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Fall17-OcularMotility > Block 2 > Flashcards

Block 2 Flashcards

1
Q

What is the purpose of external observations?

A

Identify gross abnormalities of the eye and adnexa

Eye alignment, facial features, head position, posture, gait, carriage

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2
Q

What is pseudoesotropia?

A

Excess epicanthal folds make it look like the person is bilateral esotropic

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3
Q

How do we record cover test?

A 
Correction
Magnitude
Eye 
Phoria or tropia
Constant or Intermittent 
Distance or near
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4
Q

How do we record EOMs?

A

Full and smooth

  • pain
  • diplopia
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5
Q

How do we do Hirschberg?

A

Penlight 50-100cm

Corneal reflex monocularly

Corneal reflex binocularly

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6
Q

What is angle lambda with exo position?

A

Positive

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7
Q

What is angle lambda with eso position?

A

Negative

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8
Q

How do we do Krimsky?

A

After hirschberg, place prism over FIXATING eye until corneal reflex is normal in the deviating eye

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9
Q

Which prism do we use for eso?

A

Base out

BORE

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10
Q

What prism do we use for exo?

A

Base in

BIRX

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11
Q

In Krimsky, how much of a prism diopter deviation is 1mm?

A

22 prism diopters

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12
Q

What is Bruckner test?

A

To evaluate the symmetry of binocular fixation

Strabismus, anisometropia, media opacities, posterior pole anomalies, presence of refractive error, good for infants and young children

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13
Q

How do we do Bruckner?

A

No correction

Ophthalmoscope light 80-100cm from patient

Illuminate both pupils - compare red reflex

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14
Q

What does it mean in Bruckner if both reflexes are equally bright?

A

Binocular vision

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15
Q

What does Bruckner mean is one eye has a darker red reflex and the other has a brighter, lighter reflex?

A

Strabismus

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16
Q

What does a media opacity look like?

A

Dimmer eye itch a shadow maybe spot

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17
Q

What does a retinoblastoma look like?

A

Brighter eye

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18
Q

What does it mean if there is a crescent toward the top on Bruckner?

A

Hyperopia

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19
Q

What does it mean if there is a crescent toward the bottom of Bruckner?

A

Myopia

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20
Q

What do we write if there is a normal Bruckner test?

A

Bright equal reflexes

Anything else: OD brighter than OS
Hyperopia OD > OS

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21
Q

Conjugate movements in the vertical meridians where retinas are rotated in the same direction and by the same amount?

A

Cycloversion

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22
Q

This is disconjugate movement in the vertical meridian of the retina and are rotated in the opposite directions to maintain a single image?

A

Cyclovergence

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23
Q

Tendency of the vertical meridians of the retinas to deviate from the straight ahead position in binocular vision which manifests in the absence of fusion

A

Cyclophoria

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24
Q

What is the purpose of double Maddox rod?

A

Detect a Torsional misalignment

Measures cyclodeviation but does not differentiate between a phoria vs. a tropia

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25
Q

How do you do double Maddox rod?

A

Trial frame with Maddox rod lenses

Red over right eye - lines vertically - patient will see horizontal lines

Rotate orientation of Maddox rod until 2 lines are parallel

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26
Q

How do we interpret Maddox rod?

A

The line is perceived to be tilted in the direction in which the underacting muscle would rotate the eye

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27
Q

Which muscle would be weak in extorsion?

A

Superior oblique

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28
Q

Which muscle would be weak in intorsion?

A

Inferior oblique

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29
Q

This is a machine used to assess objective and subjective angle of deviation

A

Amblyoscope

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30
Q

What is Parks 3 Step for?

A

Identify the muscle responsible for vertical deviation

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31
Q

How do we do Parks 3 step?

A

Identify which eye is hyper in primary gaze

Identify whether the vertical deviation increases on right or left gaze

Identify if vertical deviation increases on right or left head tilt

You circle the UNDERACTING muscles that are affected

The paretic muscle is circled 3 times

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32
Q

What is the bielschowsky test?

A

With parks 3 step

+ sign = increase in hyperdeviation on head tilt of one side vs. the other - incomitant deviation, superior oblique paretic muscle

  • sign = comitant deviation or incomitant devation without superior oblique involved
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33
Q

What is the forced duction test?

A

When restricted movement is found - we need to determine what is causing it

Topical anesthesia
Patient fixates to side of limited gaze
Use forceps or cotton swap to push conj. In opposite direction
Move eye in opposite direction

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34
Q

What if you get resistance in forced duction test?

A

Mechanical restriction of muscle - positive sign

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35
Q

What if the eye moves when you do forced duction test?

A

A paretic muscle, the innervation isn’t quite right - palsy

  • sign
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36
Q

What is the Hess-Lancaster test for?

A

Evaluate the alignment of the eyes and their movements both individually and in tandem

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37
Q

How do we do Hess-Lancaster test?

