): - non- paralytic (concomitant).- non- paralytic (concomitant). - paralytic (non- concomitant).- paralytic (non- concomitant).
  3. 3. CLASSIFICATIONCLASSIFICATION 1. Direction of deviation:1. Direction of deviation: - convergent (esotropia)- convergent (esotropia) - divergent (exotropia)- divergent (exotropia) - hypodeviation- hypodeviation - hyperdeviation- hyperdeviation 2. Comitancy:2. Comitancy: - comitant or non paralytic- comitant or non paralytic - incomitant or paralytic- incomitant or paralytic
  4. 4. 3. Constancy:3. Constancy: - intermittent- intermittent - constant- constant 4. Onset:4. Onset: - childhood (congenital)- childhood (congenital) - adult (acquired)- adult (acquired) 5. Unilateral or Alternating5. Unilateral or Alternating
  5. 5. 6. Apparent (psuedostrabismus)6. Apparent (psuedostrabismus) Manifest (tropias)Manifest (tropias) Latent (phorias)Latent (phorias)
  6. 6. Axes of the eyeAxes of the eye  Visual axis:Visual axis: Line passes from the fovea to the point ofLine passes from the fovea to the point of fixation (object of regard). The normal visual axesfixation (object of regard). The normal visual axes (from both eyes) intersects at the point of fixation.(from both eyes) intersects at the point of fixation.  Optical axis:Optical axis: It is the line passing through the centre of theIt is the line passing through the centre of the cornea and meets the retina on the nasal side of thecornea and meets the retina on the nasal side of the foveafovea  Fixation axis:Fixation axis: It is the line joining the fixation point and theIt is the line joining the fixation point and the centre of rotationcentre of rotation
  7. 7. Angle kappa is the angle between visual axis and theAngle kappa is the angle between visual axis and the anatomical (pupillary) axis.anatomical (pupillary) axis. -- As the fovea lies just temporal to the anatomical axis, aAs the fovea lies just temporal to the anatomical axis, a light shown into the cornea will cause reflex (on the visuallight shown into the cornea will cause reflex (on the visual axis) just nasal to the center of the cornea in both eyesaxis) just nasal to the center of the cornea in both eyes (+ve angle kappa = 5°).(+ve angle kappa = 5°).
  8. 8. •In high myopia the, the fovea lies nasal to theIn high myopia the, the fovea lies nasal to the optical axis. So, the corneal reflex lies temporal tooptical axis. So, the corneal reflex lies temporal to the center of the cornea simulating esotropia.the center of the cornea simulating esotropia. •Negative angle kappa (myopia) leads to pseudo-Negative angle kappa (myopia) leads to pseudo- esotropia.esotropia. •Large positive angle kappa (hypermetropia) leadsLarge positive angle kappa (hypermetropia) leads to pseudo-exotropia.to pseudo-exotropia.
  9. 9. PseudostrabismusPseudostrabismus  In young infants,In young infants, strabismus must bestrabismus must be differentiated from thedifferentiated from the more commonmore common pseudostrabismuspseudostrabismus PseudoesotropiaPseudoesotropia as a result of a broad bridge of the nose
  10. 10. Pseudo-deviationsPseudo-deviations Pseudo-esotropiaPseudo-esotropia Pseudo-exotropiaPseudo-exotropia •Epicanthic folds Short interpupillary distance •Negative angle kappa •Wide interpupillary distance •Positive angle kappa
  11. 11. HISTORYHISTORY  Age of onset of deviationAge of onset of deviation  Is the deviation constant or intermittent?Is the deviation constant or intermittent?  Is the deviation present for distance, near or both?Is the deviation present for distance, near or both?  Is it unilateral or alternating?Is it unilateral or alternating?  Is it present only when the patient is inattentive orIs it present only when the patient is inattentive or fatigued?fatigued?  Is it associated with trauma or physical stress?Is it associated with trauma or physical stress?  Old photographsOld photographs  Birth historyBirth history  Is there a family history of strabismus?.Is there a family history of strabismus?.  Are there any other medical problems?Are there any other medical problems?  Is there a history of toxin or medication exposure?Is there a history of toxin or medication exposure?
  12. 12. GOALSGOALS The goals of strabismus examination are to:The goals of strabismus examination are to:  Establishing a cause for strabismus.Establishing a cause for strabismus.  Diagnosing ambylopia.Diagnosing ambylopia.  Measuring the deviation.Measuring the deviation.  Assessing binocular sensory status.Assessing binocular sensory status.
  13. 13. VISUAL ACUITYVISUAL ACUITY  Visual acuity is evaluated for each eye separately andVisual acuity is evaluated for each eye separately and together, for both distant and near visions, and withtogether, for both distant and near visions, and with and without glasses.and without glasses.  Easy in adults & older children >3 yrs.Easy in adults & older children >3 yrs.  Special measurement techniques for younger children:Special measurement techniques for younger children: −− Observation.Observation. −− Optokinetic nystagmus.Optokinetic nystagmus. −− Visual evoked potentials.Visual evoked potentials. −− Forced choice preferential looking.Forced choice preferential looking. −− Graded optotypes of special construction.Graded optotypes of special construction. −− Monocular fixation.Monocular fixation.
