Muscle sequelae

Limitation of movement affecting one muscle (or one direction of gaze) is followed by
the development of muscle sequelae
• Primary under action/ paralysis of muscle e.g. RSR
• o/a of contralateral synergist (Herings) (yoke muscle) (LIO)
• Overaction (contracture) of ipsilateral antagonist (Sherrington's) (RIR)
• Secondary inhibition (u/a) of contralateral antagonist (Sherrington’s &
Herings) (LSO)

• Hering’s Law of equal innervation

– When a nervous impulse is sent to a muscle causing it to contract, an
equal impulse goes to its contralateral synergist in order to maintain
parallelism of the visual axis (yoke muscles)
• Underaction of muscle= extra nervous innervation required
– => Innervation received by contralateral synergist is in excess and
causes it to overact
• Sherrington’s Law of reciprocal innervation
– When a muscle contracts, its direct antagonist relaxes to an equal
extent allowing smooth movement
– When there is underaction of a muscle (which persists for some time),
the unopposed action results in overaction
•

•
AHP
 Place eyes in position of least deviation
 BSV is maintained or developed
 Centralize field of BSV
 Obtain foveal fixation when movement grossly restricted
 Avoid looking in direction of pain/discomfort or diplopia
Atypical AHP may develop to separate diplopic images

Head tilt
– Cyclotropia
– Vertical deviation-head tilted to side of lower eye
Face turn- horizontal deviations (lateral gaze)
– Place eyes in direction of underaction, i.e. in opposite direction of
overaction
– Move head to position of greatest overaction
Chin elevation / depression- vertical deviations (elevation or depression)

• For example u/a RSO

– Greatest action in depression and adduction (i.e. down and to the left)
therefore head moves down and to the left
– Chin depression, face turn to unaffected side
– RSO used for depression, if not working, eye will be hypertropic
 – Head tilt to lower eye, therefore tilt to unaffected side
– Chin depression, face turn to left, head tilt to left

Microtropia
Almost invariably present in microtropia (squint less than 10∆)
• A unilateral manifest strabismus of less than 10 prism dioptres in size
• Most often occurs in esotropia
• Can occur in exotropia but less commonly
• Rarely seen in vertical strabismus
• Primary Microtropia – no prior history of larger deviation
• Secondary (consecutive) Microtropia
• Following optical or surgical correction for a larger manifest deviation
e.g. accommodative esotropia
• With identity
• No manifest deviation seen –absolute fixation using the
pseudofovea
• Does not resort back to the true fovea under monocular
conditions
• Deep ARC
• Without identity
• Very small manifest deviation noted on CT (flick)
• Patient resorts back to true fovea under monocular conditions
• Shallow ARC
• Most commonly secondary to a larger squint (e.g. fully accommodative
esotropia)
• Hereditary
• Small foveal pathology
• Anisometropia- the more ametropic eye receives a blurred image
• Foveal suppression scotoma
• Fixation occurs on the edge of the scotoma
• Aim is to diagnose microtropia and assess quality of BSV from fusional
amplitude and stereoacuity
• VA- generally 1 line worse than better eye
• CT-small manifest strabismus (flick) in without identity
• Latent deviation, check speed of recovery to assess compensation
• Fixation- eccentric? Nasal and superior in esotropia
• What other type of deviation might you see on CT?
• Correct refractive error, constant wear
• Obtain and maintain best VA- PT occlusion
• Manage BSV – ensure no decompensation to larger tropia
• Surgical treatment is not an option

Optical penalisation (treatment for amblyopia)

Principal is to blur the vision of the non-amblyopic eye to stimulate vision in the
amblyopic eye
3 types
1. Distance penalisation
• use the amblyopic eye for distance fixation. Prescribe optimum correction for
distance for amblyopic eye, overcorrect non-amblyopic eye (more plus) can
still see at near
• Most commonly used
2. Near penalisation= use the amblyopic eye for near fixation. Cycloplegic used in
the non-amblyopic eye, plus lens (up to +3D) used in the amblyopic eye
3. Total penalisation
• use the amblyopic eye for all distances
• Very high plus lens (occasionally very high minus lens) used in the non-
amblyopic eye to blur at all distances
• Gross amblyopic

Distance exotropia- Divergence excess

 True
 Simulated

Intermittent Distance Exotropia

• Exotropia on distance fixation (divergence excess)
• Manifest phase is associated with inattention, poor health, fatigue, alcohol and
bright light
• Look into distance-manifest and suppression occurs
• BSV for near
– Angle for near may increase with
• Prolonged disruption of fusion
• Elimination of accommodation
– i.e. simulated distance exotropia

