PGH Basic Motility Examination (2024).pdf

Slide deck for online lecture given at the 2024 edition of the Philippine General Hospital Post-graduate Course: Basic Course in Ophthalmology

1. Basic Motility Examination
Alvina Pauline D. Santiago, MD
Pediatric Ophthalmology & Strabismus
Basic Course Lectures in Ophthalmology
Sentro Oftalmologico Jose Rizal
Philippine General Hospital
2024

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
#BasicMotilityExam (c) APSantiago 20242

3. Sensory Tests
Motor Tests
•Near Stereoacuity
•Distance Stereoacuity
•Worth 4 Dot
Ocular rotations
Measuring the deviation
Anomalous head postures
Tests of muscle function
Light reflex tests
Other Tests
Outline
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4. Sensory Testing
Near Stereoacuity
Distance Stereoacuity
Worth 4 Dot

5. Outcomes
•Enumerate requirements before performing sensory tests
•Perform correct near stereoacuity test
•Enumerate the different stereoacuity tests for distance and near
•Discuss the basis of stereoacuity tests
•Discuss the importance of sensory testing for strabismus
•Enumerate the indications for sensory testing
•Perform and interpret results of Worth 4-dot testing
•Discuss the 4PD Base out test
•Identify the amblyoscope and discuss its functions
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6. 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
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7. Sensory Testing
•Near stereoacuity
•Fly vectograph/ Titmus Fly Test
•Lang stereotest
•Random dot stereograms
•Distance stereoacuity
•Mentor BVAT
•AO vectograph
•Amblyoscope
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8. Stereoacuity tests
•Horizontal disparity
•Stimulate non-corresponding points
•Image disparity measured in seconds of arc
•40-50 sec of arc = central or bifoveal fixation
•80-3000 sec of arc = peripheral fusion
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9. 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
#BasicMotilityExam (c) APSantiago 20249

10. Lang Stereoacuity test
•Random dot stereogram
•No need for Polaroid
lenses
•Only for gross and low-
grade stereopsis
From Rosenbaum & Santiago, Clinical Strabismus Management
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11. 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
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12. Distance Stereotest
•Mentor BVAT
System
•Very good test
for assessing
control in X(T)
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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13. Sensory Testing
•Worth 4 dot
•near: tests peripheral fusion
•distance: tests central fusion
•Retinal correspondence
•amblyoscope, Bagolini lenses
•4 PD BO test: foveal suppression
•Normal response
•conjugate saccades OU,
•slow recovery in eye without the prism
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14. 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
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15. Worth Dot Test Results
http://image.slidesharecdn.com
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16. Amblyoscope or Haploscope
•Measures fusional
vergence amplitudes
•Angle of deviation
•Area of suppression
•Retinal correspondence
•Torsion
•Instrument convergence
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From Rosenbaum & Santiago, Clinical Strabismus Management 1999

17. Motor Testing
Ocular rotations
The Ideal Target
Anomalous head posture
Tests of Muscle Function
Light reflex tests
Cover Tests
Other Tests

18. Outcomes
•State laws of strabismus and apply to clinical
situations
•Evaluate ocular rotations
•Suggest clinical entities with limited ocular rotations
•Perform correct technique of measuring the
deviation
•Enumerate characteristics of ideal target when
measuring strabismus deviation
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19. Outcomes
•Enumerate factors affecting measurement
•Perform techniques that can ”find” hidden strabismus
•Perform tests of muscle functions and know their
indications and interpretations
•Perform the different light reflex tests, know their
indications and interpretations
•Perform the different cover tests and know their
indications
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20. Ocular Rotations
•State laws of strabismus and apply to clinical
situations
•Evaluate ocular rotations
•Suggest clinical entities with limited ocular rotations
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21. Ocular Rotations
•Duction: monocular
•Version: binocular
•Alert to pattern deviations: e.g., A, V
•Grading scheme:
•e.g., inferior oblique & superior oblique
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22. Agonist Muscle and its Antagonist
•AGONIST: muscle
that cause specific eye
movement
•MR: adduction
•LR: abduction
•SR: supraduction
•IR: infraduction
•SO: intorsion
•IO: excyclotorsion
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23. Agonist Muscle and its Antagonist
•AGONIST: muscle
that cause specific eye
movement
•MR: adduction
•LR: abduction
•SR: supraduction
•IR: infraduction
•SO: intorsion
•IO: excyclotorsion
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•ANTAGONIST
muscle: creates
movement opposite
that of the agonist.
•MR-LR
•SR-IR
•SO-IO

24. Yoke Muscles & Synergists
•YOKE muscles:
muscles that cause 2
eyes to move in same
direction
#BasicMotilityExam (c) APSantiago 202424
RMR
LLR
RSR
LIO
RLR
LMR
RIR
LSO
RIO
LSR
RSO
LIR