  14. 14. VISUAL ACUITYVISUAL ACUITY  Recognition acuity : Lea symbols, HOTV, Snellen ChartRecognition acuity : Lea symbols, HOTV, Snellen Chart  Detection acuity : Stycar Ball testDetection acuity : Stycar Ball test  Resolution acuity : Lea PaddlesResolution acuity : Lea Paddles
  15. 15. Assessment of VisionAssessment of Vision Birth to 12 months – forced choice preferentialBirth to 12 months – forced choice preferential lookinglooking
  16. 16. Assessment of visionAssessment of vision 12 months – 2 years Cardiff Cards12 months – 2 years Cardiff Cards
  17. 17. Assessment of Vision - Cardiff CardsAssessment of Vision - Cardiff Cards
  18. 18. Assessment of Vision – occludingAssessment of Vision – occluding glassesglasses
  19. 19. Assessment of VisionAssessment of Vision 2 – 4 years Kay Pictures2 – 4 years Kay Pictures
  20. 20. Assessment of VisionAssessment of Vision 4 – 6 years Crowded logMAR4 – 6 years Crowded logMAR
  21. 21. MOTOR EVALUATIONMOTOR EVALUATION  Extra ocular musclesExtra ocular muscles  Cover testCover test  Corneal reflex test – HirschbergCorneal reflex test – Hirschberg KrimskyKrimsky BrucknerBruckner  Dissimilar image test – Maddox rodDissimilar image test – Maddox rod
  22. 22. Evaluation of MotilityEvaluation of Motility  Two principle methods of evaluating ocular motilityTwo principle methods of evaluating ocular motility are:are: 11. Observation of ocular ductions, which are the. Observation of ocular ductions, which are the actual monocular movements of the eye.actual monocular movements of the eye. 22. Observation of binocular ocular alignment, using. Observation of binocular ocular alignment, using cover/uncover and alternate cover testing.cover/uncover and alternate cover testing.
  23. 23. Monocular movementsMonocular movements (Ductions)(Ductions) A- elevation B- depression C- abduction D- adduction E–extortion F- intortion
  24. 24. Binocular movements (Versions)Binocular movements (Versions)  Range of eye movements examined to find out, whether concomitant orRange of eye movements examined to find out, whether concomitant or paralytic squint is present. Examination performed in nine gaze positions.paralytic squint is present. Examination performed in nine gaze positions.
  25. 25. Motility testsMotility tests Tests versions and ductionsTests versions and ductions Grades under/overactionGrades under/overaction Left inferior oblique overaction Left lateral rectus underaction
  26. 26. Measurement of DeviationMeasurement of Deviation  Hirschberg corneal reflex testHirschberg corneal reflex test  Krimsky’s testKrimsky’s test  Cover uncover testCover uncover test  Alternate cover testAlternate cover test  Prism bar cover testPrism bar cover test  Maddox rod testMaddox rod test  Maddox wing testMaddox wing test
  27. 27. Hirschberg’s testHirschberg’s test Amount of deviation: note location of corneal light reflexAmount of deviation: note location of corneal light reflex 1 mm = 71 mm = 7°° or 15or 15ΔΔ Reflex at border of pupil = 15°° Reflex at limbus = 45°°
  28. 28. Hirschberg’s TestHirschberg’s Test  Used as an initial screen forUsed as an initial screen for strabismus.strabismus.  Reflection of the lightReflection of the light projected straight ahead andprojected straight ahead and near (0.5 m) on the bothnear (0.5 m) on the both corneas is observed.corneas is observed.  Angle kappa has to be keptAngle kappa has to be kept in mind.in mind. 00ºº 1515ºº 4545ºº 2828ºº
  29. 29. Krimsky TestKrimsky Test This test is used to centralize the corneal reflection in squinting eye as compared to the reflex in fixing eye. • Results are expressed in prism diopter (PD). • Convenient test for quick evaluation of the angle of strabismus, especially in the abnormal fixation of the squint eye and ambylopia.
  30. 30. Bruckner TestBruckner Test  Performed by usingPerformed by using direct ophthalmoscopedirect ophthalmoscope to obtain a red reflexto obtain a red reflex simultaneously in bothsimultaneously in both eyes.eyes.  Deviated eye will have aDeviated eye will have a lighter and brighterlighter and brighter reflex than the fixingreflex than the fixing eye.eye.
  31. 31. Prism Cover TestPrism Cover Test  MeasuresMeasures squint/misalignmentsquint/misalignment  Single prism/prism barSingle prism/prism bar  Primary position or in allPrimary position or in all positions of gazepositions of gaze  Denotes amount ofDenotes amount of deviation in PD.deviation in PD.
