Strabismus: Ugh!

If it is Strabismus, It Can be Diagnosed with a Cover Test

The Obvious and the Not So Obvious

Two Big Areas Esotropia Exotropia I Wonder if it should not be Intermittent Constant What is the Advantage of Strabismus?

Press and Efficacy: Esotropia

Plus ( T)NC .6

Good Fusion .1

Family Hx No Ambly .1

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< 20 ^ Minus .1

Dense Supp .1

Non Concom .1

Dense Ambly .1

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(T)AC .5

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NC .3

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.1 .1

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AC .1

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Press and Efficacy: Exotropia

• Plus Good Fusion Family Hx No Ambly (T)NC .8

.1

< 20 ^ Minus Dense Supp Non Concom .1

Dense Ambly .1

(T)AC .7

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TNC .5 TAC .4

.1 .1

.1 .1

.1 .1

Ugly Factors

• • • • • • • •

No Desire To Change

Anomalous Correspondence Amblyopia Intractable Diplopia Constancy Non-Concomitant Restrictions Prior Surgery?

Do They Want To Change?

Strabismic From Head to Toe

• • The Child That Did Not Want a Brother The College Student That Wanted A Husband • Esotropes want Detail and are Willing to Give up Binocularity to Get it (Developmental) • Exotropes want the “Big Picture” Panoramic Viewing (Genetic, ABI or Functional)

Anomalous Correspondence

• • • A Type of Binocularity Develops Early---????????????

Reaction of Organism to Diplopia – Sees Double – Suspends/Suppresses – Goes into an Anomalous Fusion Cortically

Anomalous Correspondence

• • Depth – Shallow-Ignore – Deep-Ugh!

Treatment – Embed the Binocularity – Move to Harmonious Anomalous – Change to Normal Correspondence

Amblyopia Maples WC, Bither M. Treating the trinity of infantile vision development: infantile esotropia, amblyopia, anisometropia. J Optom Vis Dev 2006;37: 123-130.

• • • • • Eccentric Fixation Develops Early Secret to Amblyopia (Anisometropic and Eccentric Fixation)----Fixation 0 Retino Motor Locus Treatment-Develop Central Fixation

Constancy

• • • INTERMITTENT IS EASIER The reason that Exos are easier than Esos may be that there are more Intermittent Exos If Intermittent: – Do not Patch – Work on Binocularity where you can find binocularity and expand it. WORK BACKWARDS TO BIOUCLAR AND MONOCULAR SKILLS

Intractable Diplopia

• • • • • • Late Onset Trauma Stroke Horror Fusionis The OMD Who Saw Nothing But ID’s Patch (Contact Lens), Blur, Suppress---

Non-Concomitant

• • • • • Pathology Prior Surgery Worse if Complications Restrictions almost always will not have full use Duane’s Congenital and Train other Visual Skills Brown Can be from infection of the tendon sheath and if so, when infection controlled can decrease

Seven Levels of Dx and Tx

• • • • • • • Bilateral Integration Central Fixation Monocular Equality Biocular Skills Basic Binocular Skills Advanced Binocular Skills Special (Perceptual/Cognitive/Executive)

Working the System: Testing/Demonstrate

• Bilateral Skills: Anatomical Interaction – VO Star – Harmon Bimanual Circles – Standing and Seated Posture – Dry Land Swimming – Angels in the Snow – Line Roll

Working the System: Testing/Demonstrate

• Central Fixation – Ophthalmoscopic (Visuscope) – MIT – Cover Test and Angle Lambda (Kappa) Very Gross – Past Pointing

Working the System: Testing/Demonstration

• Monocular Equality – Fixation: Wolff Wands, VO 12* Star; Fixation Worksheet; Parquetry Blocks; Chalkboard Saccades – Saccade (Real World): See Above; Wayne Saccades; Hart Chart Challenge; Battle Ship Hart Chart – Pursuit: Wolff Wands; Marsden Ball; Head Rotations; Chalkboard Pursuits; Mechanical Rotator – Near Far-Far Near: Hart Chart, Wayne Saccade – Accommodation: Kraskin Bifocal; Monocular Rock