25. Yoke Muscles & Synergists
•YOKE muscles:
muscles that cause 2
eyes to move in same
direction
#BasicMotilityExam (c) APSantiago 202425
RMR
LLR
RSR
LIO
RLR
LMR
RIR
LSO
RIO
LSR
RSO
LIR
•SYNERGISTS: muscles
moving 1 eye in the same
direction
•Adduction: MR, IR, SR
•Abduction: LR, SO, IO
•Intorsion: SO, SR
•Extorsion: IO, IR

26. Ocular Rotations
Cardinal gaze positions
RLR
LMR
RMR
LLR
RSR
LIO
RIR
LSO
RIO
LSR
RSO
LIR
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27. Ocular Motility Evaluation
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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28. Ocular Motility Evaluation
RLR
LMR
RMR
LLR
RSR
LIO
RIR
LSO
RIO
LSR
RSO
LIR
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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29. (L) Inferior oblique dysfunction
+4 +1
-4 -1
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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30. (R) Superior oblique dysfunction
+4 +1
-4 -1
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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31. Laws of Ocular Motility
•Hering’s law of equal innervation (of yoke muscles)
•Conjugate eye movements
•Dissociated Vertical Deviation violates Hering’s
•Sherrington’s law of reciprocal innervation (of
agonist-antagonist muscles)
•Duane co-contraction syndrome violates Sherrington’s
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32. Clinical Examples:
Primary vs Secondary Deviation
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From Rosenbaum & Santiago, Clinical Strabismus Management

33. Clinical Examples
#BasicMotilityExam (c) APSantiago 202433
From Rosenbaum & Santiago, Clinical Strabismus Management

34. Clinical Examples
#BasicMotilityExam (c) APSantiago 202434
https://www.aao.org

35. Measuring the Deviation &
The Ideal Target
•Perform correct technique of measuring the
deviation
•Enumerate characteristics of ideal target when
measuring strabismus deviation
•Enumerate factors affecting measurement
•Perform techniques that can ”find” hidden
strabismus
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36. Motor Testing
•Primary gaze
•Right and left gaze
•Up and down gaze
•Right and left head tilt
•Oblique gazes, occasionally
•Near: primary and down gaze
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37. Cover Tests
•Requirements:
•Appropriate correction
•Know if correction with or without prisms
•Accommodative target (above threshold)
•Distance:
•6 m: 1/6 D of accommodation
• approximates infinity
•> 6 m: X(T)
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38. The Ideal Target
•“Accommodative target” but Above threshold
•e.g. Snellen acuity 20/20
•present 20/50 to 20/70
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39. The Ideal Target
•With sufficient detail and contour
•Should sustain interest
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40. 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
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41. Factors Affecting Measurement
•Prism placement:
•plastic prisms: frontal
•glass prisms: prentice
•Stacking prisms
•Splitting prismsFrom Rosenbaum & Santiago, Clinical Strabismus Management 1999
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42. Factors Affecting Measurement
•Method of testing:
•Light reflex:
•Brückner
•Hirschberg
•Krimsky/modified
Krimsky
•Different cover tests
•Cover Test
•Alternate Cover Test
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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43. Factors Affecting Measurement
•Patient factors:
•Accommodation and AC/A ratio
•Axial length and globe size
•Amblyopia and eccentric fixation
•Refractive error and induced prisms
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44. Techniques in Finding Strabismus
•Brückner test
•Spielmann translucent
occluder
From Rosenbaum & Santiago, Clinical Strabismus Management
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45. Anomalous Head Posture
#BasicMotilityExam (c) APSantiago 202445
Santiago AP, Rosenbaum AL. Dissociated vertical deviations and head tilts. J AAPOS 1998; 2: 5-11.

46. Anomalous Head Posture
#BasicMotilityExam (c) APSantiago 202446
From Rosenbaum & Santiago, Clinical Strabismus Management

47. Tests of Muscle Function
•Perform tests of muscle functions and know their
indications and interpretations
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48. Tests of Muscle Function
•Forced duction test
•Force generation test
•Saccadic velocity analysis
•Electromyography
•Dynamic MRI
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49. Indications
•Incomitant deviation
•Limited ocular rotation
•Distinguish between restriction and paresis/palsy
•Distinguish between paresis and palsy
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50. 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
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51. Advantages
•Help in deciding between treatment options
•Monitor improvement of paretic muscles
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52. Tests of Muscle Function
•Paresis vs. restriction
•Forced duction test
•Force generation test
•Saccadic velocity analysis
•Differential intraocular pressure
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53. 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
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54. 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
#BasicMotilityExam (c) APSantiago 202454
From Rosenbaum & Santiago, Clinical Strabismus Management 1999

