c

h
a
p
t
e
CHIEF COMPLAINT, r
1
HISTORY, AND
PHYSICAL
Patients complaining of double vision may actuully be
describing blurred visin
ASHISH MEHTA, MD
rather than diplopa. Ir true diplopa
exists, ascertain whether it is monocular or binocular. If the double
EXAMINATION
vision is monocular, ocular disease other than a motility
disturbance should be considered. such as corneal abnormality.
lenticular opacification. or retinal pathology.
Binocular diplopa and/orstrongly suggcsts aarestrabismic
vertical dcviations neutrulizedoriginowith prisms in free spacc
Patients with anChief obvious
or with thc Complaint
cause such as paralytic
synoptophore. The latter or canrestrictive
also neutralize a torsional
strabismus often describe
component the location of two disparate
01" strahismus. ln strabismus imagcsthat in is acquircd aftcr
theThe
horizontal and vertical
visualand
most irnportant planes
maturity but
revealing have
(usually di fficulty
alter
component ageof7),appreciating
thepatients
medcal who do not describe
torsional
history ismisalignment.
the chiefdiplopa The latter
complaint. may
mayConcise be and
be ignoring described
a second
clear as slanted.
image.but
questioning especially when the
is
this term The
required. is also used
specific to
deviation describe
ocular is or
large: a combination
visualor they may havc
disturbance of that
vertical
poor and
Icdvisual
the acuity in one eye
horizontal misalignment.
patient to seek so thatTo
ophthalmologic twoconfinn
distinct torsion.
images paticnts
care provides are not
the should
irstseen.
insight look
Paticnts
into younger than age
at
thea patient's
vertical problem.
line (c.g., Iftheanswers
7 Irequently cdgclearnofareto
a door)
supprcss
vague, and a describe
sccondshould
questions ti Iting.
image. be
Patients
rephrasedwho appreciate
to clarify theVisualtilting
Asthenopia should
refers
confusin
patieru's or parent'sbe carefully
10 symptoms
results when evaluated
concern. of ocular
the foveachief
Certain for
fatigue
of cach or
eyetiredncss.
sees IwO It
torsion (seeare
complaints Chapter
oftenis 4).
different
heard Precipitating
usually associated
objects
frorn factors
that
patients with such 10
presenting as atrauma
interpreied
are sustained near orbrain
work
by the
strabisrnus abUI asmay also in
heing occur
the
cerebrovascular
practice. A few of accident
with
sume
these should
distance
Abnormal
visual
wiJl be
eye noted,
vision
direction.
be discussed movementsand
andwithin
may one
Visual be
may
theshould
aframework
result
confusion verify
be described if as
01'isstrabismus
an
01" or refractivo
"wobbly
expccted sensory
eyes"
specific
obtainingevents suchor
a history. as"cyes
reading,
problems
response that
in ahot
or patients
do weather.
combination moveorof
not having fatigue
both."
together,"
an ocular precipitate
Refractivc
This type asthenopia
deviation with good rcsults
of complaint can
fovcal
Irom
the onset 01" intcrmittcnt
usually
function diplopa.
anbeinimproperly
c1aritied
both eyes. bycorrectcd
asking
Patients.therefractivo
parent
however. error.
or patient
may not Relation
to point
be able
tolothc
lOa
If the sume object 01" interest
particular
abnormal
accuratcly is seen"Wobbly
activity
eycts).
describe by
such theasphcnorncnon.
this fovea
eyes" of may
reading, oneor eye
ro
much
meanand
a certain
that time of day,
less avolunteer
patient has
the
the peripheral retina in the
should
nystagmus,
information,he deviated
sought.
"Eyes eye,
Is
The c1inician
that dodiplopa
therc notassociated
maymovc results.
need Most
diplopia
10 ask or visual
specific blurring?
questions to
OIPlOPIA ANO VISUAL CONFUSION
patients with diplopia Are become
symptoms
identify aware
patients of avisual
rclicvcd
with second image.
whenconfusion.
the Diplopia
initiating activity is discontinued
3
may be relieved when the horizontal
or when the patient reads with onc eye covcrcd?
ABNORMAL EVE MOVEMENTS
ASTHENOPIA
4prcfcrencc
CLI1 ICAL icsting
20/20 reliahly
STRABISMUS
CHIEF detccts
COMPLAINT. MANAGEMENT arnhlyopia
HISTORY. ANO if the dcviation
onlyPHYSICAL EXAMINATION 5
cxcccds 1.210- PD.~'
20/25 Otherwisc. other clinical methods 01" asscssing visin
are rcquircd,
5
2.5 20/50
togetherThc IO-PD " muy test Mobius
reflect an syndrome.
incomitant
is isthespccificully
sanie and
in both designcd
eycs, craniofacial
strabismus to such
alternating anomalies
asscss as fixation
fixation Duane
should(see be Chapters
noted when 24. 26. the
syndromc.
prefcrcncc
al inA prcvcrbal
complaint
and
prism 30is01'
for
childrcnmovedahnormal
a more
who tromare eyc
dctailcd
not eye
onc movement
discussion).
strabismic
10 the other, or should
who Thehuvc he can rcliably prcdict
test
cxplorcd
small deviations.
Q. further lthy may asking
thc heabscnce aboutoftheunequal
pcrformed presence
cither in thc ofbase-down
vision a in prefcrrcd gazc patients with free
or basc-
orthotropic
.: 5 20/100
position
up or wherhcr
position." an anomalous
The alternation
prism aftcrhead
is placcd in posture
induccd ofis one
frontesotropia. adopted, eyt!
11' a while
strong an fixation prcfcrcncc is
-
(/)

