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Binocular vision patient....what should I do?

Step by step to encounter BV patient

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Binocular vision patient....what should I do?

  1. 1. WHAT SHOULD I DO?? Prepared by Anis Suzanna Binti Mohamad Optometrist Ophthalmology Department, Hospital Sultanah Bahiyah
  2. 2.  SOP
  3. 3.  Hirschberg  Cover test (CT)  Ocular motility test (OMT)  Prism Cover test/ Krimsky test  Amplitude of accommodation (AA)  Near point convergence (NPC)
  4. 4.  Purpose:  To determine the approximate positions of the visual axes of the two eyes under binocular conditions  Used to identify a strabismus when other more precise methods cannot be used.
  5. 5.  Penlight
  6. 6. 1) Direct the penlight toward the patient’s eye from a distance of 50 to 100 cm. 2) Instruct patient to look at the light. 3) Place your eye directly behind the penlight and observe the location of the corneal light reflexes in each of the patient’s eyes. 4) Compare the locations of the eyes’ corneal reflexes: 1) If the two reflexes are in the SAME relative positions in each of the two eyes-pt does not have strabismus. 2) If the two reflexes are NOT in the same relative positions in the two eyes, the patient has a strabismus. Determine the direction of the deviation by observing the position of the two reflexes relative to the position of angle kappa in the fixating eye.
  7. 7. Position of the corneal reflex relative to the position of angle Kappa in the fixating eye Type of deviation Nasal Exo Temporal Eso Above Hypo Below Hyper RECORDING  If there is no strabismus, record “Symmetry” or “Orthophoria “.  If there is a strabismus, record the eye that is deviated, the size of the deviation, and the direction of the deviation.  Eg: RE corneal reflection displaced 15°/30°/45° temporally
  8. 8.  Purposes:  Objective test used to detect a squint  All diagnosis of squint is based on the results of the cover test
  9. 9.  Fixation targets  33cm – spotlight, detailed target, small picture or a Snellens letter  6m – spotlight, small toy or picture or Snellens letter  >20m – easily seen landmark at eye level  Occluder  Black paddle  Spielman  Card
  10. 10.  One eye is covered  Watch the movement of the uncovered eye to take up fixation  If no movement of the eye is noted cover the other eye and watch the uncovered eye.  If no movement has been seen repeat the test but this time watch the movement of the covered eye when the occluder is removed.
  11. 11. MANIFEST - OBVIOUS SQUINT  Look for movement of the uncovered eye  Cover the straight eye  Cover the eye with the best visual acuity or the lowest refractive error LATENT – HIDDEN SQUINT  Movement of the covered eye
  12. 12. RE moderate esotropia LE moderate exotropia 1. With or without glasses 2. Distance (at 6m/at 33cm) 3. Rate of recovery for phoria 4. Note if diplopia is present upon remoal of cover (if present indicates poor recovery or control) 5. Note laterality of deviation (RE, LE or alternating) 6. Constancy of the deviation (contant/intermittent) 7. Note characteristic of deviaion whether there is any change from phoria to tropia
  13. 13.  A.k.a extraocular motilities (EOM) test  Equipment  Penlight
  14. 14. 1. Patient head must be straight and ask to remove spectacles. 2. Ask patient to follow the light with their eyes without moving their head.Ask pt to report any diplopia or pain during the test. 3. Place the torch at pt’s eye level ~50cm away. 4. Note the corneal reflex. 5. Move the target to the 9 position of gaze (Broad H or Union jack) pattern can be used. 6. Carefully look for any misalignment of the eyes as well as lid position. 7. Determine whether the movement of the eyes is smooth (pursuit) and accurate. 8. Perform cover test at all position of gaze (if necessary). 9. Duction test must be performed if underaction of any muscle is observed.
  15. 15.  Underaction (u/a)  Overaction (o/a)  Jerky movement or nystagmus at any position  Pain or diplopia
  16. 16. 1. Limitation on ADDUCTION of LE 2. Downshoot of LE
  17. 17.  Hirschberg  Cover test  EOM

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