55. 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 conjunctiva fused in one layer
•limits stretching/tearing of conjunctiva
•provides firm grasp
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56. Passive Forced Duction
From Rosenbaum & Santiago, Clinical Strabismus
Management 1999
•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
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57. Passive Forced Duction
•For oblique muscles
•Retroplace globe
•Follow oblique muscle path
•Guyton’s oblique traction test
•Stress test for obliques
•Retroplace globe
•Torsional movement
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58. Oblique traction testing
From Rosenbaum & Santiago, Clinical Strabismus Management 1999#BasicMotilityExam (c) APSantiago 202458

59. Oblique traction testing
From Rosenbaum & Santiago, Clinical Strabismus Management 1999#BasicMotilityExam (c) APSantiago 202459

60. 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
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61. Forced Duction Results
•Absolute restriction
•Graves, Brown
•Uniform restriction
•Scar tissue, muscle contracture
•Leash phenomenon
•Scar tissue, long standing contracture
•Duane syndrome
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62. Pitfalls: Forced Duction
•Patient apprehension
•Errors in technique
•“Falling off”
•Failure to proptose for rectus or retropulse globe for obliques
•Succinylcholine (Anectine)
•Posterior restrictions
•Co-contractions
•Co-existing paresis and restriction
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63. Active Force Generation
•Apply a counteracting force
•Using the same grasp on
limbus
•Counter-traction to feel
resistance
•WOF: corneal abrasion,
conjunctival hemorrhage
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From Rosenbaum & Santiago, Clinical Strabismus Management 1999

64. Active Force Generation
•Differential IOP
•Paresis vs. palsy
•Combined paresis and restriction
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65. FDT, FGT, Diagnosis
DiagnosisForced DuctionForce
Generation
Mechanical
restriction
RestrictedNormal
Muscle palsyFreeAbsent
Paresis &
restriction
FreeWeak
#BasicMotilityExam (c) APSantiago 202465
Common pitfall: mild paresis
Correlate with saccadic velocity analysis

66. Saccadic Velocity Analysis
•Study eye movement velocity
•muscle activity
•return of muscle function
•EOG : problem when testing vertical saccades
•Infrared
•Scleral search coil
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67. Office Saccadic Velocity
•Look at 2 separate targets
•At least 20 deg movement
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 1999
#BasicMotilityExam (c) APSantiago 202467

68. 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 1999
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69. Clinical Applications:
Saccadic Velocity Analysis
•Paralytic Strabismus
•Restrictive Strabismus
•Lost or slipped muscles
•Neurologic Disorders
•Myasthenia Gravis (MG)
•normal then weakens;
•use with Tensilon
•Progressive External
Ophthalmoplegia (PEO)
•general slowing
•Inter-nuclear
ophthalmoplegia (INO)
•slowed adduction
•normal abduction
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70. Slowed Saccadic Velocities
•LR palsy abduction
•SO palsy downgaze
•Moebius horizontal
•Myasthenia normal then slows
•Slipped/Lost reduced 20-50%
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71. Light Reflex Tests
Brückner Test
Hirschberg’s corneal light reflex tests
Krimsky / Modified Krimsky
•Perform the different light reflex tests, know their
indications and interpretations
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72. Brückner Test®Ametropia
®Strabismus
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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73. 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 1999
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74. Krimsky vs Modified Krimsky
•in front of deviating
eye (modified
Krimsky)
•underestimates true
angle
•better at near
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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75. LIGHT REFLEX, COVER TESTS
(Courtesy of R. Pena, MD)
MODIFIED KRIMSKY
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76. Cover Tests
Cover Uncover Test
Alternate Prism Cover Test
Simultaneous Prism Cover Test
Prism Under Cover Test
•Perform the different cover tests and
know their indications
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77. Cover Uncover Test
•Must be performed
before alternate
cover test
•Cover test: tropia
•Uncover test:
phoria
•Also for fixation
preference
#BasicMotilityExam (c) APSantiago 202477
https://www.youtube.com/watch?v=f5HbIZi4u70

78. 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)
•End point: No movement of eyes
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79. ALTERNATE PRISM & COVER TEST
Gold standard for
measuring deviation
LIGHT REFLEX, COVER TESTS
(Courtesy of R. Pena, MD)
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80. 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
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81. SIMULTANEOUS PRISM & COVER TEST
Used for monofixation
LIGHT REFLEX, COVER TESTS
(Courtesy of R. Pena, MD)
#BasicMotilityExam (c) APSantiago 202481

82. 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 the other eye
#BasicMotilityExam (c) APSantiago 202482

83. PRISM UNDER COVER TEST
Used for DISSOCIATED
VERTICAL DEVIATION (DVD)
LIGHT REFLEX, COVER TESTS
(Courtesy of R. Pena, MD)
#BasicMotilityExam (c) APSantiago 202483