.....
appropriate
e accommodativcfound. target the test Physical
is prcscnted
may not be aExamination
al near and/or indicator
reliablc distancc. of uncqual visual
E 10
Spontaneous alicrnation 20/200 acuity: 01' afixution
fixutionbetwcen prcfcrcncc themay eyes should
two persist in treatcd he amblyopes despite
e
observed, 11' one cyc the sumeis clcarly rccognition prctcrrcd,
ASSESSMENTacuity thatincye bothiseyes.
OF covercd
VISION 10
oallow the other cye to assumc PatientsHistory
fixation and be obscrvcd
with infantile esotropia for whomaintcnance
demonstrate cross fixution can
--
o
:J 20
(/)
blink.
al 40or -wiih
20/400 Visual
01' tixation. 11' tixation
Past History signs inpast
a smooth
occurs
acuity
is heldstatcd
be reliably
other
pursuit.
for more testing
theficlds
10 havc in
than cqual ophthalrnology
5 scconds,
of inmedicine.
approximately
midlinc
acuity through
cithcr equal cyc.
onlyisif akin
It Ifprovides
a to obtaining
switching
fixationiscrucial
acuity prcfercncc
01' Iixution
information
vitul
persists
a: Gcncrally,
prcsent.History questions
20/800
Smoothofpursuii regarding
altermay
patching asked visual
during
be elicited
History
moving function
history
a targct at near and
taking
pastbymidlinc is the
should
movinginto key bemeasure
based
thc abduction.
lixation for monitoring
unequal acuity the
on theand
targct ofchief complaint.
spectacle
at distancc effectiveness
wear
exists. Certain
Type
by rotating
The eye of thc ofpaticnr's
basic
that treatmenl
information
does not headpie kin isor amblyopia.
uprcquircd
fixation
swivcling thc It helps predict
isfrom
umblyopic."
strabismus
any patientchair," History
with Thcprcoperativeof
a strabismic and postoperative
disorder, This intorrnationmonocular isfixation preference.
cxamining trauma Previous surgery
same proccdurc is performcd on thc othcr
summarized
cye. in Tablcwhich
Strabismus surgery
1-1. muy influence rnanagernent.
11' patients
Othercannot
Orthotropic ocular recall
patients Complete
without
procedures specific occlusion
a tixation strabismus is mandatory
prcfcrcncc surgical for
on theproccdures.
IO-PD monocular
test assessrncnt 01"
they usuallyRetinal
will dcmonstratc rerncmber visual
reattachment
no acuity.
whether
diffcrence
Othcr mcthods An
surgery
surgery
in occlusive
rccognition
01' was performed
visual patchasscssmeru
acuity
acuity should
in oncbe
bctwccn orinused
the preverbal in any child
childrcn
both
two eycs.": Repair
eyes. This of orbital
without
canincludc
~7 Orthotropicguidc patientsAlternate
floor
nystagmus.
the fracture
c1inician
who havc
Methods
Childrcn
in seeking
a tixution
of
reponed
clucs Assessing
10 havethe
during
prefercncc.
Vision
normal
or in
acuity in both
Glaucoma implant optokinctic
surgery nystagmus (OKN) rcllcx testing. torced-choice
ocular
exhibir examination eyes
(c.g
than 10prcfcrcntial
lessBlepharoplasty PD 01' may inlooking
.. conjunctival
dcviation. reality(FPL) be Preverbal
profoundly
scarring).
cannot TheChildren
be rcliably amblyopic
direction
concludcd in acuity
of onc. Visual acuity
Visual tcchniqucs
Milestones (c.gin Teller
..Infancy curds), and
the deviation
10 ha ve amhlyopia is
Cata ractsweepreports
usually
bascd
surgery from
not another
forgotten.
on tixarion analysis
visuul-evokcd exarniner
cspecially
potentials alonc. may if have
prcopcrativc
(VEP) (Fig. 1_1 ).In bcen obtained binocularly
photographs are
A falsc impressionThc
Periocular or
available, with
surgery inadcquate
Photographs
Atofbirth. cqual a blinking
appropriatc occlusion
vision are invaluable
response
binocular thatto allowed
in a monoixator hright
response topeeking
for assessing
lights with
theshould OKNthrough the good
besrimulus
presento Ais
an anomalous
periphcral fusion maySinushead eye.
posturc.
surgery
Ashe early
vcstihulo-ocular
consistcnt gaincd as from
with 3reflcx
months
visual thisisacuity
test.
observcd
Altcrnating
of agc, of someby fixation
7 infants
days
approximaicly in may
a full-tcrm infant."
show transient
20/400 in ihc
Thc Orbital
prcscnce decompression
01' associated surgery
neurologic signs and syrnptoms may
may be observcd It
aftcr
Neurosurgery mayrcmoving
fixation
ncwborn.": beano induccd thc
As eye
22following by from
the gcntlc, itssystem
response
visual Iacultutivc
rapid .. rotation
This
matutes. scotoma
ofvisual
progressivclythe child's head
improves.
acuity to one
corrclates and
providc crucial
during presentation of diagnostic
bythc
side
with tian vertical
(doll's
months assistance:
appropriatehcad prisms.
of agemancuver).these
the the
11' infant
increase includc
The
in paticnt
the shouldnormal
OKN heudachc.
clearly
cxpericnccs
responseresponse until isiland
fixate a nystagmus
follow
reuches 2000 an
seizures. Birth ataxia.
History
vertical diplopia. tixaiion ucquired
Age
with
object.
by may
ageboth Atnystagmus.
20be athis
slow
to switchcd.
30ugeand muscle
andfast
rnonths. giving weakness.
(succadc)
thereafter.a fulsc
Unfortunately. the fatigue.
impression
phase. words which
OKN shouldsteady,
"central.
testing subside
has scvcral in
and
ptosis, ofand bowel
gestation
01' cquul acuity. limitations." or
Birth bladder
Maintcnancc
approximately
maintained (CSM incontinence.
Thc01'3 targci
seconds. Variability
) .. arestimulus
Iixation usedA to
should blind in
describe
must c1inical
be orobscrved
ocabnormally
rixation
prcscntcd sightcd
ability.
undcr child
"Central"
rigidly
weight
features ora worsening with
throughout Problems during
pursuit.
cannot
smooihstandardized
refers pregnancy aAfatigue
toeasily inhibir
poorcr-sccing
corneal
test suggests
the induccd
light
conditions cyc
reflexmyasthenia
will
from
spccifying bealighting
vestibularunablcgravis.
tixation nystagrnus,
10 light
and which
falJing
thc spccd 01'in may
the
target
Characteristic systcmic
pcrform ihis task. rcvcaling take
cerner abnorrnalities
more
presentation its
of truc than
the lOvisual
15
pupil. may
lolcvcl.
stimulatc be
30 seconds
The rcexnoicd
both is in
toalso
central paiients
resolve.
considercd with
and peripheral normal if it falls
visiono Thesc in
Duane syndrome.
Oevelopmental
Altcrnativcly. 25-PD Milestones
theIn samcneonates.
base-inlocation
rcquirements Motor
thcitbest
prism
makc in fixation
can
difficult be 10used
both cyestarget
rcpcat inundcr
theis themonocular
preverhal
test human
with theface-if
OKN not the
conditions.
drum in
and speech
childrcn." The test need development
examincrs not heof then Delay ccrtainly theocclusion
mothcr's. Visual rnilcstones mayboth be
Steadiness
thc clinical fixation
pcrformcd
setting. is with
asscssed
Morcovcr, withOKN
the a 01'
musclecithcr
responselight held in tront
rcquircs 01"
of visual maturation
delayed inasprematurity and neurologic disease. Cerebral
cyc. or through a smooth the child
normal pursuit.
(sensory) itEither
is moved of these
input and rnancuvcrs
slowly.(motor) An accomrnodative
may
output, result
An infant withpalsy
target such
a normalmay
as a