Intermittent Distance Exotropia - Investigation

• History- px not aware of symptoms, may notice enlarged FOV, closes one
eye in sunlight
• VA-equal, unless manifest most of the time/anisometropia
– Binoc VA may be poor for distance if px using accomm to keep eyes
straight
• CT-also assess in far distance, recovery? https://www.youtube.com/watch?
v=ztrmoVbLCTQ
• OM- V pattern may be present
• NPC- monitor, reduction suggests decompensation to constant
Intermittent Distance Exotropia - Investigation
• Binocular function- fusional amplitude, stereoacuity
• Suppression – what result?
• Measurement of deviation- PCT
– 33cm, 6m & far distance
– Monitor changes in size over time
Intermittent Distance Exotropia - Investigation
True vs. Simulated
• 1 hour occlusion or +3.00DS
 • If deviation at near constantly less than distance- TRUE
• If deviation at near equals distance after 1 hour-
SIMULATED
• High tonic accommodative convergence obscures the true
nature of the deviation at near
Intermittent Distance Exotropia – Management
 <15D angle
 Orthoptic exercises
 Anti-suppression & appreciation of diplopia
 Convergence exercises
 Fusional amplitude- which?
 Increase relative convergence- which?
 Refractive Correction
 correct myopia, astigmatism, anisometropia
 Refractive modification= concave lenses up to -3D
 Leave hyperopia uncorrected?
Intermittent Distance Exotropia – Management
 <15D angle
 Prisms –which base direction?
 Tinted spectacles if decompensation occurs in bright sunlight
 Occlusion therapy if required
 Surgery
 Prevent deviation from becoming constant
 Aid with cosmetic appearance when manifest
 Usually wait until px older

Central suppression scotoma

Pathological extension of retinal rivalry
Prevents foveal image of deviating eye from being perceived
Can be tested with prism, synoptophore, hess/lees screen, bagolini lenses
Can be monocular- when the the image from the dominant eye always predominates
over the image from the deviating/more ametropic eye or alternating
Can be facultative –only when eyes are misaligned or obligatory- constant

• 4 prism dioptre test BO- checking for central suppression scotoma

• Bagolini lenses- small central scotoma

Accommodative Insufficiency
Symptoms & Signs
• Pre-presbyopic age
• Blurred near vision, usually both eyes affected
• Headaches, asthenopia
• Reduced accommodation using RAF rule (uniocular and
binocular) -differentiate from Convergence Insufficiency- how?
Aetiology
• Disuse of accommodation, change of occupation
 • Poor general health
• Local trauma, brain injury, temporary
• Post pregnancy
• Antihypertensives, antidepressants, antihistamines
Investigation
– Distance vision is normal with poor near vision
– Accommodation- reduced uniocularly and binocularly
– Low powered lens will result in clear vision
– CT- esophoria at near on extreme effort to accommodate
– Over convergence
Management
– Correct any hyperopia
– Temporary plus correction up to +2.00, wean off
– Accommodative exercises as in Convergence Insufficiency
– Jump accommodation, push up accommodation
– Miotics to increase depth of focus
– Need regular review

Accommodative Inertia
Delay in exerting accommodation and then relaxing it once exerted. Difficulties
changing focus
– May be presbyopic, uncorrected hyperopia or early cataractous lens
changes
• Correct uncorrected refractive error- hyperopia & astigmatism important
• Small reading add +1.00
• General health related?
• Accommodative exercises depending on age
• Regular breaks from near work
• Assess the number of times the patient can change from looking at near text
with +2.00D, then flipped to -2.00D in one minute
• Recorded as cycles per minute (cpm)
• Typically 8cpm binoc, 13cpm monoc
• If reduced, flippers used to improve accommodation