Working the System: Testing

• Biocular Skills: In My Opinion-The Key to Effective Amblyopic and Strabismus Therapy • • • • Suppression Anomalous Correspondence Double but MORE THAN Double-Equally Real “The one I am attending”

Biocular

• • • • • • • Tests (Anomalous Correspondence-Press) Bagolini Lenses Polarized Vectogram Amblyscope Worth Four Dot Maddox Rod with Red Lens Hering-Bielschowsky After Image

Working the System: Testing

• Tests (Suppression) – Bagolini Lenses – Keystone – Brock String – Quoits (Cross) – Binocular Refractions – Physiological Diplopia – Retinal Rivalry – Others

Working the System: Testing

• Basic Binocular – Tons of Tests – Retinoscopy – Phorias – Vergences – Telebinocular – Stereo

• • • • • • •

The Intermittent Trope Can you get Stereo?

If Stereo – Demonstrated with Peripheral Targets Brock Stereo Motivator or Quoits on a Window Build Ranges Ramp Step Ability as measured by Accuracy as measured by the Speed and Stamina of the Patient A Ass Speed means both Fast AND Slow Minimal Differences (Quoits and 1 ^ difference)

Rules of Engagement ”Where the Eye looks and were the Brain thinks it looks is different”

• • • • • • • • Start Were They Are and Go Where They Ain’t Start Slow and Start Low Synapses that Fire Together Continue to Fire Together Analyze the Procedure: All VT is Bio-Feedback Patient & Therapist MUST BE involved Know What you are Attempting to Accomplish Be Enthustatic Accomplishment is the Best Reward

Working the System: Therapy

• Central Fixation – Pleoptics • • • Ophthalmoscopic Bleaching Fixation/Saccade/Pursuit Smaller and Smaller – MIT – Eye Hand Activities

Working the System: Therapy

• Bilateral Skills – Yoked Prisms with Motor Activities • • • Line Roll Line Walk Harmon (Lowman) Board – Harmon Circles – Van Orden Circles

Working the System: Therapy

• • • • • • Monocular Equality (Biocular & Binocular) Monocular Disassociated Binocular (MDB) Marsden Ball MDB Pointers AN 12 pointed Star MDB Kraskin Bifocal Rock MDB Modified Modified UpDegrave MDB

Working the System: Therapy

• Biocular – Squinchel – Marsden Ball – Physio Diplopia – Quoits – Brock String – 12 Pointed Star

Working the System: Therapy

• Binocular Esotrope – Luster – Gross/Peripheral/Moving Targets • • • • • • • Give Me 5 on the Balance Board Touch my Fingers Top Clear/Bottom Clear/Both Clear (= Blur) Quoits-Suppression and Fusion Keystone without Detail Encourage Periphery Motor Activities

Working the System: Therapy

• Extotropes – Rx (+) and tend to be poorer academic achievers – “Take This Job and Shove It” “ I Quit” – High Sx: See COVD-QOL Checklist – Functional or Nerve/Muscle Damage – Needs “Orthoptics”: Fixations, Pursuits, Vergence, ACCOMMODATION – Get Stereo; Let Stereo Go; Regain Stereo – See 1/See 2

Skeffington’s Model

• Exotropia – Divergence Excess Needs + at Near (Cooper, NO!) – Sympathetic and Parasympathetic-Exos Peripheral Dominant – Social and Biological Clash – Myopia/Esotropia – Hyperopia (Normal Refraction)/Exotropia

Working the System: Therapy

• Esotropes – Minimal +; Monocular (-) Followed by Low + – Tend to be High Achievers (Bull Dogs) Low Sx – Want their own Way (Spoiled?-Indulgent Parents) – Will tell you what they think you want to hear – Developmental or SERIOUS PATHOLOGY – Ah, Ha is Needed. That is how you do it