.-",
. ,#.'
Figure
in loss Family 1-1. Comosnson
of coopcration be and
srnall. of
associated
an svsremanc
thurnb-sized with acully
ahnormal data or absent
test assumes saccades (generatcd as the
History sensory
obtained wnb optokmeuc nystagmus (OKN) testmg.
unreliable
systcm will roy have isabcst
rcsult, Thc
poor coupled
OKN with
response the
thatir light.
a motorNystagmus
problern
"
or
IixutionPresence
torcea-cboce will
Table be1-1. fast
prcfcrrcd
of exists. phase
oscillations
hereditary
preteceoust History The
lookmg
inof nystagmus).
thc
rcsult
response
forms
Taking (FPLJ,
eyc
ofinin wiihout
unsteady
has
strabismus
Strabismus
and The normal
been
visual
prisms
tixation.
obscrvcd
Response fast inphase
bcforc
"Maintcnanccir,maywithout
infants notofbe evident.
" fixation"
a visual

.'
.',''- ..........
bccausctoootenust
evoked prisms
strabismus Following
induce
refers an
surgery
cortex.
(VEP) ofmovements
tocsotropic
the
suggcsting
{Moddied ability
family
fromshift ro und
members
iluuDobson may
kecp
an noteye
a the be duc
conscqucnt
cxtragcniculatc
V. fixed toonsmooth
decline
systcm a target pursuit
incxists.'when but either rather
eye
.,# .. __ .... - ,
may rcprcsent mtents.hypometric saccades. These ,
acuity.DY:
Tel/er 11' acuityofscunv
VIsual
Review is mcovered.
Systems FPL
human tcchniqucs rely
A reviewon thcand principie that an ,,,,, infants
infant prcfcrs rnay be
comoenson of behavioral and etectrophyslologlcal ,, ,
misdiagnoscd
The CSM asrncthod bcing blind cannot bccause reliablyof poor saccudic
detect
, , cxcursion.
amblyopia unless
slUdles Neurologic
Vls/on Res symptoms 1978: 18 1469- 7483 Reprmled ,,' ~
strabismus with a fixation preferencc is prcscnt. Fixation , ,,.,x
.....
Other systemic
wirh perm/ss/on of Elsev/er abnormalities
Sc/ ence.J
Fixation Patterns ,
, 0
8
-- -'
.
-' "
, ,
6 CLlNICAL STRABISMUS MANAGEMENT

X Fantz. el al (1962) - OKN

b. Alten (1978) FPL
Sokol (1978) VEP
Marg. el al (1976)
VEP "" Harter. el al (1977)
VEP 20/1600
1 3
O Held. et al (pers.comm) FPL5
6
4
Age. months\J Alkinson & Braddick
Io (1978) FPL 2
I
 -

