Orthoptic examination

guide lines for orthoptic assessment

1. General orthoptic Examination Siraj Safi

2. Introduction Examination of the patient has two main aims. Diagnosing the nature and degree of the ocular motor disorder. Detecting other ocular and non-ocular disorders and assessing their relationship to the motility problem.

3. Examination Order Assessment of the patient’s appearance, including his facial features and head posture. Measurement of the uncorrected and corrected visual acuity Observation of the position and function of the eyelids. Observation and measurement of the position of the globe.

4. Examination Assessment and measurement of the ocular deviation and ocular movement Refraction with cycloplegia Investigation of binocular function Laboratory and radiological investigations

5. Examination Order General Appearance : The following condition are associated with high incidence of strabismus and eye movement problems Hydrocephalus Microcephalus Albinism Downs syndrome etc

6. Examination Order Head posture? An abnormal head posture has three possible components Face turn to the right or left side Head tilt to the right or left shoulder Chin elevation or depression

7. PIC 1

8. Examination Order Visual Acuity Applying proper test and method of assessment To find out any decrease in vision

9. Examination Order The eye lid The eyelid position is symmetrical on both sides. The height of each palpebral fissure is 9-11 mm The resting position of the upper eyelid margin is 1-2 mm below the superior limbus . Movement of the upper eyelid from down-gaze to up-gaze measures 15-1 8 mm. This relationship is normally maintained in the different positions of gaze.

10. Examination Order Eyelids Palpebral fissures Variants from the normal palpebral fissure shape or size can result in pseudostrabismus or can be characteristic of certain ocular motility disorders.

11. Fissure changes during ocular movement An increase or decrease in the height of the palpebral fissure can be characteristic of some incomitant conditions, for example: Narrowing of the fissure on adduction and widening on abduction are diagnostic features of Duane’s retraction syndrome. The fissure commonly widens on adduction in Brown’s syndrome.

12. Epicanthus Epicanthus is a fold of skin which arises in the medial portion of the upper eyelid and is inserted into the lower eyelid at the medial canthus . It is usually bilateral and symmetrical Epicanthus gives rise to pseudoesotropia in young children Epicanthus is physiological and usually disappears by 7 or 8 years of age

13. Blepharophimos Blepharophimos is an upward fold of the skin of the lower eyelid near the inner corner of the eye , where the patient has bilateral ptosis with reduced lid size, vertically and horizontally.

14. Eye lid position and movement Eyelid anomalies comprise: Upper eyelid too low- ptosis or pseudoptosis ; Upper eyelid too high-lid retraction / lid Lag Abnormal eyelid movement Marcus Gunn jaw-winking phenomenon Aberrant regeneration

15. ocular deviation and ocular movement ocular deviation Preliminary inspection should include comparison of the corneal reflections in the two eyes as the patient fixates a light source at 33 cm A cover test should be used at near and distance to detect the deviation and differentiate manifest and latent strabismus The prism cover test is the preferred routine method of measurement in suitable cases

16. ocular deviation and ocular movement Ocular movement Versions and ductions should be assessed by asking the patient to follow a moving target, usually a spotlight, from the primary position to the limit of each of the other eight positions of gaze The movement of the two eyes should be compared and underaction and overaction noted. An alternate cover test should be used to confirm the findings

17. Cycloplegic Refraction Cycloplegia is essential for accurate refraction of children, otherwise full correction of the refractive error may not be achieved

18. Binocular function Binocular function Comprises Retinal correspondence Supression Sensory and motor fusion Stereopsis

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