Persistent Diplopia in Visually Mature Patients
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Management of Microtropia
Br J Ophthalmol: first published as 10.1136/bjo.58.3.281 on 1 March 1974. Downloaded from Brit. J. Ophthal. (I974) 58, 28 I Management of microtropia J. LANG Zirich, Switzerland Microtropia or microstrabismus may be briefly described as a manifest strabismus of less than 50 with harmonious anomalous correspondence. Three forms can be distinguished: primary constant, primary decompensating, and secondary. There are three situations in which the ophthalmologist may be confronted with micro- tropia: (i) Amblyopia without strabismus; (2) Hereditary and familial strabismus; (3) Residual strabismus after surgery. This may be called secondary microtropia, for everyone will admit that in most cases of convergent strabismus perfect parallelism and bifoveal fixation are not achieved even after expert treatment. Microtropia and similar conditions were not mentioned by such well-known early copyright. practitioners as Javal, Worth, Duane, and Bielschowsky. The views of Maddox (i898), that very small angles were extremely rare, and that the natural tendency to fusion was much too strong to allow small angles to exist, appear to be typical. The first to mention small residual angles was Pugh (I936), who wrote: "A patient with monocular squint who has been trained to have equal vision in each eye and full stereoscopic vision with good amplitude of fusion may in 3 months relapse into a slight deviation http://bjo.bmj.com/ in the weaker eye and the vision retrogresses". Similar observations of small residual angles have been made by Swan, Kirschberg, Jampolsky, Gittoes-Davis, Cashell, Lyle, Broadman, and Gortz. There has been much discussion in both the British Orthoptic Journal and the American Orthoptic journal on the cause of this condition and ways of avoiding it. -
Binocular Vision
Continuing education CET Binocular vision Part 5 – Binocular sensory status and miscellaneous tests In the latest addition to our occasional series on the assessment and management of binocular vision in practice, Priya Dabasia looks at sensory status and its measurement. Module C16058, one general CET point for optometrists and dispensing opticians he preceding accounts in ● Confusion – the superimposition this mini series of binocular of two dissimilar images in higher vision (BV) testing have processing, experienced predominantly detailed procedures for on observing complex scenes such as ‘a the cover test (CT), ocular room’. The same patient is more likely motility and heterophoria to report diplopia on viewing a small, Tcompensation. The final two articles bright target such as a penlight aim to outline the assessment of ● Retinal rivalry – the observation binocular sensory status, stereopsis and of alternating percepts or a combined convergence. ‘mosaic’ so that images from each eye Having two frontally positioned eyes are never seen simultaneously. separated by approximately 65mm enhances many aspects of our visual Anomalous retinal correspondence performance – a wide panorama, (ARC) is considered a more efficient higher acuity, and three-dimensional sensory adaptation to heterotropia as perception to a distance of 200 metres, suppression occurs in localised zones provided both eyes are fully functional Figure 1 to the fovea of one eye corresponds to a rather than spanning the binocular and coordinated together. Anomalies Worth 4-Dot point temporal to the fovea in the other field. It facilitates a weaker form of of binocular function have often been test eye. In reality, BSV can still be achieved BSV, relieving diplopia while enabling described as ‘the hidden learning with misaligned visual axes provided a good level of depth perception of up disability’ as they impair academic the disparity occurs within the limits of to 100’’. -
Routine Eye Examination
