2016 Basic Motility Exam

PGH Basic Course Lecture 2016

1. Basic Motility Examination
Alvina Pauline D. Santiago, MD
Pediatric Ophthalmology & Strabismus

Basic Course Lectures in Ophthalmology
Sentro Oftalmologico Jose Rizal
Philippine General Hospital 2016

2. Basic Strabismus Evaluation
• Chief complaint and History
• Vision assessment (with vision screening)
• Gross evaluation and slit lamp examination
• Refraction and need for cycloplegia
• Sensory & Motor examination (Motility
Examination)
• Dilated posterior pole evaluation

3. Sensory Testing
• Perform before any type of monocular occlusion
• e.g., visual acuity testing, cover tests
• Must wear correct prescription
• May need to correct deviation
• Prefer to do on a second visit

4. Sensory Testing
• Near stereoacuity
• Fly vectograph/ Titmus Fly Test
• Lang stereotest
• Random dot stereograms
• Distance stereoacuity
• Mentor BVAT
• AO vectograph
• Amblyoscope

5. Stereoacuity tests
• Horizontal disparity
• Stimulate non-corresponding points
• Image disparity measured in sec of arc
• 40-50 sec = central or bifoveal fixation
• 80-3000 sec = peripheral fusion

6. Titmus fly test
• Monocular cues
• Need polarized glasses
• Image displacement
may be detected by
alternate suppressors
• Turn book 90 degrees,
should be flat
From Rosenbaum & Santiago, Clinical Strabismus Management

7. Lang Stereoacuity test
• Random dot stereogram
• No need for Polaroid
lenses
• Only for gross and low
grade stereopsis
From Rosenbaum & Santiago, Clinical Strabismus Management

8. Random Dot Stereogram
• 2 plates of randomly
displayed dots, one plate
to each eye
• Shape of figure
displaced horizontally
relative to other plate
• No monocular cues
• Normal may fail
From Rosenbaum & Santiago, Clinical Strabismus Management

9. Distance Stereotest
• Mentor BVAT System
• Very good test for
assessing control in
X(T)
From Rosenbaum & Santiago, Clinical Strabismus Management
From Rosenbaum & Santiago,
Clinical Strabismus Management

10. Red-Green Distance
Stereotest

11. Sensory Testing
• Worth 4 dot
• near: tests peripheral fusion
• distance: tests central fusion
• Retinal correspondence
• amblyoscope, Bagolini lenses
• 4 pd BO test: foveal suppression
• N: conjug sacc OU, slow recov in nonprism eye

12. Worth Dot Test
• 2 green lights
• 1 red light
• 1 white light
• Red-green glasses
• Usually red over right eye
• At 1/3 m:
• W4D separated by 6 degrees
• Tests peripheral fusion
• At 6 m:
• 1.25 degrees
• Tests central fusion

13. Worth Dot Test Results
http://image.slidesharecdn.com

14. Amblyoscope or Haploscope
From Rosenbaum & Santiago, Clinical Strabismus Management

15. Amblyoscope
• Measures fusional vergence amplitudes
• Angle of deviation
• Area of suppression
• Retinal correspondence
• Torsion
• Instrument convergence

16. Motor Testing
• Ocular rotations
• Measuring the deviation
• Anomalous head posture

17. Ocular Rotations
• Duction: monocular
• Version: binocular
• Hering’s law
• Sherrington’s law
• Alert to pattern deviations: e.g., A, V
• Grading scheme:
• e.g., inferior oblique & superior oblique

18. Ocular Rotations
Cardinal gaze positions
RLR
LMR

RMR
LLR

RSR
LIO

RIR
LSO

RIO
LSR

RSO
LIR

19. Ocular Motility Evaluation
From Rosenbaum & Santiago, Clinical Strabismus Management

20. Ocular Motility Evaluation
RLR
LMR

RMR
LLR

RSR
LIO

RIR
LSO

RIO
LSR

RSO
LIR

From Rosenbaum & Santiago, Clinical Strabismus Management

21. (L) Inferior oblique dysfunction
+4 +1
-4 -1
From Rosenbaum & Santiago, Clinical Strabismus Management

22. (R) Superior oblique dysfunction
+4 +1
-4 -1
From Rosenbaum & Santiago, Clinical Strabismus Management

23. Motor Testing
• Light reflex tests
• Cover tests
• Other tests
• wear correction
• no prisms

24. Motor Testing: Light Reflex Tests
• Bruckner test
• Hirschberg light reflex
• Krimsky/modified Krimsky

25. Bruckner Test
® Ametropia
® Strabismus

From Rosenbaum & Santiago, Clinical Strabismus Management

26. Hirschberg’s Corneal Light Reflex
• 3.5 mm pupil:
• 15 deg at pupil edge
• 30 deg between limbus
and edge of pupil
• 45 degrees at limbus

• Not a true linear relationship:
21 pd/mm decentration
From Rosenbaum & Santiago, Clinical Strabismus Management

27. Krimsky vs Modified Krimsky
• in front of deviating
eye (modified
Krimsky)
• underestimates true
angle
• better at near
From Rosenbaum & Santiago, Clinical Strabismus Management

