Basics of Strabismus testing

Laura May, CO
Madison Kincade

http://www.allaboutvision.com/conditions/strabismus.htm

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 Strabismus
• Strabismus is any misalignment of the eyes
• Estimated that 4% of the U.S. population has
strabismus
• Commonly described by the direction of
deviation
• Can be described by cause of strabismus

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 Types of Strabismus
• Esotropia = ET
– E(T), E
• Exotropia = XT
– X(T), X
• Hypertropia = HT
– H(T), H
• Dissociated Vertical Deviation = DVD
• Measurements at near use ‘ symbol
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 Testing Techniques

http://www.guldenophthalmics.com/products/index.php/occluder-short-handle-black.html

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 Cover tests
• Cover-uncover test
• Alternate prism cover test
• Simultaneous prism cover test
• Patch test (Marlowe)

https://ohioamblyoperegistry.com/about/

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 Cover Test

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 Uncover Test

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 Alternate Prism Cover Test

25 PD

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 Alternate Prism Cover Test

30 PD

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 Simultaneous Prism Cover Test

6 PD

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 Simultaneous Prism Cover Test

10 PD

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 Estimation Techniques
• Hirschberg
• Krimsky

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 Angle Kappa
• The angle between the visual axis and the
pupillary axis

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 Motor fusion
• Types and normal ranges
– Convergence
• Near: 35-40 pd
• Distance: 20-25 pd
– Divergence
• Near: 15pd
• Distance: 7pd
– Vertical vergence
• 2-3 pd (base up/down)
– Cyclovergence
• 1-2 degrees http://www.guldenophthalmics.com/products/index.php/prisms/bv-15-b-16-set.html

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 Vergences
Simultaneous control of eyes in opposite direction
Convergence
1. Tonic – constant innervation tone to the EOM while awake
2. Accommodative – near reflex, near triad
3. Fusional – stimulus to maintain clear, single image
4. Relative – amount of BO prism person can handle
5. Proximal – controlled by awareness of near
6. Voluntary – ability of eyes to converge without stimulus
Divergence
1. Tonic
2. Fusional
3. Relative
Vertical
1. Tonic
2. Fusional

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 NPC/NPA
• Near point of convergence (NPC)
– Accommodative target moved towards patient’s
nose, break point recorded when patient becomes
XT
– 10cm or less = normal
• Near point of Accommodation
– Prince rule used to measure
– Tested monocular and binocularly
http://www.west-op.com/berensaccommod.html

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 Binocular Vision
• Worth 4 dot
– SBV
– Suppression
– Diplopia
• Titmus Fly
– Stereo
– Monocular clues

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 Bagolini Striated Lenses
• Bagolini lenses test for:
– Diplopia (ET/XT)
– Fusion or Harmonious ARC
– Suppression Scotoma
– Suppression

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 Detection and measure cyclotropia
• Double maddox rods
• Synoptophore
• Bagolini lens
• Fundus photography

http://www.ophthalworld.de/lshop,showdetail,2004g,en,,vorhalter_und_leisten.neue_vorhalter_und_leisten,01130,8,Tshowrub--
vorhalter_und_leisten.neue_vorhalter_und_leisten,.htm

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 Diplopia
• Testing in clinic
• Monocular vs. Binocular
• Treatments
– Fresnel prism/ground in prism
– Fogging/occlusion

http://www.medicalnewstoday.com/articles/170634.php

http://www.eyecareandcure.com/ECC-Products/Occluders-Maddox-Rods

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 AC/A ratio
• Gradient
• Heterophoria

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 Prism adaptation test
• Uses
– Determine position of motor stability with
acquired ET
– Determine fusion potential
– Determine risk of surgical over-correction

http://www.eyecareandcure.com.sg/fresnel-presson-prism35d-pi-4243.html?image=0

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 Extraocular Muscles

http://marineyes.com/anatomy/muscles.html

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 Extraocular Muscles
• Agonist: primary muscle that is moving eye
• Antagonist: opposite muscle that is relaxing in
the same eye
• Synergist: muscle helping the eye move along
with the agonist
– Ispilateral synergist: same eye
– Contralateral synergist: opposite eye – Yoke pair
• Contralateral Antagonist: opposite eye that
antagonist of the yoke pair in that eye
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 Extraocular Muscles
• Herring’s Law: innervation to the EOM
generated by yoke pairs/contralateral
synergist.
• Sherrington’s Law: reciprocal innervation.
• Listing’s Law: no torsion occurs
• Donder’s law: torsion is produced

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 Yoke Muscles

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 Extraocular Muscles
Muscle Primary Action Secondary Cranial Nerve
Action Innervation
Lateral Rectus Abduction None 6th CN
Medial Rectus Adduction None 3rd CN
Superior Rectus Elevation Adduction, 3rd CN
intorsion
Inferior Rectus Depression Adduction, 3rd CN
extorsion
Superior Oblique Intorsion Depression, 4th CN
abduction
Inferior Oblique Extorsion Elevation, 3rd CN
abduction