paid ro anomalous head postures. Distancc and near acuity testing

should he repeated in the torced primary position to check for
Figure 1-2. Teller acuity cards used for resting viston In
dctcrioration, preverbal children. tcooaes of Visrech Consultants. Inc.J
When assessing monocular vision in a patient with nystagmus. un
As childrcn become occludcr
verbal.placed in front acuity
rccognition eye muy
01' one may cause nystagmus to worsen.
he assessed.
Allen
to lookpicturcs lcading
or matching
at a pattcrn stimulusgamos a decline
torather (e.g rccordcd
inhomogencous
than.. aShcridan acuity.
Gardner target (Fig.means of monocular
or Other
HOTV
1 may he
1-2).~' ~~ used asocclusion
Reliable should
initial rcquires
tesring rccognition beacuity
used tests.
a cooperative thatchild
providc
hutas thc
wcll as a Iorm 01' pcriphcral
sorne
gold
standardobservcr,
traincd binocular
is to useTeller
Sncllcn cues
cardsto letters.
oprotype
acuity preventAsrcsolution
measure worsening 01' nystagmus
thc child acuity
maturcs. in hut permit
illitcrate
cycles perEdcgrcc. monocular
testingThis
becomcs
muy ovcrcs assessment
possible.
timareAIIen 01'pictures
Snellcn centralovcrestimate
recognition
visiono
acuity."Four methods are
acuity when
Fixation prcfcrcncc
commonly
comparcd is with
a more
uscd: remole
the illiteratc
reliahlc E
occlusion,
or Sncllcn
indicator opiotypc
high acuity.
of amblyopia
plus len ses for fogging,
than
Parcnts may neutral
practico thc dcnsity
E gamc filler.
at homcor American
with theOptical
child (AO) vecrograph testing.
hefore
Tellcr acuity cards in paticnts with strahismus.!" Thc bcncfit of FPL
testing. Also. Snellen The mcthod
optotypes used(lctters
to measure or acuity should
numbers) canhe henotcd, ano subsequent
techniqucs lies in their ability to sequcntially follow patients with sus-
introduced cvcn in atcstingyoungshould
child use the same method
to familiarize so that
thc paticnt withmeaningful
thc cornparisons
pcctcd subnormal visiono cnsurc that vision is dcvcloping
test. of visual ucuity ean be obtaincd.
appropriately in both eycs. and monitor amblyopia thcrupy."
Older chiklren are ahle Remoto occlusionstandard
to memorize is most rcJiable in coopcrative
eyc charts in most patients.
Swccp VEP tcsting has bccn rclincd sincc its original description.
olficcs. This can The occluder is placed
he circurnvcntcd by aasking
ccrtain patients
distance in to front
rcudof one eye hut close
~ However. dcspite convincing cvidcncc of its validity in assessing
backward or bcginenough in theso middlc
that thcbeforecyc cannot sec the
proceeding eithcr syrnbols prcsentcd.
in acuity
visual acuity, its uscfulness is limitcd bccausc it is a sophisticated test
dircction. The Mentor Alternatively.
BVAT system a translucent
allows theserniopaque (Spielmann)" occludcr may
rundom gencration
rcquiring cxpcnsive cquipmcOl ano tcchnical cxpcrtisc."' 2~ .. 17. ~I
01' acuity symhols. be Thisusedis (Fig. 1-3). advantagcous
cspecially High plus lensfor amblyopic
occlusion is a simple yet cffcctive
patients rcceiving treatment
techniquc. whoAmake lens frequent + 4.00
at least officc visits.
O lsolated
more than the known or
targets overestimatcanticipated
acuity in patients
refractive bothcred
error forby acrowding when can
given distance oc uscd. 11'
targets areAssessment
prcscntedneutral ofdcnsity
in a line. Vision in Nystagmus
11' a paticnt
ilters cannot
are uscd. undcrsumd
the highestwhercfiller that does not
to start.Assessment of Vision
an assistunt should point tointheVerbal
symbol Children
of interest without
Before assessingappreciably
monocular worscn
vision the
in nystagmus
nystagmus should
patients.he choscn.
one AO vcctograph
obscuring the rest 01' the symhols in that linc.
rnust asccrtain thc smaIlcst distuncc and ncar acuity targets visihle
with binocular viewing. Attcntion should Figurehe 1-3. Splelmann occluder.
8 ClINICAL STRABISMUS HISTORY. ANO PHYSICAL EXAMINATION 7
MANAGEMENT
CHIEF COMPLAINT.

testing requires wearing polarized glasses. The vcctograph projects

letters corresponding 10 those in the polurized glasses. The right
and left eyes view leuers in the right and left polarized lenses.
respectivcly.

SENSORV
bcucr is considcrcdTESTING indicativo 01' bifoveal fixation. Stercoacuity
Sensory testing worse
is an than 40 seconds
integral part of of are suggests peripheral
strabisrnus evaluation.fu sion.
Beeause one may notRandom know dot stercograms
a paticnt's motor(e.g . thc
status on TNO initial and randot E) are
alternative
consultation. it is advisable tests for near srcrcoacuity (Fig. 1-5). These stcreograms
10 bcgin with sensory tesiing. specifically
stereoacuity testing.Iack monocular
Patients with cues"' but are more
poorly~K controlled difficult to understund and
interrninent
deviations may break complete.
down Red/green
into a frank or polurized
tropia if glasses
binocularityneed is ro he worn. and thcy
may impede
disrupted even momentarily by anycooperarion
form of monocular by sorneocclusion
children.(e.g Thc TNO test is based
.. during visual aeuityon Near
the
andanaglyphic
cover (red/green
testing).
Stereoacuity AII dissociation)
sensory testing mcthod. is Many believe the
performed with the red/green
appropriate glasscs are more
refractive dissociating iban the polarizcd glasses of
correction.
Numerous stereoacuity
the Titmus teststest.
at near
eontributing
ha ve bcen to decreascd
describcdorinabsent the stereoacuity mea-
literature. The Titmus tly stereotest
surcmerus.": ~') is most readily available and
perhaps ihe most familiar A fewbUIpatients
has limitations
who are (Fig. stereoblind
1-4). Theon random
Titmus dOI testing exhibir
Figure
stereotcst has monocular
legitimare 1-5. Random
cuesstcrcoacuity
in the fty. the dot stereoecunv
on three
the Titmus test
animals.test Rlght
and alhalfis ofnot
that tbe based
book test
on
shows random dot stereograms. Left half of the test consists ot
least ihe first row of monocular
circles. Thecues most
contour stereo targets.
or obvious
alternation. of these
Thc inability
elues is lateral
to perform on random dot
displaccment of thetestingtargets.!"
may Truebe duestereopsis
to (1) crowdingmay beeffeets
confirmed from by closely placed rundom
rotating the test target
dots 180
in thedegrees.
stereogram:
The (2) targeta lack
thatofwasmonocular
elevatedcues, preventing the
should sink or regress vergence
below movcmcnts
thc plane ofneeessarythe book.toOne appreciate
may also dsparity-the basis 01'
lateral displacernent
verify by asking if stcrcopsis: and (3) is an the inability
basis of01'thcmonofixators
paticnt's to resolve the
2
response. Rapid alternation
numerous01"fusionalviewing ambigutes
by the IwO in the
eyestest.enahles a
highly observant individualThc Frisbyto appreeiate
and Lang"stereopsis."?
stereotests do not Therequire
same glasses (Fig. 1-6).
patients can give appropriate
The Frisby responses
stereotest is10cumbcrsorne
rotation. bUIand nonedifficult
will for young children
achieve more than to 140understand.
seeonds ofBy arethe stercoacuity,
time most childrcn
suggesting are ihat
able to cooperare with
true stereopsis begins thisattest,
levelstheybener
are than
able this.
lo pertorm any of the tests requiring glasses. In
The level at which contrast.
the wings the of Lang y areis grasped
the test uscful in suggests
childrcn the bccuusc it depicts
stereoaeuity lcvel. Patients
rccognizablc
with normal Oistance
objccts stereoaeuity
(e.g .. Lang (40 Stereoacuity
1: aseeonds
star. cut, of and ear) at various
are) will grasp the wings
levels
Twoseveral
oftypes centimeiers
disparity. Stereopsis
01' stereotests aboyecanavailable
are the
be Titmus
demonstrated.
fortestdistance
but stereoacuity
the precise
plane. whereas monofixators
level
testing.of stereoucuity
The with less01'than
older cannot
thesenormal
be quaruified.
is the stereoacuity
AO vectograph will stcrcotest. whieh is
grasp the wings closer to the testbceause
dissoeiating plane. Stereoability
of the need ro of 40
wearseconds
polarzed of glasses. Mnreover.
are or lateral displaccmcm of circular targets provides monocular cucs. More
rcccntly, the Mentor BVAT system was developed to assess distancc
Figurestercoacu-
1-4. Titmus fly stereoacuity test.







