• POOR direct/indirect NFV
• diplopia not blur
• Inc MEM
• USU. HYPEROPES, maximize +
• vert prism
• add lenses moderately affective
• **HORIZONTAL prism - better than for exos
• occlude for amblyopia
• VT
• surgery

phase 1: Near then distance, get feeling of divergence, normalize NFV and accomodation, Mag > speed

Phase 2: accurate NFV and PFV, speed>mag, Int distance

Phase 3: integrate artificial binocular accom. w/ vergences

• If acute - usually Neurological
• POOR direct/indirect PFV
• Diplopia not blur
• Dec. NPC; MEM variable
• Optimal correction
• Vertical prism
• Added lenses, moderately affective, adjunct to VT
• Occlude for amblyopia
• VT*****
• Horizontal prism - if VT not possible or failed; usu high phorias
• Surgery

Phase 1:Learn convergence, normalize PFV and NFV, Mag>speed

Phase 2: accurate NFV and PFV, speed>mag

Phase 3: artificial binocular accomodation with vergences

Accomodative Dysfunction - Physiology/phrmacology

• increase in power of lens to see objects @ near
• Accom controlled by ANS - primarily the parasympathetic (fast-Ach), causes miosis, convergence via CNIII,
• Sympathetic system inhibits accom (SLOW), dilates, use parasympatholytic and sympathomimetic (PE)

Insuff/infacilty:

• ANS (parasympatholytic/sympathomimetic)
• Alcohol/weed
• Phenothiazides
• antihistmaines
• CNS stimulants (ADD meds)
• Artane (parkinsons)

Excess:

• ANS (parasympathomimetic/sympatholytic)
• Morphine
• Digitalis (HR)
• Sulfonamides/Carbonic ANhydrase inhib

1. Accom Insufficiency - ill-sustained, paralysis, unequal

2. accom excess

3. accom infacility

• dec in accom AMPS by >2 D based on expected for age
• Linear dec till 40yo then rapid decline till final 1D
• Ave: 18.5-1/3age
• lowest: 15-1/4age
• near complaints
• dec PRA (accom and vergence)
• fails MAF
• may or may not fail BAF
• may or maynot have large lag - depends on ptnts ability to access convergence

1. Ill-Sustained - NORMAL amps!, low PRA, fails - MAF on repeatitions, Large lag, ESO @near

2. Paralysis - pre-presbyopes, FRANK dec mono/binoc amps, Fails NRA/PRA bc starts with blur!, Large lag, Fails + and - facility

3. Unequal - Poor balance/adies/neurological, reduces ASYMETRIC amps, May PASS nra/pra, large ASYMETRIC lag, Fails MAF (+ and/or -)

• accommodation exceeds demend
• UNCORRECTED HYPEROPIA
• spasm
• PSUEDOMYOPE
• accom hysteresis
• CI - using accom to dec exo
• idiopathic
• Towards end of day near complaints, difficulty focus at distance (esp after near work)
• NORMAL AA
• poor + MAF
• LOW lag
• low NRA w/ norm BO
• Maybe ESO w/ low BI to blur

• Difficult to focus at distance; no pattern!!
• NORMAL AA
• POOR + and - MAf
• Normal Lag
• Low PRA/NRA w/ NORMAL ranges
• GREATEST PROBLEM W/ PRISM STEPS
• NO PATHOLOGICAL CAUSES

Ocular - Pulling, itching, asthenopia

Blur, Diplopia, Reading difficulty

Fatigue, Nausea, vertigo (esp car sickness)

Cyclovertical Signs

Head turn, tip, tilt

Axis shift

CT - "prism adaptations"

secondary vertical - usu high exo

• High/Persistent symptoms w/ intact BV system
• Low MAgnitude Strabismus
• Refractory BV
• Poor BI and BO, and really poor recovery

Diagnostic Test for vertical

(DONT rely on any ONE test)

• Maddox rod, Modified thorington, aniso
• Von grafe
• Fixation disparity, associated phoris - flash
• Diagnostic occlusion - symptoms but NO signs
• CT

Diagnostic Test for Cyclos

(DONT rely on any ONE test)

• Double maddox rod
• Double maddox prism
• saladin
• CT of cyclo
•  ophthalmoscope - see if macula is in bottom 1/3 of optive nerve, if too far up or down eye could be encylo or excyclo

1. correct ametropia - esp large cyl
2. prism
3. added lenses
4. therapuetic occlusion - acute/neuro diplopia
5. VT for VERTICALS!!
6. surgery, only if >15pd

• rx weakest prism amount to resolve symptoms
• case dependent on how much to rx
• 1/5 of vertical vergence amplitude
• flip prism technique, prism amount to make it equal on both choices
• **FIXATION DISPARITY -fastest most reliable! if horizontal prism neutralizes FD - VT
• No vert prism adaptation but there is LATENCY
• put prism in for 20 mins, recheck, if find more put in more prism for another 20 mins, recheck if no more RX prism, if find more DONT Rx