  32. 32. •Cover test detects heterotropia. •Uncover test detects heterophoria. •Alternate cover test detects total deviation. •Prism cover test measures total deviation
  33. 33. Dissimilar image testsDissimilar image tests Maddox wing Maddox rod •Dissociates eyes for near fixation (1/3 m) •Measures heterophoria •White spot converted into red streak •Cannot differentiate tropia from phoria
  34. 34. Double Maddox Rod TestDouble Maddox Rod Test  Torsional deviations can be measured withTorsional deviations can be measured with double maddox rod test.double maddox rod test.  The Maddox rods placed parallel in both eyes;The Maddox rods placed parallel in both eyes; better if of different colours.better if of different colours.  pt. asked whether the two lines align exactlypt. asked whether the two lines align exactly with each other.with each other.
  35. 35. Measurements of ocularMeasurements of ocular misalignmentmisalignment Synoptophore:Synoptophore:  Measures angle ofMeasures angle of deviation.deviation.  Assesses retinalAssesses retinal correspondence.correspondence.  Checks for & measuresChecks for & measures Fusion.Fusion.  Checks for & measuresChecks for & measures Stereopsis.Stereopsis.
  36. 36. SENSORY EVALUATIONSENSORY EVALUATION  Normal binocular vision comprises of simultaneousNormal binocular vision comprises of simultaneous perception, normal fusion amplitude, and stereoscopy.perception, normal fusion amplitude, and stereoscopy.  In the strabismus particular mechanisms are disturbed,In the strabismus particular mechanisms are disturbed, changing retinal correspondence and frequentlychanging retinal correspondence and frequently producing suppression of various degree.producing suppression of various degree.
  37. 37. Synoptophore:Synoptophore:  Examination of the simultaneousExamination of the simultaneous perception means determination ofperception means determination of the angle of strabismus and retinalthe angle of strabismus and retinal correspondence assessment.correspondence assessment.  Fusion amplitude evaluated with theFusion amplitude evaluated with the use of nearly the same pictures,use of nearly the same pictures, differing in only small details.differing in only small details.  Stereoscopy examined with the use ofStereoscopy examined with the use of slightly decentred special pictures.slightly decentred special pictures. They are, therefore, projected on theThey are, therefore, projected on the dispart retinal point, but withindispart retinal point, but within Panum’s area, giving the impression ofPanum’s area, giving the impression of depth and stereoscopy.depth and stereoscopy.
  38. 38. Tests for sensory anomalies Bagolini striated glasses a - Normal or ARC b- Diplopia c - Suppression d - Small suppression scotoma
  39. 39. Tests for sensory anomalies Worth four-dot test a - Prior to use of glasses b - Normal c - Left suppression/ amblyopia d - Right suppression/ amblyopia e - Diplopia
  40. 40. 4 Prism Test4 Prism Test  A 4 diopter prism placed in front of one eye andA 4 diopter prism placed in front of one eye and the recovery is noted.the recovery is noted.  Strength of prism moves image a little bit inStrength of prism moves image a little bit in foveal area, leading to recovery movement of thefoveal area, leading to recovery movement of the other eye.other eye.  Test done to rule out scotoma.Test done to rule out scotoma.  Prism can be used BI, BO, BU or BD.Prism can be used BI, BO, BU or BD.
  41. 41. STEREOPSISSTEREOPSIS
  42. 42.  Qualitative tests forQualitative tests for StereopsisStereopsis::  Lang’s 2 pencil testLang’s 2 pencil test  SynoptophoreSynoptophore  Quantitative tests forQuantitative tests for Stereopsis:Stereopsis:  Random Dot testRandom Dot test  Titmus Fly TestTitmus Fly Test  TNO TestTNO Test  Lang’s Stereo TestLang’s Stereo Test
  43. 43. Tests for stereopsis Titmus • Red-green spectacles TNO random dot test • ‘Hidden’ shapes seen • Polaroid spectacles • Figures seen in 3-D Lang • No spectacles Frisby • ‘Hidden’ circle seen • No spectacles • Shapes seen
  44. 44. Titmus Fly Test:Titmus Fly Test:  A stereo-test.A stereo-test.  Measures stereoacuity from 3000Measures stereoacuity from 3000 secs of arc to 4o secs of arc.secs of arc to 4o secs of arc.  Fly test is for gross stereoacuity.Fly test is for gross stereoacuity.  Circle patterns consist of 4 circles;Circle patterns consist of 4 circles; one with graded disparity and canone with graded disparity and can only be seen binocularly. (800 –only be seen binocularly. (800 – 40 secs of arc).40 secs of arc).  Animal patterns denote 400 – 100Animal patterns denote 400 – 100 secs of arc.secs of arc.

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