.

ity." Thc test is a computerizcd systcm in which liquid crystal

binocular glasses are conncctcd 10 a microprocessor (Fig. 1-7). The
glasses contain a liquid crystal shuttcr aperturc for cach eye that
selectively hlocks OUI light trunsmission. Each eye is presented with
disparate images altcrnating at 60 Hz. The rapid alternation of thcse
images allows simultaneous pcrccption. because thc frequency is
higher thun the binocular
Figure lateral
1-7. critical
Psuent flickcr
holdmgfusion level of
l/quid crystal 30 Hz. glasses for the
bmocular
Two disiancc stcreoacuity
Mentor BVAT are includcd
testsaistence in this system: thc
stereotest.
If stereoacuity
randot tumblingFigure can
E (Fig. be
green-to demonstratcd
measure
1-8)Lang with
binocularity.
andI contour the
circlcs The tests
(Fig. test disNormal
may
1-9). cusscd
he used to determine the
1-6. stereoacuity test.
previously. Worth
patients exhibir lower levels(W4D)
four-dot
presence testingsuppression.
01'ofstcrcoacu
fusiono withnOI
itynced thcbe done
and
randot Etotest."
diplopaassess
(Fig. 1-10). Iftwo red
binocular
Distancefunction. Itor may,
stereoacuity however.
thrcetesting
grecn lights be are
used to patients
secn,
differentiates define thewith
suppression size and
is presento
poor If four lights are
location 01' athose
control from suppression
huving scotoma
sccn. fusion
good cxists in many
control but patients
must he with
in intermittent vcriicdstrabismus
exotropia by (see
thc presence 01' motor
with
Chapter than A
less12).52 normal stereoacuity
fusion
dynamic on (see
covcr testing.
stereoacuity testJater
Athat discussion).
paticnt who sees
measures In
fivethc
motion lights has diplopa hUI
in
dcpth has01'
abscnce stcrco
bcen ability.
must hethc
described. test may provide
\~distinguished
Prcliminary from one
results useful
who
suggest information
this is ifarapidly beiween two
alternares
that
fusion can be dcmonstratcd.
more sensitivo red and
mensure three grccn
01' control dots. All deviations.
in intermittent other responses are equivoca].
Figure
Worth." in thc earlyThc 1900s. 1-8. Random
describcd dOI
using tumbling
rcd/grccn E tetqe:and
glasses for tne Mentor BVAT
usefulness and rcliahility 01' the W4D
distance stereoacU/ty test. (From Zanom D. Rosenbaum AL: A new
test has bccn criticizcd
four dOls-one white.method
oncsevera
for red.for
and
1 rcasons:
IWO
evaluatmg ( 1)distence of thc red/greco
Reversa!stereoscuuv. J Peoeu Ophthalmol
Worth Four-Dot Test
Strstusmus 1991;28:255 Reprmted wnt: oemussioo of Stsck, Inc.J
 CHIEF COMPLAINT. HISTORY. ANO PHYSICAL EXAMINATION 9