CET Continuing education Routine eye examination Part 3 – Binocular assessment In the third part of our series on the eye examination, Andrew Franklin and Bill Harvey look at the assessment and interpretation of binocular status. Module C8290, one general CET point, suitable for optometrists and DOs he assessment of binocular previous question. Leading questions function is often one of the should be avoided, especially when weaker areas of a routine, dealing with children. If they are out if observation of candidates of line ask the patient ‘Which one is out in the professional qualifica- of line with the X?’ Ttions examination is any guide. Tests are You should know before you start the done for no clearly logical reason, often test which line is seen by which eye. because they always have been, and in If you cannot remember it from last an order which defeats the object of the time, simply look at the target through testing. Binocular vision seems to be one the visor yourself (Figure 1). Even if of those areas that practitioners shy away you think you can remember, check from, and students often take an instant anyway, as it is possible for the polarisa- dislike to. Many retests and subsequent tion of the visor not to match that of the remakes of spectacles are the result of a Mallett Unit at distance or near or both, practitioner overlooking the effects of a Figure 1 A distance fixation disparity target especially if the visor is a replacement. change of prescription on the binocular If both eyes can see both bars, nobody status of the patient. -
Cranial Nerve Palsy
Cranial Nerve Palsy What is a cranial nerve? Cranial nerves are nerves that lead directly from the brain to parts of our head, face, and trunk. There are 12 pairs of cranial nerves and some are involved in special senses (sight, smell, hearing, taste, feeling) while others control muscles and glands. Which cranial nerves pertain to the eyes? The second cranial nerve is called the optic nerve. It sends visual information from the eye to the brain. The third cranial nerve is called the oculomotor nerve. It is involved with eye movement, eyelid movement, and the function of the pupil and lens inside the eye. The fourth cranial nerve is called the trochlear nerve and the sixth cranial nerve is called the abducens nerve. They each innervate an eye muscle involved in eye movement. The fifth cranial nerve is called the trigeminal nerve. It provides facial touch sensation (including sensation on the eye). What is a cranial nerve palsy? A palsy is a lack of function of a nerve. A cranial nerve palsy may cause a complete or partial weakness or paralysis of the areas served by the affected nerve. In the case of a cranial nerve that has multiple functions (such as the oculomotor nerve), it is possible for a palsy to affect all of the various functions or only some of the functions of that nerve. What are some causes of a cranial nerve palsy? A cranial nerve palsy can occur due to a variety of causes. It can be congenital (present at birth), traumatic, or due to blood vessel disease (hypertension, diabetes, strokes, aneurysms, etc). -
Worth 4 Dot App for Determining Size and Depth of Suppression
Article Worth 4 Dot App for Determining Size and Depth of Suppression Ann L. Webber1, Thomas R. Mandall1, Darcy T. Molloy1, Lucas J. Lister1, and Eileen E. Birch2,3 1 School of Optometry and Vision Science, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia 2 Retina Foundation of the Southwest, Dallas, TX, USA 3 UT Southwestern Medical Center, Dallas, TX, USA Correspondence: Ann L. Webber, Purpose: To describe and evaluate an iOS application suppression test, Worth 4 Dot Queensland University of App (W4DApp), which was designed and developed to assess size and depth of Technology, 60 Musk Avenue, Kelvin suppression. Grove, Queensland 4059, Australia. Methods: e-mail: [email protected] Characteristics of sensory fusion were evaluated in 25 participants (age 12– 69 years) with normal (n = 6) and abnormal (n = 19) binocular vision. Suppression zone Received: August 12, 2019 size and classification of fusion were determined by W4DApp and by flashlight Worth4 Accepted: December 13, 2019 Dot (W4D) responses from 33 cm to 6 m. Measures of suppression depth were compared Published: March 9, 2020 between the W4DApp, the flashlight W4D with neutral density filter bar and the dichop- Keywords: suppression; binocular tic letters contrast balance index test. vision; Worth 4 Dot Results: There was high agreement in classification of fusion between the W4DApp Citation: Webber AL, Mandall TR, method and that derived from flashlight W4D responses from 33 cm to 6m(α = Molloy DT, Lister LJ, Birch EE. Worth 0.817). There were no significant differences in success rates or in reliability between 4 Dot App for determining size and the W4DApp or the flashlight W4D methods for determining suppression zone size. -
