Orthoptics Introduction test

Orthoptics evlauation and its test includes accomodation and convergence

1. ORTHOPTICS INTRODUCTION & INDICATIONS Pratyush Dhakal

2. INTRODUCTION WHAT IS AN ORTHOPTIC EVALUATION It is a systemic and step by step phenomenon of evaluation of the efficacy of eye muscles during normal binocular eye movements to maintain binocular fusion. It leads to an idea of Accomodative , Vergence or Fusional Vergence Anomalies and provides a guideline to treat the causes and rectify it by practice of some orthoptic exercises accordingly.

3. INDICATIONS Basic questions to be answered.. Whether the patient has binocular single vision. Whether the patient has diplopia Whether the patient has suppression. Ocular alignment and status of accomodation .

4. INDICATIONS MAIN C/O OF PATIENTS HEADACHE Detailed history should be taken.. Duration Whether it persists for few minutes or continues for long hours.

5. INDICATIONS Time of Onset Is the headache associated only during reading time or any sort of near work. During watching system for continuously. Increases while going out in sun, associated with pain around eyebrows. How it gets relieved

6. INDICATIONS INTERMITTENT BLURRING OF VISION DURING READING The patient complains of sudden blurring of vision after 1-2 hours of reading. Gets worsened after stressful work. Associated with headache.

7. INDICATIONS INTERMITTENT DIPLOPIA Cases of intermittent diplopia should be ruled out as a need for orthoptic evaluation. As it indicates an Intermittent Divergent Squint.

8. INDICATIONS DIFFICULTY TO FOCUS AT DISTANCE & NEAR SIMULTANEOUSLY Some patients complains of difficulty to focus at a near object immediately after looking at a distant object. This might gives an indication of accomodative defect. We need to check the accomodative facility after doing NRA & PRA and MEM findings.

9. INDICATIONS BLURRING OF VISION MORE AT DISTANCE THAN NEAR This may be a case of Divergence Insufficiency. It should be always ruled out with Divergence Paralysis where the patient will have the same problem for distance & near both. Sometimes the patient complains of an inward turning of eyes during distance vision.

10. INDICATIONS SPLITTING OF IMAGES WHILE MOVING AN OBJECT FORWARD This is a case of Convergence Insufficiency. Fusional Vergence needs to be checked to rule out Fusional Anomalies along with convergence insufficiency. Accomodative component should also be ruled out.

11. INDICATIONS INWARD TURNING OF EYES & FATIGUE WHILE READING This may indicate a case of Accomodative Excess or Convergence excess. May lead to accomodative spasm or may be a case of Pseudomyopia . Parents often complain that the child is doing lot of mistakes while writing.

12. INDICATIONS CLINICAL SIGNS.. We will get a varying reflex in this situations. Normally a case of pseudomypia . Patient will accept a high minus. Due to over accomodation . MEM value will show a low value or lead in accomodation .

13. indications Gross reduction in Near Vision. Patient finds difficult to read the N 6 line. If it is a convergence excess then NFV will be low, but we will get a normal MEM value or a little high MEM.

14. ORTHOPTIC EVALUATION STEP BY STEP

15. Orthoptic evaluation WORTH 4 DOT TEST Habitual Correction Red-green goggles Both for distance and near.

16. Orthoptic evaluation 3 green RE-Suppression 2 red LE-Suppression 5 lights - Diplopia

17. ORTHOPTIC EVALUATION MADDOX ROD TEST for detection of distance phoria

18. Orthoptic evaluation MADDOX ROD – PHORIA Patient’s Habitual Correction. RE-Maddox Rod. Fixation light or pen torch. Both distance and near. Measure vertical and lateral phoria . Increasing prisms kept infront of other eye till orthoposition .

19. Orthoptic evaluation NEAR POINT OF CONVERGENCE Maintaining fusion Pentip or Fixation target in RAF Target double Subjectively & Objectively Should be checked recurrently To see if there is a recede of NPC

20. ORTHOPTIC EVALUATION AMPLITUDE OF ACCOMODATION Normally with a RAF rule First binocularly then monocularly Binocularly- Accomodative response with convergence Hofster Formula= 18.5 – (0.3 * Age)

21. Orthoptic evaluation TESTS DONE PUSH UP NEGATIVE LENS TO BLUR

22. ORTHOPTIC EVALUATION PUSH UP N 6 target Move the target Target should be blur Note in dioptre

23. Orthoptic evaluation NEGATIVE LENS TO BLUR N 6 target @ 40 cm Monocularly Subjective correction Add minus lenses Report to blur

24. Orthoptic evaluation NEGATIVE RELATIVE ACCOMODATION N6 target given Add plus lens binocularly 0.25 – 0.50 clicks Note first sustained blur Normal value of NRA is +2.50 DS

25. Orthoptic evaluation POSITIVE RELATIVE ACCOMODATION N 6 target given Add minus lens binocularly 0.25-0.50 clicks Note first sustained blur PRA value related with NFV value measured in Step Vergence test.

26. Orthoptic evaluation Some basic terms NFV : NEGATIVE FUSIONAL VERGENCE It measures the amount of divergence of the patient’s eyes to maintain binocular fusion in presence of a stimulus (minus lens) PFV : POSITIVE FUSIONAL VERGENCE It measures the amount of how much the patient’s eyes converge to maintain fusion in presence of a stimulus( plus lens)

27. Orthoptic evaluation DYNAMIC RETINOSCOPY With static correction Dynamic card attached to to retinoscope Room light on Fixate on dynamic card or read aloud Strongly active accomodation .

28. Orthoptic evaluation DYNAMIC RETINOSCOPY (Contd..) Neutralise both the meridians Static – Dynamic = Lag of accomodation . +0.25 to +1.00 normal Above +1.00D – lag Minus - lead

29. Orthoptic evaluation ACCOMODATIVE FACILITY Dynamics of accomodative response N6 target given Flippers close to eyes Flip when target clears First plus lens side kept Select according to NRA PRA value.

30. Orthoptic evaluation ACCOMODATIVE FACILITY Flipper or accomodative rock Monocularly and binocularly No. of flips per minute is noted Monocularly 12cpm for +/- 1.50D

31. Orthoptic evaluation STEP VERGENCE TEST Horizontal prisms arranged together in increasing steps. First Base-In then Base-Out For distance and near both 6/60 or 6/36 fixation target Base-in for Near (NFV value) correlated with PRA value.

32. Orthoptic evaluation FUSIONAL RANGE Fusional Range( Synaptophore ) Abduction and adduction Fusion slide +7 to -10 degree

33. Orthoptic evaluation AC/A RATIO Ratio of Accomodative Convergence and Accomodation . AC/A Ratio = IPD(cm) + W.D in mt *(Near phoria –Distance Phoria )

34. Orthoptic evaluaTION BROCK STRING Look at the 1 st bead - V shape 2 nd bead – X shape 3 rd bead – A shape

35. Orthoptic evaluation LIFE SAVER CARD CAT CARD

36. ORTHOPTIC EVALUATION ACCOMODATIVE HART CHART

37. Orthoptic evaluation TAKE HOME MESSAGE ‘’Giving a proper orthoptic treatment and follow up report results in rapid cost effective and permanent improvement in visual skills”

38. THANK YOU