Concomitant and Incomitant, AHP and Hess chart

4rd Year Student Of Optometry at ISRA School Of Optometry

1. Orthoptics Presentation Presented By: Tehseen Javaid Muhammad Amin

2. CONCOMITANCE / INCOMITANCE ABNORMAL HEAD POSTURE HESS CHART CONT ANT:

3. DEFINITIONS CONCOMITANT DEVIATION : Angle of deviation remain same in all directions of gaze and there is no limitation of ocular movements. INCOMITANT DEVIATION: Angle of deviation varies in different position of gazes and there is limitation of ocular movements. Secondary angle of deviation is greater than primary deviation

4. DIFFERENCIAL CRITERIA COMITANT DEVIATION INCOMITANT DEVIATION OCCURANCE More common Less common ONSET Usually congenital Usually acquired DEVIATION Primary angle is equal to secondary angle Secondary greater than primary angle MOVEMENT No limitation Limitation AHP None Present DIPLOPIA None Amblyopia CAUSE Hereditary Uncorrecte d refractive error Usually injury Vascular diseases DIFFERENCES: DEPTH PERSCEPTION None due to suppression Present when do AHP

5. INCOMITANT DEVIATION CLASSIFICATION NEUROGENIC MYOGENIC MECHANICAL 3 RD NERVE PALSY 6 TH NERVE PALSY 4 TH NERVE PALSY DOUBLE ELEVATOR PALSY DOUBLE DEPRESSIVE PALSY Myasthenia gravis Chronic Progressive External Ophthalmoplegia Orbital myositis Brown syndrome Duane syndrome Orbital injury Thyroid eye disease

6. CONGENITAL AND ACQUIRED INCOMITANT STRABISMUS INVESTIGATION CONGENITAL ACQUIRED PRESENTATION Unacceptable cosmetic appearance symptoms of decompensation, Unaware of AHP. Diplopia and occasionally pain OCULAR MOTILITY Often full muscle sequlae Muscle sequlae not fully developed DURATION Longstanding Recent BINOCULAR FUNCTION Extended vertical fusion range Normal fusion range

7. ABNORMAL HEAD POSTURE

8. ABNORMAL HEAD POSTURE : AHP is a motor adaptation and it is adapted in the interest of comfortable vision COMPONENTS OF AHP : Face turn towards right or left side Chin up or down Head tilt towards right or left shoulder ASSESMENT OF AHP : Compare ear is more visible Check whether eyes are level Observe chin from side

9. CAUSES OF AHP : OCULAR CAUSES Obtain BSV Maintain BSV Overcome symptoms Improve visual acuity Protect eyes Separate diplopia in paralytic strabismus Nystagmus NON OCULAR CAUSES : Shyness Habit Deafness Mental developmental delay Arthritic condition Non ocular torticollis(Contracture of Sterno- mastoid muscle . How to confirm either AHP is ocular or non ocular?

10. EXAMINATION OF COMPONENTS OF AHP FACE TURN: CHIN ELEVATION OR DEPRESSION HEAD TILT

11. AHP IN PARALYTIC CONDITIONS: NEUROGENIC PALSIES : 3 rd nerve palsy Complete Incomplete(divisional or isolated) 4 th nerve palsy 6 th nerve palsy MECHANICAL PALSIES: Brown syndrome Duane’s syndrome AV PATTERNS: A eso or V exo A exo or V eso NYSTAGMUS:

12. Hess chart/lees screen

13. 1:Dissociation of the eyes by either : Red and green goggles in case of hess The mirror in case of lees screen 2:Foveal projection inn the presence of normal retinal correspondence : 3:Herring’s law and sherrington’s law: Explain the development of muscle sequlae. Principles

14. 1:Diagnosis of: U/a or o/a of eom . Mechanical or neurogenic palsy Congenital/long standing Acquired/recent palsy 2:planning of surgery and post-op effects of surgery 3:Monitoring of surgery Full muscle sequlae will include : E.g : sr u/a = io o/a : Ir o/a = so u/a Uses of Hess charts/lees screen

15. What is the direction of the deviation eg : Eso , exo , hyper, hypo? What is the size of the deviation? Is the deviation concomitant or incomitant ? Is there a smaller field ? Which is the affected muscle(s) or nerve(s) ? Has the muscle sequelae spread to produce concomitance ? Is the aetiology mechanical or neurogenic ? Is there an a or v pattern ? Interpretation of Hess chart

16. Diagnose it

17. THANK YOU