Management of Vith Nerve Palsy-Avoiding Unnecessary Surgery
MANAGEMENT OF VITH NERVE PALSY-AVOIDING UNNECESSARY SURGERY P. RIORDAN-E VA and J. P. LEE London SUMMARY for unrecovered VIth nerve palsy must involve a trans Unresolved Vlth nerve palsy that is not adequately con position procedure3.4. The availability of botulinum toxin trolled by an abnormal head posture or prisms can be to overcome the contracture of the ipsilateral medial rectus 5 very suitably treated by surgery. It is however essential to now allows for full tendon transplantation techniques -7, differentiate partially recovered palsies, which are with the potential for greatly increased improvements in amenable to horizontal rectus surgery, from unrecovered final fields of binocular single vision, and deferment of palsies, which must be treated initially by a vertical any necessary surgery to the medial recti, which is also muscle transposition procedure. Botulinum toxin is a likely to improve the final outcome. valuable tool in making this distinction. It also facilitates This study provides definite evidence, from a large full tendon transposition in unrecovered palsies, which series of patients, of the potential functional outcome from appears to produce the best functional outcome of all the the surgical treatment of unresolved VIth nerve palsy, transposition procedures, with a reduction in the need for together with clear guidance as to the forms of surgery that further surgery. A study of the surgical management of 12 should be undertaken in specific cases. The fundamental patients with partially recovered Vlth nerve palsy and 59 role of botulinum toxin in establishing the degree of lateral patients with unrecovered palsy provides clear guidelines rectus function and hence the correct choice of initial sur on how to attain a successful functional outcome with the gery, and as an adjunct to transposition surgery for unre minimum amount of surgery. -
Suppression and Retinal Correspondence in Intermittent Exotropia
Downloaded from bjo.bmj.com on May 23, 2012 - Published by group.bmj.com British Journal of Ophthalmology, 1986, 70, 673-676 Suppression and retinal correspondence in intermittent exotropia JEFFREY COOPER AND CAROL DIBBLE RECORD From the Institute of Vision Research, SUNYIState College of Optometry, 100 East 24th Street, New York, New York 10010, USA SUMMARY Suppression scotomas and retinal projection (retinal correspondence) were measured in six intermittent exotropes during deviation. Measurements used red-green anaglyph stimuli presented on a black background which could be varied from 3-4 minutes of arc to 3024'. Results showed non-suppression of all points between the fovea and the diplopia point. Harmonious anomalous retinal correspondence was usually observed. Two subjects had spontaneous changes from anomalous retinal correspondence to normal retinal correspondence without a concurrent change in ocular position. Conventional testing resulted in more variable results in regard to retinal correspondence and suppression, suggesting that non-suppression and anomalous retinal corres- pondence occur when black backgrounds are used for testing. Patients with intermittent exotropia of the diverg- image and anomalous retinal correspondence (ARC) ence excess type (DE) or basic exotropia usually do in the deviated position and normal retinal corres- not complain of diplopia when their eyes are deviat- pondence (NRC) in the aligned position on the ing.' Parks2 believes that the absence of diplopia is Hering-Bielschowsky afterimage test.' due to a dense temporal hemiretinal suppression. We therefore attempted to qualify the depth of Using a technique employing Risley prisms, suppression in deviating intermittent exotropes while Jampolsky3 demonstrated that DE patients have a monitoring ocular position. -
Binocular Vision