84. Dissociated Vertical Deviation
Courtesy of N. Paderna, MD
#BasicMotilityExam (c) APSantiago 202484
DVD OD
DHD OS

85. Cover Tests
Cover TestIndication
Cover Uncover TestPhoria
Alternate Prism Cover
Test
Total Deviation
Prism Under Cover TestDissociated Vertical
Deviation
Simultaneous Prism
Cover Test
Monofixation Syndrome
#BasicMotilityExam (c) APSantiago 202485

86. Other Tests
Red Glass Test
Parks 3-step Test
Evaluation of Torsion
MRI for Imaging
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87. Outcomes
•Know how to perform the red glass test and interpret
results
•Know the indication for the Parks 3-step test
•Perform the Parks 3-step test and interpret the results
•Enumerate the different tests for torsion and know
how to perform them
•Enumerate the indications for MRI for strabismus
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88. Red Glass Test
#BasicMotilityExam (c) APSantiago 202488
https://entokey.com/diplopia-2/

89. Red Glass Test
#BasicMotilityExam (c) APSantiago 202489
https://entokey.com/diplopia-2/
RL
-drawn as patient sees it
-uncrossed diplopia: Esotropia
RL

90. Red Glass Test
#BasicMotilityExam (c) APSantiago 202490
https://entokey.com/diplopia-2/
-drawn as patient sees it
-crossed diplopia: Exotropia
L RLR

91. Red Glass Test
Right hypertropia
•red image below
white image
•Drawn as patient
sees it
#BasicMotilityExam (c) APSantiago 202491
https://entokey.com/diplopia-2/

92. Parks 3-step Test
•Isolated
cyclovertical
muscle palsy
#BasicMotilityExam (c) APSantiago 202492

93. Parks 3-step Test
Left Hypertropia
1.Of 8 cyclovertical
muscles: 4
LSO, LIR, RSR, RIO
2.Of 4 cyclovertical
muscles: 2
increase on R gaze: LSO,
RSR
3.Of 2 cyclovertical
muscles: 1
increase of L tilt: LSO
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94. (Masked) Bilateral
superior oblique palsy
•V pattern
•Reversal of hypertropia
•Frames 1 and 3
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95. Torsion Evaluation
•Funduscopy
•Fundus photography
•Blind spot mapping
•Red-Green Hess/Lee Screen
•Double Maddox Rods
•Oblique (& Vertical) muscle dysfunction
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96. Normal Optic Nerve Head-
Fovea Angle Relationship
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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97. Direct Ophthalmoscope View:
Fundus Torsion
ExcyclorotationIncyclorotation
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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98. Indirect Ophthalmoscope View:
Fundus Torsion
ExcyclorotationIncyclorotation
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Flipped image from Rosenbaum & Santiago, Clinical Strabismus Management 1999

99. Inferior Oblique Overaction
PREOPPOSTOP
From Rosenbaum & Santiago, Clinical Strabismus
Management 1999
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100. Torsion Test: Double Maddox
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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101. Magnetic Resonance Imaging
•Cross-sectional area
•Applications:
•EOM palsy
•EOM heterotopy
•Severed/extirpated muscles
•Entrapment
•Mass
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102. Normal coronal section
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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103. Demer, J L. Miller JL. “Orbital Imaging in Strabismus Surgery.” Clinical Strabismus Management, 1st ed., W.B.Saunders Company, 1999, pp. 84–88. Google Books,
Macias, Emilio, III. ”Pattern Strabismus.” Pediatric Ophthalmology and Strabismus: A Comprehensive Guide to Diagnosis and Management, 1st ed., 2022, 306.
Normal coronal section

104. From Rosenbaum & Santiago, Clinical Strabismus Management 1999
MRI for Imaging
#BasicMotilityExam (c) APSantiago 2024104

105. CASE 1CASE 2
Courtesy of J. Redondo Villanueva, MD
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High Myopia with Esotropia

106. G = globe
L = LR
S = SR
Angle of Dislocation of the Globe
Yamaguchi M, Yokoyama T, Shiraki K. Surgical procedure for correcting globe dislocation in highly myopic strabismus. Am J Ophthalmol. 2009; 149:341.e2–346.e2. [PubMed: 19939345]
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107. References
•Rosenbaum AL, Santiago AP. Clinical Strabismus
Management: Principles and Surgical Technique
1999, Elsevier, Philadelphia.
•Santiago AP, Rosenbaum AL. Dissociated Vertical
Deviations and Head Tilts. J AAPOS 1998; 2: 5-11.
•Von Noorden GK. Binocular Vision and Ocular
Motility: Theory and Management of Strabismus.
1990, Mosby, Philadelphia.
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108. Laser vision ;-)
No more than a pinhole effect!
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