it cannot be concluded with certainty that it does not exist because of

the limitations just discussed. Peripheral fusion may still be
demonstrated despite the absence of stereoacuity ano W4D fusion if
less dissociating tests such as Bagolini striated glasses are used.
The size 01' a suppression scotornu can be quantified using the
W4D Ilashlight.?" To perform this calculation, the target size (W4D
llashlight) presented at distance and near is measurcd along with the
distancc it is hcld trom the patient. The size 01' the scotorna is
calculated using the tangentCorrespondence
Retinal angle (6) of the ratio of the object size
(a) to object distance (b): tan e = a/b (Tablc 1-2). The degree 01'
Retinal
fusion maycorrespondence
also be dcfinedrcfers based10on thetheability
size of sensory system
the scotoma:
01" thc a 3.0-
to appreciate
6.4- degreethescotoma perceivedsizcdirection 01' the fovea
mean s peripheral and other
fusin: 1.14 retinal
to 3.0
elemcnts
dcgrces indicaresin each eye relative
macular to the
fusion: and other.
fovealIn fusion
orthotropic
is indipatients,
cuted if
glasses changes thethethc object from
response
scotoma 01"is rcgard
less
Iusion stimulatcs
than eachFor
degree.
suppression.
10 1.0 fovea
and vicesimultaneously
cxample, a patient who and
thereforc
fuses atFor
versa. in sorne patients. 13isexample.
localized
inches subjectively
butthc
suppresses atas72bcing
higher contrast of straight
inchcs thc ahead. The
has a scotoma sizetwo
of
eyes
green images compensares haveforcorresponding
2.29 degrees and has macular
reduced contrastretinal
sensielernents
fusiono tivity in the that have a common
visual direction.
amblyopic eyc. changing thc response Corresponding
depcnding on elements
whethcrlocalizethe an object at the
same
grecn glass is in front 01' point in spacc. Thc
the amblyopic or theIWo foveascye,
normal represent
(2) Thc the highest dcgrce 01'
luminance under correspondencc.
which testing is pertormcd is difticult to
siandardizc in the c1inicalNormalseuing.retinal(3) correspondence
The poor quality occurs01'inmanystraight eyes (no tropia)
commcrcially
Figure 1-9. Contour undcr
available
cuete binocular
red! grccn
target conditions
for glasses
tbe permits
Mentor or thc
BVAT when the patient's objcctivc and
appreciation
a.stence
01' monocular
stereoecuuv (4) Thc angles
testcues.subjeciivc test isofdissociating
srrabismus are the same.
becausc 01' thcThe objcctive angle is
measured
anaglyphic (color) nature 01' theby test
the alternate prismThe
glasses used. cover
test test.
muyThe not subjective angle is
determined
rclect the true binocular status by undermeasuring
everydaythe amount
visual 01' neutralizing prisms
conditions.
Thc response muy rcquired
be chcckcd for superimposition
by reversing theorcolor fusiono Prisms01'are placed over thc
in front
nonfixing
either eye. 11' difcrcnt cye until
responses are diplopa resolves.
given. fusion the direciion 01' disparity
is tenuous.
changes
suppression is possible. or the (crossed
results are 10 uncrosscd).
invalid. or fusion occurs. A more e1aboratc
A newer polarized mcthod
version 01' determining
decreases the rctinal correspondence
dissociating nature 01' employs the synopto-1
phoreFusion
the anaglyphic method.' (see also canChapter 2). bcucr, hUI the test is
be dctcctcd 6.3
Anomalous retinal corrcspondcnce
more dilficult for children to understand. Preverbal children may be (ARC) is present when the
4
objcctive
asked to touch the dots at near,and subjective
but thcir responsesangles are not equal.
are unreliable and It is a sensory 2.6
poorly prcdictive 01'adaptation
truc sensory of status."
the immature visual systern to an abnormal motor 3
1.18
position
Dcspite criticisms, thc W4D 01' thetestcye.rernains
It allowsuseful tor sorne
the child semblance of binocular
assessing 0.
binocularity in a vision in the paticnt
coopcrative presencewhcn of strabismus
the results and are prevents diplopia. 910
Suppression
unequivocal. 11' fusion cannot beisdernonstrated.
an accompaniment however.
01' 1
0.
75
Table 1-2. Measuring Scotoma Using
Distance Flashlight Scotoma Size
is Held
0.5
2
Figure 1-10. Worth the Worthtour-aot cese. Flashlight for Near(ft) (degrees)0.3
Four-Dot 0
ARe with a IucultutivcThescotorna 4-PD hase-out in the test nonfixing
is used eye. Faculsmall
10 dcrcct tativesuppression scotomas
implies that thc scotorna
associated can chango to thc othcrsyndrome
with monolixation cyc i f ti xat or asiona ismotor test 01' bifoveal
switchcd. preven: ingfixation.
diplopa.The 4-PD base-out prism is placed over one eye as the patient
There are two typcs xutcs of an accomrnodativc
ARe: harmonious targct anoal distancc.":
unharmonious. 1ft The farther the targct.