BINOCULAR VISION Rahul Bhola, MD Pediatric Ophthalmology Fellow The University of Iowa Department of Ophthalmology & Visual Sciences posted Jan. 18, 2006, updated Jan. 23, 2006 Binocular vision is one of the hallmarks of the human race that has bestowed on it the supremacy in the hierarchy of the animal kingdom. It is an asset with normal alignment of the two eyes, but becomes a liability when the alignment is lost. Binocular Single Vision may be defined as the state of simultaneous vision, which is achieved by the coordinated use of both eyes, so that separate and slightly dissimilar images arising in each eye are appreciated as a single image by the process of fusion. Thus binocular vision implies fusion, the blending of sight from the two eyes to form a single percept. Binocular Single Vision can be: 1. Normal – Binocular Single vision can be classified as normal when it is bifoveal and there is no manifest deviation. 2. Anomalous - Binocular Single vision is anomalous when the images of the fixated object are projected from the fovea of one eye and an extrafoveal area of the other eye i.e. when the visual direction of the retinal elements has changed. A small manifest strabismus is therefore always present in anomalous Binocular Single vision. Normal Binocular Single vision requires: 1. Clear Visual Axis leading to a reasonably clear vision in both eyes 2. The ability of the retino-cortical elements to function in association with each other to promote the fusion of two slightly dissimilar images i.e. Sensory fusion. 3. The precise co-ordination of the two eyes for all direction of gazes, so that corresponding retino-cortical element are placed in a position to deal with two images i.e. -
Strabismus: a Decision Making Approach
Strabismus A Decision Making Approach Gunter K. von Noorden, M.D. Eugene M. Helveston, M.D. Strabismus: A Decision Making Approach Gunter K. von Noorden, M.D. Emeritus Professor of Ophthalmology and Pediatrics Baylor College of Medicine Houston, Texas Eugene M. Helveston, M.D. Emeritus Professor of Ophthalmology Indiana University School of Medicine Indianapolis, Indiana Published originally in English under the title: Strabismus: A Decision Making Approach. By Gunter K. von Noorden and Eugene M. Helveston Published in 1994 by Mosby-Year Book, Inc., St. Louis, MO Copyright held by Gunter K. von Noorden and Eugene M. Helveston All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the authors. Copyright © 2010 Table of Contents Foreword Preface 1.01 Equipment for Examination of the Patient with Strabismus 1.02 History 1.03 Inspection of Patient 1.04 Sequence of Motility Examination 1.05 Does This Baby See? 1.06 Visual Acuity – Methods of Examination 1.07 Visual Acuity Testing in Infants 1.08 Primary versus Secondary Deviation 1.09 Evaluation of Monocular Movements – Ductions 1.10 Evaluation of Binocular Movements – Versions 1.11 Unilaterally Reduced Vision Associated with Orthotropia 1.12 Unilateral Decrease of Visual Acuity Associated with Heterotropia 1.13 Decentered Corneal Light Reflex 1.14 Strabismus – Generic Classification 1.15 Is Latent Strabismus -
Internuclear Ophthalmoplegia As a Presenting Feature in a COVID-19-Positive Patient Varshitha Hemanth Vasanthpuram,1 Akshay Badakere 2
Case report BMJ Case Rep: first published as 10.1136/bcr-2021-241873 on 13 April 2021. Downloaded from Internuclear ophthalmoplegia as a presenting feature in a COVID-19- positive patient Varshitha Hemanth Vasanthpuram,1 Akshay Badakere 2 1Ophthalmic Plastic Surgery SUMMARY was unremarkable. His vitals at the time of screening Services, LV Prasad Eye Institute, A 58-year -old man presented with vertical diplopia were 94% saturation of peripheral oxygen (SpO2), Hyderabad, India temperature of 35.8°C and pulse rate of 91 per 2 for 10 days which was sudden in onset. Extraocular Child Sight Institute, Jasti V movement examination revealed findings suggestive minute. His overall systemic status was stable, with Ramanamma Children’s Eye of internuclear ophthalmoplegia. Investigations were no respiratory symptoms noted. Care Centre, LV Prasad Eye Institute, Hyderabad, India suggestive of diabetes mellitus, and reverse transcription- PCR for SARS-CoV -2 was positive. At 3 weeks of INVESTIGATIONS follow-up , his diplopia had resolved. Neuro-ophthalmic Correspondence to Extraocular motility examination, the abducting manifestations in COVID-19 are increasingly being Dr