binocular vision patient....what should i do?

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OMG….BV patient WHAT SHOULD I DO?? Prepared by Anis Suzanna Binti Mohamad Optometrist Ophthalmology Department, Hospital Sultanah Bahiyah

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Page 1: Binocular vision patient....what should I do?

OMG….BV patientWHAT SHOULD I DO??

Prepared by Anis Suzanna Binti Mohamad Optometrist Ophthalmology Department, Hospital Sultanah Bahiyah

Page 2: Binocular vision patient....what should I do?

IF I AM OPTOMETRIST….

SOP

Page 3: Binocular vision patient....what should I do?

BASIC TEST

Hirschberg Cover test (CT) Ocular motility test (OMT) Prism Cover test/ Krimsky test Amplitude of accommodation (AA) Near point convergence (NPC)

Page 4: Binocular vision patient....what should I do?

1) HIRSCHBERG

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.

Page 5: Binocular vision patient....what should I do?

EQUIPMENT

Penlight

Page 6: Binocular vision patient....what should I do?

STEP-BY-STEP PROCEDURE

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.

Page 7: Binocular vision patient....what should I do?

Relationship between the position of the corneal reflex and the type of the deviation on

the Hirschberg test

Position of the corneal reflex relative to the position of

angle Kappa in the fixating eye

Type of deviation

Nasal Exo Temporal Eso

Above HypoBelow 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

Page 8: Binocular vision patient....what should I do?

EXAMPLES

Page 9: Binocular vision patient....what should I do?

2) COVER TEST

Purposes: Objective test used to detect a

squint All diagnosis of squint is based on

the results of the cover test

Page 10: Binocular vision patient....what should I do?

EQUIPMENT

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

Page 11: Binocular vision patient....what should I do?

STEP-BY-STEP PROCEDURE 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.

Page 12: Binocular vision patient....what should I do?

EXAMPLE

Page 13: Binocular vision patient....what should I do?

Types of squint 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

Page 14: Binocular vision patient....what should I do?

RECORDING

RE moderate esotropia

LE moderate exotropia

1. With or without glasses2. 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

Page 15: Binocular vision patient....what should I do?

3) OCULAR MOTILITY TEST A.k.a extraocular motilities (EOM)

test

Equipment Penlight

Page 16: Binocular vision patient....what should I do?

STEP-BY-STEP PROCEDURE

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.

Page 17: Binocular vision patient....what should I do?

9 position of gaze

Page 18: Binocular vision patient....what should I do?

RECORDING

Underaction (u/a) Overaction (o/a) Jerky movement or nystagmus at

any position Pain or diplopia

Page 19: Binocular vision patient....what should I do?

Abnormalities of EOM using numerical grade

Page 20: Binocular vision patient....what should I do?

EXAMPLE

1. Limitation on ADDUCTION of LE

2. Downshoot of LE

Page 21: Binocular vision patient....what should I do?

BV assessment sheet

Page 22: Binocular vision patient....what should I do?

BV assessment sheet

Page 23: Binocular vision patient....what should I do?

HANDS ON

Hirschberg Cover test EOM

Page 24: Binocular vision patient....what should I do?

THANK YOU, HAVE A NICE DAY