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 Cranial Nerve Palsies
Common causes of CN palsies
Nerve Childhood Adult life > 55yr
3rd Trauma Intracranial Hypertension
aneurysm and diabetes

4th Trauma Trauma Trauma

6th Idiopathic, MS, Space Hypertension,
isolated benign, occupying diabetes, space
increased ICP, lesion, Trauma occupying
Trauma lesion

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 Ocular rotations
Ductions vs Versions

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 Ductions
Horizontal Ductions Vertical Ductions

Supraduction
Primary

Infraduction
Adduction Cyclo-Ductions

Excycloduction

Abduction

Incycloduction

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 Versions
Dextrosupraversion Supraversion Levosupraversion

Dextroversion Levoversion

Levoinfraversion
Dextroinfraversion
Infraversion

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 Objective measurements
• Distance and near fixation
• Nine diagnostic positions of gaze
• Head tilts
• Three-step test

http://schorlab.berkeley.edu/passpro/oculomotor/assets/images/Fig5-8.gif

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 Pattern Strabismus
• A-pattern
– Increasing ET or decreasing XT in up gaze
– Decreasing ET or increasing XT in down gaze
– A pattern must have 10 pd of incomitance
• V-pattern
– Increasing XT or decreasing ET in up gaze
– Decreasing XT or increasing ET in down gaze
– V pattern must have 15 pd of incomitance

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 “VAVA”
• V-ET – most common
• A-ET – most common in patients with Down
syndrome
• V-XT
• A-XT – least common

http://www.cyber-sight.org/bins/volume_page.asp?cid=735-2858-4397-4403-4604-4619

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 Abnormal Head Postures
Characteristics Ocular Non-ocular
Cover test Abnormal EOM Normal motility
Straighten head - Able to passively Unable to passively
straighten head straighten head
- Longstanding AHP more
difficult
Occlusion When one eye occluded, When one eye occluded no
head will straighten change in AHP
Facial Asymmetry No or slight facial Marked facial asymmetry
asymmetry
Head position Turn and tilt vary Tilt and turn to side of
depending on muscle contracted
affected sternocleidomastoid
muscle

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 Esotropia

http://www.pedseye.com/strabismus_esotropia.htm

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 Esotropia
Infantile Acquired
Congenital Accommodative Esotropia
Nystagmus blockage syndrome Non accommodative Esotropia
Ciancia Syndrome Acute comitant Esotropia
Duane’s Syndrome Cyclic Esotropia
Abducens palsy Sensory Esotropia
Moebius Syndrome Divergence Insufficiency
Divergence Paresis
Spasm of near reflex
Medial rectus restriction
Lateral rectus weakness
Consecutive and secondary Esotropia
Small angle Esotropia
Monofixation Syndrome

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 Esotropia
• Classification
– Age of onset
• Infantile
• Acquired
– Role of accommodation and refraction
• Non-accommodative
• Refractive
• High accommodative convergence to accommodation
ratio
• Partially accommodative

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 Psuedoesotropia
• Prominent epicanthal folds
• Narrow interpupillary distance
• Negative angle kappa
• Enophthalmos
• Craniofacial malformations

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 Congenital Esotropia
• Onset near birth
• Usually large angle > 30PD
• Associated vertical deviations common
• Latent nystagmus
• Cross fixation

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 Accommodative Esotropia
• Onset age 6mo – 7yrs, average 2.5yrs
• Moderate to high hyperopia
• May be only partially accommodative
• May have a high AC/A
• Can be intermittent or variable
• May decompensate

http://webeye.ophth.uiowa.edu/eyeforum/cases/129-accommodative-esotropia.htm

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 Duane’s Syndrome
• Congenital miswiring of LR muscle with the branches from the
medial rectus subnucleus
• 3 clinical types
• PF changes
• Globe retraction

By Jmarchn - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=20423772

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 6th CN Palsy
• Signs and Symptoms
– Limitation in abduction
– Ductions > versions
– D ET > N ET’
– Face turn toward paretic eye
– ET larger in affected gaze
– Can be unilateral or bilateral

http://entokey.com/neuro-ophthalmology-6/

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 Duane’s vs VI palsy
Clinical Characteristics Type 1 Duane's VI Nerve Palsy
Complete absence of Typical Not Always
abduction
Large ET in primary No Yes
Globe retraction in Yes No
adduction
Lid fissure widening on Yes Possible
abduction
Upshoot/downshoot Yes No
Diplopia Rare Yes
Greater ET at distance Rare Common

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 Monofixation Syndrome
• Small manifest ET
• Central scotoma
– 4 BO test
• 4 BO prism held in front of either eye, watch for a shift
and convergence
• Mild amblyopia common
• Reduced stereoacuity