Akshay Badakere; nystagmus in the left eye and the saccades were akshaybadakere@ gmail.com recognised around the world. Ophthalmoplegia due indicative of INO. Fatigue and ice pack test were to cranial nerve palsy and cerebrovascular accident negative. Initial blood investigations of complete Accepted 26 March 2021 in COVID-19 has been reported. We report a case blood count, lipid profile and 24- hour urine protein of internuclear ophthalmoplegia in a patient with were within normal range. Fasting and postprandial COVID-19. blood sugar levels were 121 mg/dL and 205 mg/dL, respectively, and haemoglobin A1c (HbA1c) was 7.5%, suggestive of diabetes mellitus. -
Surgical Classification of Squints with a Vertical Deviation
Br J Ophthalmol: first published as 10.1136/bjo.39.3.129 on 1 March 1955. Downloaded from Brit. J. Ophthal. (1955) 39, 129. COMMUNICATIONS SURGICAL CLASSIFICATION OF SQUINTS WITH A VERTICAL DEVIATION* BY ALFREDO VILLASECA Hospital Salvador, Santiago, Chile VERTICAL squints, either pure or associated with horizontal squints, are of great practical importance, since binocular single vision can only be attained if there is perfect parallelism of the visual axis in both the horizontal and vertical directions. The statistics given by various authors show that vertical deviations are very frequent: White and Brown (1939) found the following distribution in 1,062 cases : un- complicated lateral deviation in 347 patients, uncomplicated vertical deviation in 358, and combined vertical and lateral deviation in 357. Dunnington and Regan (1950) found that 50 per cent. of 79 cases of concomitant convergent strabismus showed a vertical component. Scobee (1951), in 457 cases of convergent strabismus, found 195 (43 per cent.) copyright. with a vertical component. In his patients the frequency of involvement (paresis) of the vertically acting muscles was as follows: Muscle No. of Cases Superior rectus ... ... ... ... ... 60 Superior oblique ... ... ... ... ... ... ... 32 Inferior rectus ... ... ... ... ... ... ... 25 of the same eye 20 Both depressors (superior oblique and inferior rectus) http://bjo.bmj.com/ Both superior obliques ... ... ... 15 Both inferior recti ... ... ... ... ... ... 13 Superior rectus of one eye and inferior rectus of the other eye ... ... 11 Both superior recti ... ... ... ... ... ... ... 7... Both elevators (superior rectus and inferior oblique) of the same eye ... 6 Superior oblique and inferior rectus of both eyes ... ... ... 2 Inferior oblique ... ... ... ... ... ... ... ...1 Miscellaneous groupings ... .. ... ... ... ... ... 3 He makes no specific mehtion of patients with concomitant hypertropia or on September 23, 2021 by guest. -
Diplopia Evaluation
Diplopia [ ] Monocular (monocular if diplopia present even when only 1 eye open) vs [ ] Binocular (binocular only when both eyes open) Causes If painful, think of the following: Red Flags Monocular diplopia Binocular diplopia usually d/t something usually d/t disconjugate Compressive lesion/tumor/aneurysm >1 cranial nerve deficit distorting light through alignment of eyes eye to retina Sinusitis/abscess/cavernous sinus thrombosis Pupillary involvement cataract CN palsy (3rd, 4th, 6th) corneal shape problems Myasthenia gravis Orbital myositis Other neurologic s/s alongwith diplopia (keratoconus) uncorrected refractive Orbital infiltration (e.g. Trauma (fracture/hematoma) Pain error (usually thyroid infiltrative astigmatism) ophthalmopathy, orbital pseudotumor) Skull base tumors (pain often unrelated to eye movement) Proptosis other: corneal scarring, Other causes: CVA dislocated lens, affecting pons/midbrain; malingering compressive lesion (aneurysm, tumor); History idiopathic; inflammatory/infectious (sinusitis, cavernous sinus monocular vs binocular? gait difficulties (CN 8) thrombosis, abscess); Wernicke’s ; orbital myositis; trauma intermittent or constant? difficulty with bladder control (MS) (fracture, hematoma); tumors near base of skull/sinuses/orbits; images separated horizontally or vertically or a weakness/sensory abnormalities (intermittent or botulism; GBS/Miller- combination of both? constant) Fisher; MS vision changes? (CN2) N/V/diarrhea (botulism) Key points numbness of forehead/face/cheek (CN5) swallowing or speech difficulties