Ramin Sahebghalam M.

D
Oculoplastic and Strabismus Fellowship

2011

Cover tests. Corneal light reflex tests. Dissimilar image tests. Dissimilar target tests.

Eye movement capability. Image formation and perception. Foveal fixation in each eye. Attention. Cooperation.

Cover-uncover test, Alternate cover test, Prism and cover test. Prism and coveruncover test, Prism under cover test.

An absence of movement of an eye when the other eye is covered occurring in both eyes, means that the patient does not have a heterotropia It does not differentiate between orthophoria and heterophoria.

The patient's right eye is covered while fixating a series of distant accommodative targets. After 2 to 3seconds, the right eye is uncovered , cover rapidly is moved to the other side and left eye is covered. The patient whose eye moves on alternate cover has either a heterophoria or heterotropia. Differentiation between the two requires the coveruncover test.

A temporal horizontal shift is esophoria or esotropia, A nasal shift is exophoria or exotropia, The movement of the eye downward is hyperphoria or hypertropia . If both eyes make movements downward, it is called dissociated vertical deviation.

Is used to measure the size of DVD, Base down prism is place on the eye, Cover is place in front of prism, Prism power is increased until no movement of the eye can be seen after removing the cover.

Hirschberg, Krimsky and Modified Krimsky, Bruckner, Major amblyoscope.

A light reflected in the deviated eye:

Nearer the pupillary center than the margin: 5, At pupillary margin : 15, Midway between pupillary margin and limbus it is 25, At the limbus it is 45 to 60, and beyond the limbus it is 60 to 80.

Each 1-mm deviation of light reflex represents 7 or 15 of deviation. Brodies rule: 1 mm=21 (using flash photographs
with millimeter rulers included for standardization, Brodie estimated a Hirschberg ratio of 21 prism diopters/mm, this angle correlates highly with that derived from alternate prism and cover testing).

Traditional: center the displaced light reflex by putting appropriate prism over deviated eye. Modified: hold the prism over fixating eye (easier to read).

The Krimsky test is especially useful in: Younger patients, Patients unable to maintain concentration
prolonged prism and alternate cover testing, or both eyes.

for

Patients with diminished central fixation

in one

Dissimilar image tests are based on the

patient's response to diplopia created by 2 dissimilar images. Maddox rod test, Double Maddox rod test, Red glass test.

Are based on the patient's response to the dissimilar images created by each eye viewing a different target; the deviation is measured first with one eye fixating and then with the other. Lancaster red-green projection test, Hess screen test, Major amblyoscope test.

Torsional strabismus occurs when the eye is abnormally rotated about the visual axis. Malfunction of the vertical rectus and oblique muscles is responsible. Evaluation of torsion is mandatory in vertical strabismus, whether or not the patient complains of torsional diplopia.

Evaluation of torsion is not possible with external landmarks. While the actual axis of rotation is close to visual axis, it is easier for most examiners to visualize the fovea moving relative to the optic nerve.

Primary oblique muscle overaction (most common). Secondary oblique muscle overaction ( most common :S.O paralysis). Restrictive processes involving cyclovertical muscles: 1. Thyroid ophthalmopathy 2. Brown syndrome, 3. Blowout fracture 4. Local myotoxicity (retro or peribulbar injections) Orbital displacement (plagiocephaly)

Anatomic (objective) torsion refers to anatomic rotation of eye. Subjective torsion refers to the patients perception of rotation. Comparison of anatomic and subjective torsion can help determine the time of onset of cyclovertical strabismus.

Fundus Photography (most accurate), Blind spot mapping, Indirect Ophthalmoscopy (easiest).

Easily performed Quick Quantitative

Provides a diagrammatic representation of horizontal, vertical and torsional strabismus in 9 diagnostic positions of gaze.

Method: Patient is seated 1 meter from screen with head straight, wearing anaglyphic goggles. Room darkened. Examiner projects the red streak obliquely on the center of scale ( primary position).

Method: The streak is rotated upon patients command to be seen vertical. The patient is asked to place the green streak in the same place as the red streak. The actual location of projected streaks is manually recorded.

Method: Test repeated in 9 diagnostic positions of gaze. Examiner and the patient change flashlights and repeat the test.

Interpretation: The Lancaster red-green test is interpreted as if the two streaks are direct projections from the foveas: Left side of the plot indicates the left gaze and the right , right gaze. If the red streak is rotated clockwise, the right eye is extorted, if the red streak is upper, the right eye is upper. If the red streak is on the right, there is exotropia and vice versa.

Recent onset V pattern ET , right hypertropia and subjective extorsion.

Old V pattern ET & right hypertropia ,no subjective torsion

The examiner can read the amount of subjective deviation directly from the screen. If this degree is equal to formerly measured objective deviation (measured in coveruncover test, then NRC is present. If the two amounts are not equal, ARC is present Superimposition of both targets on zero shows harmonious ARC.

Possible in children who can count to five. If the visual acuity can be determined, so can the Worth 4 dot response. The test is performed with ordinary room illumination to provide the usual peripheral vision clues. Results should be reported as suppression or fusion. Best at detection of suppression.

Distant Worth 4 dot test. Near Worth 4 dot test.

3 macular scotoma : Far W4DT: no fusion @ 6 m fusion begins @ 2.5 m Near W4DT: no fusion @ 2m fusion begins @ 0.66 m

When NRC: In both far and near tests:

ET: Homonymous diplopia (5 dots)

XT:
Heteronymous diplopia (5 dots)

When ARC:

Sees 4 dots Test must be done @ near 5 suppression scotoma in ET (40 cm) >5 suppression scotoma in XT

Forced ductions, Active force generation, Saccadic velocity.

This test places obilque muscles on maximum stretch by simultaneously retroplacing, torting and rotating the globe. Forced duction of rectus muscle are best done by pulling the eye forward to put these muscles on maximum stretch.

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Intraoperative assessment of completeness of an oblique muscle weakening procedure is the most useful application of this test. The test must be done before and after oblique tenotomy and disinsertion. The test can confirm the diagnosis of oblique muscle overaction.

Deciding over tuck or recess in SO paresis. Differentiation of IO paresis and Brown. The test helps differentiate hyperdeviation causes: inferior oblique overaction, DVD, rectus contracture.

Is investigated in adult patients with constant starabismus.( a study on 424 patients by Kushner B.J, Archive of Ophthalmo,vol 120, Nov 2002)

Patient wears appropriate correction. Patent fixes to an accommodative Snellen optotype near to his vision threshold in better eye. Neutralize the deviation by placing prisms over the deviating eye and ask the patient if he sees double. Then remove the first prism and introduce increasing rotary or bar prisms, begin with 0 and overcorrect the deviation by 5 to 10 .

If the patient sees double in any of the former stages, then he/she is asked about type of diplopia: Cross or uncross ? Sharp, or shadowy ghost images? What is the distance between the two images?

Does not see double in any test :no risk. A shadowy ghost image in far periphery :(ARC):very low risk of temporary or constant post- op diplopia. Intense and close together:a little risk. Unable to subjectively localize the second image (lost or confused localization):

9% of all adult patient with constant strabismus undergoing surgery will develop post op diplopia. 0.8% of such patients will develop constant diplopia.

28% of patients with positive pre-op prism test will develop temporary post op diplopia. 2% of such patients will develop permanent post-op diplopia.

Temporary post-op diplopia

Sensitivity Specificity Positive predictive value Negative predictive value 100% 73% 28% 100%

Permanent post-op diplopia

100% 67% 2% 100%