10 CLlNICAL
Harmonious occurs
AReSTRABISMUS
the more whcn central
Orthophona the the
MANAGEMENT subjcctive
arca bcing
Smallangle
angle is zero.
tested. Testing
esouopra
CHIEF Foris repcatcd
COMPLAINT. with
MlCrolrop,a/
HISTORY. ANOthe
truerrnutent Monol,.atoon
cxamplc. a patient prismwho has over20the POoppositc
of esotropia
eye. on PHYSICALcovcr
alternare
Exotrop,a EXAMINATION 11
but who reportsIn aa subjcctive
tesiing percepuon:
Pallent's bifoveal fixator fusiniheresponse
normal with responseBagolini
is a conjugare saccadic
OO
Four-PD Test for Foveal Suppression
OO
OSX OSX OXO D
lenses (without neutralizing
version movement prisms)in both has eyes. harmonious
followed ARe. by a slower vcrgcncc
Unharmonious ARerecovery occurs when movemcnt the subjectivc
in the eye is greatcr
without
anglc than A 4-PD base-out
the prism.
zero but less than the prism objecover tivetheanglc.
right eye Thiswill causefrom
results incomplete
temporal displacement of the imagc
sensory adaptution, aon testtheartifuct.
retina in or this
a chango in the original
eyc. Nasally directed strabismus
saccadcs occur in the right
Cover Tesl o Shift Sh,ft No Sh,lI
anglo. eye. ano temporally directcd ones occur in the left eye (versin
In ARe.F,xallon
two different
move but
ment related
inCenlral
thephenomena
direction of occur:
theCentral
apex
First.01'rhcthe fovca
prisms). Next.Frxa 00
Eccenrnc slower
in the dcviuiing
Rellnal eyc vergence
loses the sume movernent
NRC visual direcied
directionHarmoruous
as the fovea
nasally in bothin theeyesHarrnoruous
(convergence)
fixing eye. So me leSIS
Conespondence 01' ARe evaluare
establishes bifoveal fixation.
ihc relationship
The.movement
RCof the foveas is hest observcd
. RC in the
10 one another (e.g ..eye without the
aftcrimage testprism.
and the amblyoscope l. Sccond.
the fovea 01' the fixingWhen cye shares a comrnon
a suppression visual dircction
scotorna is present.with a
a 4-PD base-out prism
pcriphcral retina! element
placcd in front the dcviating
01' this eye eye.willOther testsmovcmcnt.
not clicit of ARe 11' placed in front
determine the relationship
01' the01' the fovea
fixing eye. the of initial
the fixing cye tosaccadc
conjugare the retina! toward the apcx 01' thc
pcriphery in the nonrixing
prism iseye noicd.
(c.g . The Bagolini
slow recovery
striated glasscsmovcment and the in the eye without the
amhlyoscope). prism will not be secn, however. identifying it as the cye with foveal
The uftcrimagc supprcs
test labels sion the (fig.fovea
1-12).of each eye with a linear
afterimuge. Each foveu Four is stimulated
atypical responses separatelyin(rnon normal ocularly).
putients Thchave been reponed
patient views a linearwith lightIhisfilamenttest while
1K
~~:the(1)central The zonc eye 01' the ligh:
without rhe prism makcs no
is occludcd 10 allowmovemcnt
the Iovca 10whereas lixatc butthercmain eye with unlabcled.
the prisrn Thcmakes the expected
vertical afterimugenasally is presentcd
directed 10 version movernent.eyc.
the dcviating Thisbecausc
occurs when versin and
suppression scotomas usuaIly movcmcnts
vergcnce occur ulongarethcequal horizontal
but oppo meridiano
site in direction in thc cye
A horizontal uftcrimagc without willthebeprism obscurcd or when if placcd
the versinin tront 01' a in this eye is too
movcment
dcviating eyc with supprcssion.
small to be The vertical afterimage
apprcciated. (2) Normalismovcrnent prcscntcd is not observed in
first becuusc it is casier
either10eye untilAftcr
rccall. a Icw thescconds
prescntationlater. ofThisaftcrimages,
occurs with inattention to the
thc paticnt rcculls and druwstarget
tixation his oror her pcrccption.
detective fusiono In normal retinal movcments in thc
(3) Oscilluting
correspondence a sume eross direction
with a central are seengap is seen.
in both eyes,11' thcrc isby slow recovcry 01'
followed
esotropia ano ARe. thc Postoperative
fusion aftcrimagcs
by disconjugatcwillDiplopa
he crosscd: in exotropia (4)
eye movements. with Delay in vcrgcncc
ARe. the aftcrimagcs will beis uncrosscd,
moverncnt seen following Patients
the initialwithmovc mcnt. most apparent in the
ecccntric
fixation should havceye In sorne
thewithout
afterimagcs situations. predicting postoperative
placed dirccrly on thc Iovcu. This diplopi:l m:ly be crucial
the prism.
in deciding onusing
may be done ophthalmoscopically a treatment
a visuscopic strategy. In the clinic. prisms that simulate
The second atypical response target.
is akin to the response to a 4-PD base-
overcorrection are held before the patient's eyes at distance ano near. 11'
Bagolini striated outglassesprismdoplaceo not hain ve frontdioptric
01' anpowers eye with huta havc
scotoma. cxccpt that the
no diplopia is reported. no further testing is required: diplopia is
narrow striations running
normal in one principal
response meridiano
is seen longcr at
alter aorierucd 45 and periodo Atypical
observation
unlikely. Ir diplopia is described. the patient is given sufficient time to
135 dcgrecs during responses
testing. Thcsc 2 and lenses4 muy allow cvaluaiion
be suspectcd of retinal
if a patient apprcciatcs diplopa. A
resolve it. Prisms are pl:lceo on J:lnelli clips or on a trial frame for 15 to
corrcspondcncc at distancc
patient with and near a trucwirh minimal
scotoma dissociation
suppresses without ano diplopa. Thc most
20 minutes. 11' apparent diplopi:l resol ves. Irue diplopia is unlikely. 11'
rclcct the binocularsignificant
status under causecvcryday
01' an atypical visual response
conditions. is aThedetective fusion rcllcx.
Ihe patient remains diplopic. Fresncl <ldd-on prisms are tried and Ihe
paticnt's response is chccked
seen withwhile poorlixating
fusionala convcrgcncc
light al near. amplitudes
Immediately(motor) and less than
palient reevaluated in a week.
ucr the response. normalcovcr testing
stcreoacuity is done over the relatively clcar
(scnsory).
Bagolini lcnscs to check for a dcviation. 11' the response is unclear. thc
 12 ClINICAL STRABISMUS MANAGEMENT

0 00
0 Type of ocular devrauon
EsotropraEsotropra
or Exotrop,a
DiplopiaAdducts
that resol ves is unlikely to represen: Abducts pcrsistent postoperative