A

Low light at 1 m
Patient wears red/green glasses - right over red

Examiner has red light, so right eye fixating - testing left eye

Ask patient to superimpose light on yours

Swap lights to test other eye

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38
Q

How do you interpret Hess-Lancaster?

A

Position of deviation

Size - which has the smaller field - this is the affected eye
Displacement of field - interiorly is the underaction - affected muscle
Differing size fields - recent
Similar size fields - long standing condition
Comitancy - deviation is same in all positions of gaze

Shape - sloping fields - A vs. V pattern

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39
Q

In Hess Lancaster, what is the difference between a mechanical restriction vs. a palsy?

A

Palsy will have an overaction in ipsilateral antagonist

Mechanical restriction will not

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40
Q

What is the NSUCO oculomotor test?

A

Assesses pursuits and saccades

Use 2 fixation targets - look back and forth 5 cycles

Use 1 target and draw a circle - 2 times each way

Evaulate body, head, and eye movement on a scale 1-5

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41
Q

What is developmental eye movement (DEM) test?

A

Visual-verbal ocular motor assessment

Also checks on vision therapy progress

Habitual near lenses, normal room light, Harmon distance (elbow to middle finger)

Patient calls off a series of numbers as quickly as possible with NO finger pointing
Compare response times to table of expected values

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42
Q

What is the DEM pretest?

A

Ensure the child knows their numbers

Must complete within 12 seconds

Do not administer DEM is child fails pre-test

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43
Q

What is DEM tests A and B?

A

Testing vertical saccades
40 numbers

Record the time it took to complete

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44
Q

What is DEM test C?

A

Testing horizontal saccades

80 single digit numbers

Record time

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45
Q

What are things to watch out for in DEM test?

A

Subsititutions (cross out with slash) - its okay if they correct it right away, don’t slash it

Transposition (place arrow where number got read out of sequence)

Omission - circle if omitted

Addition - plus sign where extra number was added

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46
Q

What is the DEM ratio?

A

Horizontal time / vertical time

Time x 80 / (80 - o + a)

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47
Q

What is a type 1 DEM test?

A

Average/normal performance

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48
Q

What is a type 2 DEM test?

A

High horizontal time
Normal vertical time

Oculomotor dysfunction

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49
Q

What is a type 3 DEM test?

A

High horizontal
High vertical
Normal ratio

Difficulty with automaticity of number naming

50
Q

What is a type 4 DEM test?

A

Abnormal horizontal time
Abnormal vertical time
Abnormal ratio

Deficiency in oculomotor skills AND in automaticity (combo of 2 &3)

51
Q

What is the King-devick test?

A

Similar to DEM, visualverbal motor skills assessment

52
Q

How do you perform King-Devick?

A

Show demonstration card, give test card 1 - if takes longer than 50 seconds stop here. If not, show test card 2, if total time from 1+2 is longer than 100 seconds, stop here. If not go on to card 3. Add up total time and total mistakes.

If patient is less than 10 y/o and unable to do test 3, stop and sum just 1 and 2 with errors.

Compare results to chart of norms

53
Q

What are Groffman tracings?

A

Tests oculomotor assessment for detecting reading diabilities

Hand card to patient and trace squiggles with eyes only NO fingers

54
Q

How do you score Groffman tracings?

A

The time it takes to complete then compare to table of norms

Wrong number reached or used fingers = 0 points

If there is excessive head movement, body squirming, and facial grimaces - oculomotor-motor coordination problem

55
Q

What is the most sign of having a neuromuscular abnormality?

A

Tropia or phoria

56
Q

What are things that can disrupt fusion?

A

Alternating cover test
Fatigue
Illness
Stress

57
Q

What is a non comitant tropia?

A

It is seen in one gaze but not any other gaze

58
Q

What should you do when measuring and prescribing prism?

A

Always verify your findings by going over and under to check

Always verify ortho by using BI and BO!!

59
Q

How do you split a vertical prism?

A

If you have a 8 BU OD with nothing OS, you should Rx: 4 BU and 4 BD

60
Q

How do you split vertical prisms?

A

Rx BU and BD to correct it

61
Q

How do you split horizontal prisms?

A

Rx both in the same direction! (Both BO or Both BI)

Otherwise it won’t do anything

62
Q

What is torticollis?

A

Abnormal head posture - turn, tilt, chin up or chin down

Could have many causes

63
Q

What are some causes for ocular torticollis?