28. LIGHT REFLEX, COVER TESTS
(Courtesy of R. Pena, MD)
MODIFIED KRIMSKY

29. Motor Testing: Cover Tests
• Primary gaze
• Right and left gaze
• Up and down gaze
• Right and left head tilt
• Oblique gazes, occasionally

• Near: primary and down gaze

30. Cover Tests
• Requirements:
• Appropriate correction
• Know if correction has no prisms or with prisms
• Accommodative target
• Distance:
• 6 m: 1/6 D of accommodation
•  (approximates infinity)
• > 6 m: X(T)

31. The Ideal Target
• Above threshold
• e.g. Snellen acuity 20/20
• present 20/50 to 20/70

32. The Ideal Target
• With sufficient detail and contour
• Should sustain interest

33. Toys as Targets
• One toy one look
• With detail
• May be coupled with a
light
• Sounds for tracking but
not vision testing

34. The Ideal Target
• Maximum plus, least minus correction
• Allows minimal accommodation at 6 m
• Accommodation exerted only 1/6 Diopter,
considered zero for strabismus measurement
purposes

35. Factors Affecting Measurement
• Prism placement:
• plastic prisms: frontal
plane
• glass prisms: prentice
position
• Stacking prisms
• Splitting prisms
From Rosenbaum & Santiago, Clinical Strabismus Management

36. Factors Affecting
Measurement
• Method of testing:
• Light reflex:
• Bruckner
• Hirschberg
• Krimsky/modified
Krimsky
• Different cover tests
• Cover Test
• Alternate Cover Test
From Rosenbaum & Santiago, Clinical Strabismus Management

37. Factors Affecting Measurement
• Patient factors:
• Accommodation and AC/A ratio
• Axial length and globe size
• Amblyopia and eccentric fixation
• Refractive error and induced prisms

38. Cover Tests

39. Cover Uncover Test
• Must be performed before alternate cover test
• Cover test: tropia
• Uncover test: phoria
• also for fixation preference

40. Alternate Prism Cover Test
• Prisms before deviated eye
• primary vs. secondary deviation
• Unless strabismic eye is preferred for fixation
• Evaluates total deviation: manifest (tropic) and
latent (phoric)

41. ALTERNATE PRISM & COVER TEST
Gold standard for
measuring deviation
LIGHT REFLEX, COVER TESTS
(Courtesy of R. Pena, MD)

42. Simultaneous Prism Cover Test
• Tropia under binocular conditions
• Monofixation syndrome
• Estimate angle of deviation
• Present prism and cover simultaneously
• Absence of movement in tropic eye means correcting
prisms are accurate

43. SIMULTANEOUS PRISM & COVER TEST
Used for monofixation
LIGHT REFLEX, COVER TESTS
(Courtesy of R. Pena, MD)

44. Prism Under Cover Test
• For Dissociated Vertical Deviation
• Evaluate one eye at a time
• Prism and cover presented to the same eye
• Separate true hypertropia by using BU prism
neutralization in other eye

45. Dissociated Vertical Deviation
Courtesy of N. Paderna, MD

46. PRISM UNDER COVER TEST
Used for DISSOCIATED
VERTICAL DEVIATION (DVD)
LIGHT REFLEX, COVER TESTS
(Courtesy of R. Pena, MD)

47. Techniques in Finding
Strabismus
• Bruckner test
• Spielmann
translucent occluder
From Rosenbaum & Santiago, Clinical Strabismus Management

48. Other Tests
• Red glass test
• Maddox rod
• horizontal, vertical
• torsional
• Parks 3-step test for isolated cyclovertical muscle
palsy
• 3rd step is Bielschowsky maneuver

49. (L) Superior oblique palsy

50. Parks 3-step Test
Left Hypertropia
• I. Of 8 cyclovertical
muscles: 4
• LSO, LIR, RSR, RIO
• II. Of 4 cyclovertical
muscles: 2
• increase on R gaze: LSO,
RSR
• III. Of 2 cyclovertical
muscles: 1
• increase of L tilt: LSO

51. Torsion Evaluation
• Funduscopy
• Fundus photography
• Blind spot mapping
• Red-Green Hess/Lee Screen
• Double Maddox Rods
• Oblique (& Vertical) muscle dysfunction

52. Normal Optic Nerve Head-
Fovea Angle Relationship
From Rosenbaum & Santiago, Clinical Strabismus Management

53. Direct Ophthalmoscope View:
Fundus Torsion
Excyclorotation Incyclorotation
From Rosenbaum & Santiago, Clinical Strabismus Management

54. Indirect Ophthalmoscope View:
Fundus Torsion
Excyclorotation Incyclorotation

55. Inferior Oblique Overaction
PREOP POSTOP
From Rosenbaum & Santiago, Clinical Strabismus Management

56. Torsion Test: Double Maddox
From Rosenbaum & Santiago, Clinical Strabismus Management

57. Tests of Muscle Function
• Forced duction test
• Force generation test
• Saccadic velocity analysis
• EMG
• Dynamic MRI