O.~OD
LE preterred
diplopia, Postopcrative diplopa that persists may be bothersome and for fixallon
require additional
strabismus. ametropia.intcrvcntion.
eyeslenticular
are dcviarcd. opacity,
thc light or retinal
reflcx will pathology.
fall on diffcrcnt
The locations in os thc
dcviatcd or Amplitudes
amctropic dcviuting
eye demonstrates
and fixing eyes. a brighter
The rcflcx rel1ex is displaced o
than the nasally in cxotropia
Fusiona'
fcllow eye. whereasand lenticular
tcmporully opaciries
in csotropia.
or retinalEach pathology
millimctcr ---=-
cause01' dcccntrarion. has
Knowing
cithcr a morethe dulJpatient's fusionalbccn
orclassically
a brighter amplitudes
than normal
taught 10 providcs
reflcx.
equalThc
Palient's
7insight
test into
degrees
percepnon:
shouldorhis
15he orPO of misal Shih
..
ignmcnt.
her ability in
perforrned 10 acontrol
dimly Asan a intermittent
general room
illuminated rule,dcvia if iion.
with thecoaxial Base-OUI
pupils lighting.
are 3.5 ACover
prisms mm are
direct inIestdiamctcr, a Shift ~reflex
uscd for scopc
ophthalmo with
convcrgcncc, displaced
a halogcn hase-in
10 thelight Iorsourcc
pupillary is preferred.
divcrgcncc.
rnargin is buse-up
15 Thc dcgrccs: for lo halfway Central
child
Fillalion Stays
bctwecn
Cenlral
for supravergcncc. abducted
on the parcnt's
infravcrgcnce,
sits and the
lap while
pupil and
base-down thc coaxial
limbus. is shoncAmplitudes
30 dcgrccs:
light on the
und lo jusi
pupils.are
outsidc
Relinal thc limbus. Suppression
ARC wilh 45
rneasurcd
The examinerusing sitsrotaryat prisms orStudics
approximately
degrecs, prisms arm's haveinshown
held free spacc
length from
that (prism bar or
thcconversin
thc paticnt.
Correspondence from (Tolal) J 00 lo
dcgrecs
Foveal
loosc prisms)
Normally, hothas the paiient
pupils
prismconstriclfixes on and
dioptcrs an accommodative
is not light
linearrel1exesfor aJltargct in both
dcgrecs al distancc displacerncnt Suppression
01' eyes bUI is csti
and near.equaJly
bccomc Details dull.of mutcd
dctcrmining
The10corneal be 21 convergcncc
light reflcx
PO/mm 01'and divcrgcnce fusional
(Hirschberg)
dcccruration." can be
I~
No adduction of
00 - patient
observed
amplitudes (dcscribcd
are discussed Krimsky
latcr), in Chapier
Amblyopia Test. may12 Thc be inrcrmit
on dctected
Krimsky
Tvpe 01 tent
by le exotropia,
ohserving
ocular is
SIdevanon an cxtcnsion 01' the
Exotrop,a
experiences
Figure 1-11. Responses to the Bagolml stnetea
where
the
glass the information
monocular
test response
for retoet hasinpreved
Hirschberg
correspondence mostand
thc presence
corneal useful
light anin
reflex
01'suppres- the ESOlrop,a
clinical
test. II scuing.
asymmetric retlex." If the displaced
repositions diplopialight
Slow
irnmediate
ston.
Figure maintained
Forvcrgcncc
tnese
1-12. reflex
moverncnts
figures.
Response fixation
ro the
to
Bagoltm occurs
cerner
4 dissipate
onsm lenses slowly.
with
01'
aomeis thc pupillary
are Determining
dcviating
oti-
base-out test with
eyc fusional
constriction prisms. Prisms held in
for foveaJ
ented at
divcrgcncc
when 135imrncdiutely
moving
suppression. degrees
theWhen
A. lighl
frontin pasms
front
from
uftcr
uf thc 01thetne
measuring right over
fixing
dcviuting
are placed eye
cyc and
fusional
eye arethe
10
tne abnormal
fcrrcd
convergcncc
prceye.
left may with incomitunt
in patients
eyc.
aextroversion
at 45 degrees m irom of tne left eye. Adducts
The oercep-
resuh in artificially
amblyopia
occurs durmg retosuon
is unlikely. und
low Thcfusional
paralytic
Careful ofBrckner
deviations
rhls diver
eye.
mcasurerncnt tegence
sI is01'amplitudes.
mdlcaring
(scc unrcliablc
the absence
Chaptcr angle 5).
Palient's Measuring
in paticnts
01'The te sI is oftcn
ofdcviation
foveal
percepuon: pcrforrncd
in strabismus is
uon 01 oblique
svooiession. If alines seen
suporession by each
scotoma eye under
presenr. no movemenr WIII be
vertical
younger
bmocular fusional
than 8 months,amplitudes
crucial
;JI ncar inahernatcly
bccausc planning
thc with
asymrnctrical
primary ~ IS
surgery. horizontal
position hUIamplitudes
dimming
Cover muy
tests 01' he aredone
thc red
or for othcr
prefcrrcd positions
clinically, of
observedconditions
from enner IS sbown.
eye. B. AExamples
subsequenr of the
slow fusional eoducuoa
waiting
rctlcxes
types ofaoccurs
movement
few minutes
streoumo in 28%as
which
of the oght
in
m Light01'betwecn
wcll
which
eye
normal
ihe mcasurcrncnts
thc infants.'
ifreflcx patient
alternare
tbese
mcucetes tests prism
responses is covcr
should
absence
will
ofonly
are testcircumvcnt
coopcrativc.
foveal
Cover
he(mcusuring
used In lo
suooressioo this
sensory
Test deviations
themmanilcst
rncasurc theand
angle with
Shift
Shifl
latcnt
of
problcm.
Hirschherg
commonly
rhe "ght eye. C.Corneal
found are
poor
If the Ught
glven.
strabismus
dcviation)
"ghtacuity isReftex.
eyeinstays(From
patients
most
und Baslc The Hirschbcrg"
!ixation
unable
abducted. rcliablc. toincooperare
ena
rhe If
thc these
absence involvcdof cor
with
cannot
Fixalion neal
cyc. be
cover
edducuon testing.
an performed Centralin
intcrmcdiatc
Central
Cltntcal
Normal Science
retlex distance Course.
rcliesvcrgcnce observingSectton
movcmcrus 6. arePeaauic
approximatcly
onflght
theisfigures
cornea
used 20 PD
frorn for
estimarea by thc targct
ligh:
movemenr
Optunstmotogy
test mdicares
and
Brckner
tcsting
4on foveal
uncoopcrativc
PD for
Stretnsmus, vertical rcflcctcd
(convcrsation)Test.
supotesston
children
1992.
Thc
vcrgcncc. ligh:
mdistance
ortbe
Reprmted
Brckncr
bccause
Thesc eye poor
oftest
or
Retinal10 (D) tixation.
detccts
increascweak thclight
6NRC e Oiplopia
prcsencc
10rcex
NRC 10 PDtestsof
Ior
Diplopia
tusion.
convergcncc:
light source In tbe
hcld Jarrer
6 to 14
XofPDinches
ocular
muy case.
forbedivcrgcnce:
uway,
ubnormalities
uscd. IrThcsc
patienrs the expenence
andbyare 3 obscrving dlplopla
tolessa!ofaccuratc an Therc unril
thanis thc
asyrnmctric
Correspondence tetustonahernate
red rclcx No through
Suppression
Noprism thc
covcr
Suppression
with oearussion
occurs spontaneousJy.
convcrgcncc
the Amertcsn
(From
and divcrgcnce
Academy
von Noorden
ncar.
GK' Bmocular vision and
no significant dilfcrence
Ophthalmology.J
Ocular Motiltty Theoryand pupil
test in(Fig.
in vertical paticnts 1-13). with
fusional
Managemenr Itamplitudes
can
good fixation.
idcntify
of Suetusmus. paticnts
bctwecn with Mosby-
distance
St. Loius, and ncar.
Year Book. 7996 Reprmted wnb oenmssion.l Light
MOTOR ReflexTESTING Tests