A

Nystagmus - trying to turn or tilt head to get nystagmus to zero - better VA
Paretic strabismus (palsy)
Restrictive strabismus (mechanical issue)
Monocular blindness
Ptosis
Refractive error
Visual field defect

64
Q

This is when the deviation size remains the same (or within 5pd) in all positions of gaze

No muscles are underacting or overacting

A

Comitant

65
Q

This is when the deviation size is different in different positions of gaze due to an over action or underaction of one or multiple muscles

A

Non-comitant

Tested with Cover test in all positions of gaze

Can be due to innervation problems (paralytic) or mechanical restrictions

66
Q

Vergences can play a role in neuromuscular anomalies. What does convergence insuffienciency or excess and divergence insufficiency or excess create?

A

Conver. Insufficiency - exo at near
Conver. Excess - eso at near
Diverg. Insufficiency - eso distance
Diverg. Excess - exo distance

67
Q

Why don’t you want much eso anywhere?

A

It probably indicates they are over accommodating

68
Q

This is when the action of muscle is completely eliminated?

A

Paralysis

69
Q

This is when action of muscle is impaired?

A

Paresis

70
Q

This is a general term for paralysis or paresis?

A

Palsy

71
Q

What is some etiology (where did it come from) of neuromuscular deviations?

A

Fusion disrupted by sensory impairment
Mechanical restrictions
Uncorrected refractive error in hyperopia
Tropia if fusion can’t overcome abnormalities
Brainstem issues
Innervation anomalies
Neurological defects - birth injuries, cerebral palsy, developmental/special needs
VOR abnormalies
Assault in gestation - cigarette smoking (higher prevalence of strabismus), alchohol consumption, genetics

72
Q

What are some symptoms of poor fusion?

A

Fatigue, asthenopia (eye strain), headaches, avoidance, diplopia, suppression

73
Q

______ deviations are likely to cause symptoms because their fusional amplitudes are naturally limited?

A

Vertical deviations

74
Q

Why would a patient not have symptoms with a small phoria?

A

Because the sensorimotor system is able to cope with the deviation

75
Q

What is infancy ocular instability (Split)?

A

Normal in babies 2-3 mos.

Resolves by 4 mos.

Only a problem if it persists, is constant or large

76
Q

This is a latent esodevaitiotn controlled by fusional vergences so that eyes are aligned during fusion?

A

Esophoria

77
Q

This is a manifest deviation not properly controlled by fusional vergences

A

Esotropia

78
Q

Appearance of esotropia when eyes are actually aligned

Need to pinch nose bridge

Appearance improves with age

A

Pseudoesotropia

79
Q

This esotropia is onset between birth and 6 mos.

Large constant esotropia

Many have cross fixation

Use Doll’s head maneuver to see if eye abduct

A

Infantile (congenital) esotropia

80
Q

What percentage of all esotropes are infantile esotropia?

A

30-50%

81
Q

What are some forms of management for infantile esotropia?

A

Full cyclopegic refraction - want to rule out any hyperopia
Surgery allows some degree of fusion after surgery
Bifocals, prism, occlusion, VT, Botox

82
Q

Type of esotropia where the deviation is associated with the accommodative reflex

Onset is 6 mos to 7 yrs (avg: 2.5 yrs)

Starts intermittently then becomes constant - hereditary or trauma

A

Accommodative esotropia

83
Q

What type of accommodative esotropia is due to high hyperopia?

A

Refractive accommmodative ET

84
Q

What type of accommodative ET is due to high AC/A?

A

Non-refractive accommodative ET

85
Q

What type of accommodative ET is due to high hyperopia and high AC/A?

A

Mixed accommodative ET

86
Q

What percent of all esotropes have an accommodative component?

A

50%

87
Q

What is the deviation like in refractive accommodative ET?

A

Similar deviation at distance and near

88
Q

What is the range of hyperopia that can cause this?

A

+2.5 - +6.00

Avg: +4.00

If the hyperopia is over 6D, isometropic amblyopia develops b/c the patient has too much blur and will quit trying to accommodate

89
Q

What is the management for refractive accomodative esotropia?

A

Comprehensive evaluation
Cycloplegic refraction - to get hyperopia out
*give full hyperopic correction ASAP b/c time is key to recovery
Start amblyopia treatment if VA doesn’t fully improve with Rx

90
Q

This accommodative esotropia is due to high AC/A ratio. The increase in accommodation at near drives convergence but there isn’t enough vergence to diverge

A

Non refractive accommodative esotropia

ET is greater at near

91
Q

What is the AC/A ratio and how do you find it?

A

Amount of convergence induced by a change in accommodation

AC/A = tropia/phoria change / change in accommodation

*abnormal AC/A ratios are seen in binocular problems

92
Q

What is the management for non refractive accommodative esotropia?

A

Treat underlying refractive error
Give bifocals to reduce accommodation
Seg height must bisect the pupil - forces the kid to use it

Surgery is contraindicated

93
Q

This type of accommodative esotropia has high hyperopia and high AC/A ratio?

A

Mixed accommodative esotropia

94
Q

What is the management plan for mixed accommodative ET?