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 Exotropia

http://optometrist.com.au/exotropia/

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 Exotropia
Infantile Acquired
Congenital exotropia Intermittent exotropia
Sensory exotropia Secondary or consecutive exotropia
Convergence insufficiency exotropia
Third nerve palsy
Duane syndrome type 2
Sensory exotropia

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 Exotropia
• Classification
– Age of onset
• Infantile
• Acquired
– Distance-near relationship
• Basic (D=N)
• Divergence excess (D>N)
• Pseudo-divergence excess
• Convergence insufficiency (N>D)

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 Pseduoexotropia
• Positive angle kappa
• Wide interpupillary distance
• Wide palpebral fissures
• Exophalmos
• Narrowing lateral canthi
• Hypertelorism

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 Congenital Exotropia
• Onset by age 6 months
• Associated vertical deviations
• Large angle > 30pd
• Latent nystagmus
• May have associated neurological
abnormalities

https://www.aapos.org/terms/conditions/49

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 X(T)
• Broken down X
• Monocular lid closure
• Wider VF
• No diplopia
• Control
– Good, fair, poor

http://www.omicsgroup.org/journals/peripapillary-staphyloma-in-a-child-with-intermittent-exotropia-2165-7920.1000424.php?aid=33470

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 Convergence insufficiency
• Characteristics
– Reduced convergence amplitudes
– May c/o headaches, asthenopia and eye strain
– May have intermittent diplopia
– May have reduced NPC

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 Convergence insufficiency
• Treatments
– Pencil pushups
– Stereogram
– Computer orthoptics
– Prisms

http://computerorthoptics.com/

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 3rd Cranial Nerve
• 3rd CN
– Superior division innervates
• Superior rectus
• Levator
– Inferior division innervates
• Inferior recuts
• Inferior oblique
• Medial rectus
• Intraocular muscles

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 3rd CN Palsy
• Characteristics
– Ptosis
– Dilation of pupil
– Limitation of adduction, elevation and depression
– Exotropia and hypotropia in primary
– Accommodative weakness
– May present as isolated extraocular muscle palsy

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 Vertical Strabismus

http://www.cehjournal.org/article/understanding-detecting-and-managing-strabismus/

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 Vertical Strabismus
Paretic Muscle Restriction Other
SO palsy Brown syndrome DVD
IO palsy Monocular Elevation Myasthenia Gravis
Deficiency
SR palsy CPEO Skew Deviation
IR palsy Congenital fibrosis PSP

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 4th CN Palsy
• Superior Oblique Palsy
– Hypertropia of affected eye
– AHP is common
– Excylotorison
– Positive Bielschowsky head tilt test
– Can be congenital or aquired
– Unilateral or bilateral

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 4th CN Palsy
Congenital/long standing Acquired
Diplopia Rare Present, but can be limited
to paretic field
Image tilting Absent Common
Comitance Spread may obscure Characteristically
paresis incomitant
Abnormal head posture May persist on covering Disappears on covering eye
eye due to contracture
Facial Asymmetry Common Absent
Past pointing Absent Present
Old photos May show AHP Negative
Amblyopia May be present Absent

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 Unilateral vs Bilateral 4th
• Bilateral SO palsy
– V pattern present
– 10 degrees of excyclotorsion, may increase in
downgaze
– Reversal of HT on side gazes, tilts or oblique fields
– ET maybe associated

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 Bilateral 4th CN Palsy

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 Parks–Bielschowsky three-step test

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 Brown Syndrome

http://www.webhealthwatch.com/eye-disorders/treatment-and-care-of-brown-syndrome.html

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 Brown Syndrome
• Inability to elevate in adduction
– Duction = version
• Hypotropia in primary and/or upgaze
• Divergence on upgaze, V pattern
• Etiology
– Congenital, traumatic, inflammatory, iatrogenic

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 IO palsy
• Inferior division of 3rd CN , look for MR, IR and
pupil involvement
• Test with 3 step test
• Overaction of ipsilateral SO
• AHP – turn to opposite side, tilt to affected
side
• Differential dx = Brown’s syndrome

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 Brown vs IO palsy
Clinical Characteristics Brown Syndrome IO Palsy
Limitation of elevation in Yes Yes
adduction
Overaction of ipsilateral SO No Yes
Versions = Ductions with Yes No
elevation in adduction
Positive forced ductions Yes No
Positive forced generations No Yes
Positive head tilt test No Yes
Pattern V A
Incyclotorsion No Yes

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 DVD
• Up-drift of eye occurring under cover or
spoontaneoulsy during visual inattentiveness
• Associated with:
– early disruption of binocular development
– Latent nystagmus
– Horizontal infantile strabismus
– Poor binocular VA
• No associated HypoT deviation http://www.mattweedmd.com/news/

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 Conclusion
• Types of strabismus
– Horizontal/vertical
– Dissociated deviations
• Testing techniques
– Cover tests
– Special testing
• EOM

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 Questions?

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