Defn of Strabismus

Loss of FUSION, w/ or w/o muscle alignment

Suppresion/diplopia can be 1st, 2nd, 3rd degree

• Hererotropia/tropia
• crossed/walleyed
• Squint
• lazy eye
• manifest tropia

Sprectrum of BV

• Clear/single/comfortable/efficient/BV
• Decreased Quality of Fusion (get last)
• Decreased stability of Fusion
• Abnormal AC/A relationship
• Loss of Fusion with good monocular skills
• loss of unilateral monocular skills (get first)

prevalance - # cases in a pop @ 1 time

2-6% (5-15 million of 288 million US)

ET 3x more likely than XT in kids and young adults

XT more common in eldery and women

risk factors or strabismus

>30%+4D uncorrected hyperopes by 3yo become ET

50% down syndrom

44% cerebral palsy

90% craniofacial dysostosis

genetics, 10x more likely, 23-70%

1. CNS defects-prevent fusion, congenital, common in preemies, DS and CP, large angle 60-100pd
2. Acuity defect-prevents feedback, ptosis, RE, cataract, maculopathy, ON defect
3. Motor Defect-prevents alignment, muscle, orbit, or innervation defect
4. AC/A and Vergence defect-
5. Optical anomalies induced by refractive correction-extreme RE, anisometropia

to classify

accurate documentation - audits and baseline

to plan management

7 signs of Strabismus

1. Direction - eso/exo/hyper/hypo
2. Frequency - how often can occur
3. Magnitude - prism diopters
4. Laterality - R/L/Alt
5. Comitancy - aniso, noncomitant
6. Periodicity, AC/A - difference btwn dist and near
7. Cosmesis

diagnosis

billing

prognosis

etiology

1. Time of onset: early aquired(4-6 mn) late acquired(2yrs)
2. Mode onset: acute/ progressive/ constant/ intermittent
3. Size: Microtrope(<10-15), mod (10-30), Large (>30)
4. AOA - has gaps: infantile, acquired, secondary, adn micro eso and exo trope (8 classes) 
5. ICD-9: follows money, doesnt have all trope options
6. CEMAS-8: Ocular motor dysfunction, sensory, horizontal trope, horiz phorias, cyclovert trope, cyclovert phoria, accom dysfunct, nystagmus
7. Other: direction, accom/refract, duane-white, Disease, pseudostrab (lid, inner canthus)  

1. Patient Hx
2. Dx sequence: RE/VA, alginment, fusion, visual efficiency, pathology
3. Dx summary - prognosis
4. Management plan

Cosmesis

School/PCP

Parent observation

Diplopia-asthenopia

positive family history

second opinion

only slightly better than hirschberg, but is objective

prism bar in front of deviated eye, accuracy <10pd

unsed on infants to find out how much to cut muscle

using oscope dial in to make face clear and look at both reflexes, supposed to be equal

if unequal, brighter reflex is strabismic eye

UCT - detects

ACT - magnitude and direction

Unilateral uncover, only strab, watch for version adn vergence, alternating, intermittent

comtancy - feilding out

Measures at optical infinity

Alternate Exclusion (ACT) - 2 images, one OD and one OS, alternatly occlude and move until no eye movements

Corneal light reflex (krimsky) - fixate OD adn move light on OS til reflection is 0.5mm nasal

stereopsis

worth dot

VA

Alt occlusion

Maddox rod

Vongrafe phorias

diplopia, cyclophoria

pastpointing-overcompensates, place object and ask ptnt to pt where its at, if recent ptnt will overcompensate, if long standing will be normal bc developed compensation

Spread of commitance-over time muscles begin to stropy, weaker antag muscle of paretic muscle evens out paralysis

Head posture/facial asymmetry

look at pictures

def:different phorias in different gazes

criteria: at least 5pd difference, can be mild/moderate/marked

can be phoria or tropia

paresis - underaction or overaction

Non-Commitant Underactions

ocular restrictions: muscle damage, adhesions

mechanical anaomolies of insertion and ligaments may restrict

Paresis:neural, most common; blocked innervation

primary - most common cause of overaction - usu obliques

secondary - not really etiology, common occurance, bc there is an underaction has to be an overaction

primary angle - smaller, normal eye is fixating, weak muscle

secondary angle - larger, defect eye fixating,

can get neutral CT, one eye neutral adn other is not - suspect paretic muscle!

changes in horizontal deviation on up &/or down gaze

A - >10pd inc in devergence in down gaze

V - >15pd inc in divergence in Up gaze (2x more common than A)

non-commitant horizontal: type 1: more innerv to med rectus; type 2: retraction on adduction, more innerv to lateral rectus; type 3: retraction on adduction but more innerv to lateral rectus

paresis of abduct, adduct or both

congenital

assoc w/: torticollis/ hearing and facial-vertibral anomolies

not a true hyper or double hyper

DHD, DTD

assoc w/ latent nystagmus (upshoots on horizontal gaze)

• AOA mechanical strabismus
• CEMAS non-comm, eso and exo
• CEMAS cyclovertical and special forms
• cyclovertical of paretic origin
• dissociated strabismus complex (DVD)
• restrictive/mechanical
• Neuro-myogenic strab
• Special forms

eso prognosis worse than exo

ARC worse than NRC

constant worse than intermittent

• bifoveal fixation in 99% ADL
• clear vision, gen comfortable
• bifixation in all gazes and a few cm NPC
• reasonable corrective lenses and prism
• stereopsis