58. Indications
• Incomitant deviation
• Limited ocular rotation
• Distinguish between restriction and paresis/palsy
• Distinguish between paresis and palsy

59. Passive Forced Duction
• Some indications:
• Trauma
• Endocrine
• Postoperative restriction of
motility
• Longstanding deviation with
secondary contracture
• Congenital restrictions
• Brown
• Duane
• Transposition procedures
• Orbital diseases
• Tumors
• Inflammation

60. Advantages
• Help in deciding between treatment options
• Monitor improvement of paretic mm

61. Tests of Muscle Function
• Paresis vs. restriction
• Forced duction test
• Force generation test
• Saccadic velocity analysis
• Differential intraocular pressure

62. EMG: Electromyography
• Limitations:
• may record activity even if muscle still
paretic
• response suppressed by GA
• still used in some cases of Duane syndrome
and Botulinum injection

63. Passive Forced Duction
• Children > 7 yrs, adults
• Topical anesthetic
• Cover one eye: ensures
fixation
• Look as far as possible in
the direction of limited
ocular rotation
• Provide fixation target
• Watch out for “falling
off” of eye

64. Passive Forced Duction
“Can the forceps rotate the eye further
than the patient can using maximal
innervation in that gaze field?”
• Grasp limbus opposite the side of limited gaze
• Tenon’s and conj fused in one layer
• limits stretching/tearing of conj
• provides firm grasp

65. Passive Forced Duction
• Follow natural arc of globe
• For rectus muscles
• Slight proptosis
• No retroplacement
• Vertical rectus: 23 deg abduction
• Results:
• cannot move globe further: restriction
• can move globe further: paresis

66. ® For Oblique Muscles:
® Retroplace globe
® Follow oblique muscle path
® Guyton’s Oblique Traction Test
® “Stress Test” for obliques
® Retroplace globe
® Torsional movement
Passive Forced Duction

67. Oblique traction testing
From Rosenbaum & Santiago, Clinical Strabismus Management

68. Oblique traction testing
From Rosenbaum & Santiago, Clinical Strabismus Management

69. Oblique traction testing
From Rosenbaum & Santiago, Clinical Strabismus Management

70. Intraoperative Forced Duction Testing
• Perform routinely to feel “normal”
• Perform esp after resections
• may be ortho in primary
• overcorrection in certain gazes
• Perform after transpositions
• Intraoperative adjustable suture
• Perform after removing suspected restrictions

71. Forced Duction Results
• Absolute restriction
• Graves, Brown
• Uniform restriction
• Scar tissue, muscle contracture
• Leash phenomenon
• Scar tissue, long standing contracture
• Duane syndrome

72. Pitfalls: Forced Duction
• Patient apprehension
• Errors in technique
• “Falling off”
• Failure to proptose or retropulse globe
• Succinylcholine (Anectine)
• Posterior restrictions
• Co-contractions
• Co-existing paresis and restriction

73. Active Force Generation
• Apply a counteracting
force
• Using the same grasp
on limbus
• Countertraction to feel
resistance
• WOF: corneal abrasion,
conj heme

74. Active Force Generation
• Differential IOP
• Paresis vs. palsy
• Combined paresis and restriction

75. Results: Force Generation
• No force generated: Palsy
• Weak force generated: Paresis
• Strong force generated: Restriction
• Common pitfall: mild paresis
• Correlate with saccadic velocity analysis

76. FDT, FGT, Diagnosis
DIAGNOSIS FDT FGT
Mech restriction restricted normal
Muscle palsy free absent
Paresis & restriction restricted weak

77. Saccadic Velocity Analysis
• Study eye movement velocity
• muscle activity
• return of muscle function
• EOG : problem when testing vertical saccades
• Infrared
• Scleral search coil

78. Office Saccadic Velocity
• Look at 2 separate targets
• At least 20 deg movt sufficient
• Compare
• briskness of agonist and antagonist
• with fellow eye
• Bring the eye where muscle has
• maximum function
• full unrestricted motion
From Rosenbaum & Santiago, Clinical Strabismus Management

79. Pitfalls: Saccadic Velocity
• Errors in technique
• failure to bring eye
where muscle is still
functioning
• Pharmacologic
• Fatigue
• Time of day
From Rosenbaum & Santiago, Clinical Strabismus Management

80. Clinical Applications: SV
• Paralytic Strabismus
• Restrictive
• Lost or slipped muscles
• Neurologic Disorders
• MG: normal then weakens; use with Tensilon
• PEO: general slowing
• INO: slowed adduction; normal abduction

81. Slowed Saccadic Velocities
• LR palsy abduction
• SO palsy downgaze
• Moebius horizontal
• Myasthenia normal then slows
• Slipped/Lost reduced 20-50%

82. Magnetic Resonance Imaging
• Cross-sectional area
• Applications:
• EOM palsy
• EOM heterotopy
• Severed/extirpated muscles
• Entrapment
• Mass

83. Normal coronal section
From Rosenbaum & Santiago, Clinical Strabismus Management

84. From Rosenbaum & Santiago, Clinical Strabismus Management

85. Laser vision ;-)
No more than a pinhole effect!