A

Full hyperopic correction
Bifocal (based on AC/A)

Surgery is not recommended unless the kid didn’t start glasses in time and it is a big angle

95
Q

This type of accommodative ET is when the accommodation contributes to but does not account for the entire deviation

After treatment, there is a reduction but then still residual ET.

Constant, unilateral
Suppression and anomalous retinal correspondence are common

A

Partially accommodative ET

96
Q

This is a type of NON accommodative esotropia - onset is after 6mos to 2yrs

Similar to infantile ET, NO accommodative component, insignificant amt of hyperopia

A

Early onset Non accommodative esotropia

97
Q

What is the management for early onset non accommodative esotropia?

A

Correct refractive error, consider prisms or bifocals

Amblyopia treatment
VT
Surgery

Consider neuro! If child was healthy now suddenly ET

98
Q

This type of ET needs a neuro eval ASAP!

Comitant (all gazes)
Sudden onset 3-5 y/o (or older)
Unilateral and constant angle
Could be a result of illness, stress, aging

A

Acute acquired ET

Manage:
Correction
Prism
Surgery - since probably had binocular vision before ET
Amblyopia treatment
99
Q

Type of ET that develops due to vision loss in one eye

Pathology prevents clear, focused image on retina or symmetrical visual stimulation OU

A

Sensory ET

Caused by: congenital cataract, corneal scarring, optic atrophy, prolonged blue, anisometropia amblyopia, ptosis

100
Q

Management for sensory esotropia?

A

Need to eliminate pathology

Polycarbonate lens for full time wear

Surgery for any residual deviation and/or cosmesis

101
Q

This type of esotropia is due to non accommodative esodeviation greater at distance

Comitant, onset in adults, decreased fusion at distance, diplopia at distance, HA

A

Divergence insufficiency ET

102
Q

Management for divergence insufficiency ET?

A

NEURO REFERRAL!!!***

Usually due to head trauma or increase intracranial pressure

Correct refractive error
BO prism fro diplopia at distance
VT
Botox

No surgery

103
Q

This type of ET is when you go eso after and exo strabismus surgery

Amblyopia could develop, unilateral or alternating

Could spontaneously improve

Treat refractive error, try BO prisms or plus lenses

Repeat surgery for large deviations

A

Consecutive esotropia

104
Q

Type of esotropia that is very very tiny

A

Microtropia

105
Q

Type of esotropia where fusional vergences are no longer able to maintain esophoria

A

Decompensating esotropia

106
Q

This is when there is proper alignment, but a positive angle kappa and wide interpupillary distance that gives the appearance of exodeviation

A

Pseudoexotropia

107
Q

Type of intermittent exotropia in childhood

XT is larger at distance and seen prominently when target is at a distance

A

Divergence excess

108
Q

Type of intermittent XT in adults where XT is the same at distance and near

A

Basic XT

109
Q

Type of intermittent XT in adults where XT is larger at near

A

Convergence insufficiency

110
Q

Bright light may cause reflex closure of one eye due to?

A

Intermittent exotropia

111
Q

This is the most common type of XT, onset is before 5yrs. Manifests during visual inattention, fatigue, or stress

A

Intermittent exotropia

112
Q

Type of IXT control that only manifests on Ct and then resumes fusion rapidly

A

Good control

113
Q

Type of control of IXT on when XT on cover test, fusion is regained after blinking or refixating

A

Fair control

114
Q

IXT manifests spontaneously and for an extended period of time

A

Poor control

115
Q

What is some management for intermittent XT?

A

Correct - mild myopia to make better, mild hyperopia will make worse

Patching, VT, prisms, surgery, Botox

116
Q

This XT is when the XT is greater at near than at distance, usually intermittent at near
Low AC/A, receded NPC

Asthenopia, diplopia, blurred vision at near

A

Convergence insufficiency exotropia

VT is very successful, or BI reading glasses

117
Q

This type of XT is seen in older patients with sensory XT or patients with longstanding XT that has decompensated.

Some experience enlarged Visual fields

Ex. Infantile XT and sensory XT

A

Constant exotropia

118
Q

This is a type of constant XT where it is present 0-6mos of age, child is likely to have neuro issues or craniofacial disorders

A

Infantile exotropia

Poor adduction, surgery is performed in order to promote some form of sensory cooperation

119
Q

This type of XT is caused by vision loss in one eye that leads to the other eye drifting out

A

Sensory XT

Poor VA, poor cosmesis, constant and unilateral, large angle

120
Q

When can you do surgery on sensory XT?

A

If VA can be improved, surgery can be useful for better alignment

If VA is not correctable, then misalignment could occur again after surgery

121
Q

This is common post surgery - could occur month or year after surgery

Before another surgery, we need to consider type an amount of previous surgery, any duction limitation/scarring or non comitancy

A

Consecutive XT

Fall17-OcularMotility (4 decks)

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