Convergence Insufficiency
Symptoms?
• Frontal headaches, eyestrain associated with near work
• Blurred vision
• Intermittent diplopia, usually horizontal, relieved by closing
one eye
Investigation
– History- same as heterophoria
– Convergence- use RAF rule, convergence insufficiency present if
less than 9-10cm, only maintained with effort & may require blink
 – Cover test- slight exophoria at near, no significant heterophoria at
distance
• Note speed of recovery
Investigation
– Accommodation: blurred vision for near may be Convergence
Insufficiency or Accommodative Insufficiency, if
Uniocular>Binocular Convergence Insufficiency suspected
– Fusional amplitude: measured at 33cm, positive amplitude
reduced, negative amplitude is normal
Management-
– Refraction- correct any significant refractive error, think about
accommodation
• Low levels of astigmatism similar symptoms to CI
• Correction of low hyperopia may help create clear image
– Orthoptic exercises- think about px selection
• Pen to nose, dot cards, positive/near stereograms
• To improve convergence & positive fusional range
• Needs regular review, treated by 6 weeks?
– Prisms
• Supplement exercises and wean off
• Exercises not successful
• elderly, limited use of exercises
Management-
– Surgery- rare for Convergence Insuffiency, risk of producing
persistent diplopia and ESOP/ESOT in distance

Duane’s Syndrome
• Congenital condition with limitation of abduction and less limitation of
adduction
• Can be bilateral or unilateral
• Relatively common 1-5% of strabismus, 0.1% in the population
• Aetiology- not fully known, can be innervational or mechanical
• Why mechanical not neurological classification?
• Follows the characteristics of mechanical deviations

Aetiology-
Innervational
Miswiring of 3rd and 6th nerves
• Innervation of the LR by extra branches of 3 rd nerve- co-
contraction
• 6th nerve absent or partially formed
• Disruption of development in embryo
• Often associated with other congenital defects e.g. coloboma,
cataracts, cleft lip
• Innervates adduction and abduction at the same time
Mechanical
• Can also be caused by thin, inelastic muscles
 • Muscles bound to orbital wall
• Incorrect insertion of medial recti/ tight MR
• Inelastic, fibrotic LR with abnormal insertions

Characteristics
• Limitation of abduction
• Less limitation of adduction in same eye
• Globe retraction on adduction with narrowing of palpebral fissure (co-
contraction)
• Widening of palpebral fissure on attempted abduction
• Poor convergence
• Face turn to affected side
• Upshoot or downshoot of affected eye on adduction

Upshoots/downshoots
• Usually occurs as the eye is rotated into adduction
• Tight lateral rectus muscle, slips over or under the globe and produces
an anomalous upshot or downshoot in adduction
• Known as “bridle” or “leash” phenomenon

classification
Brown 1950
• A- limitation of abduction, less limitation of adduction
MOST COMMON
• B-limited abduction, normal adduction
• C-limitation of adduction exceeds limitation of abduction

Huber 1974
• Type I – limitation of abduction (LR no innervation), less limitation
to adduction (LR some innervation) MOST COMMON
• Type II- Limited adduction, LR has innervation on abduction and
adduction, therefore can abduct and also counteracts MR limiting
adduction
• Type III- limited abduction and adduction, LR no innervation to
abduct but is innervated on adduction and counteacts MR

Investigation
• History- parents may notice abnormal eye movement, AHP, strabismus
• VA- amblyopia if manifest strab in PP
• AHP- face turn to affected side
• CT- w & w/o AHP
• Typically convergent deviation (esotropia)
• May have no deviation with AHP
• OM- limitations of abduction and adduction/ upshoots & downshoots
• Retraction of globe and closure of palpebral fissure (key)
• Convergence-poor
• BSV- good, maintained by HP
• Hess as permanent record of the deviation
• DD- 6th nerve palsy, medial wall fracture, inflammation
• Use PF closure and globe retraction as DD
 • Associated signs e.g. coloboma, cataracts, cleft lip

Management
• Often no tx required, asymptomatic with sl AHP and head movements
• Correct refractive error
• Referral to orthoptics for confirmation of diagnosis and treatment of any
amblyopia
• May require surgery or Botox, indications:
▫ Decompensation
▫ AHP and strabismus cosmesis
• Aims
▫ Place field of BSV centrally
▫ Reduce AHP
▫ Improve cosmesis

Ocular signs of myasthenia gravis

• Ptosis – becomes worse at end of day
• Diplopia- worse at the end of the day
• Limitation of ocular movement –can mimic any nerve palsy. Vertical
muscles> horizontal (IR common)
• incomitant strabismus
• external ophthalmoplegia

Secondary esoptropia
 Visual loss at or shortly after birth can result in either an
esotropia or an exotropia.
 Visual loss in childhood more often results in a esotropia,
probably due to the very active accommodation and convergence
mechanism at this age.
 Visual loss in later childhood and adulthood results in an
exotropia in most instances.
 Full ocular examination of utmost importance in these cases – can be
presenting sign in retinoblastoma

Management
– Surgery is indicated for cosmetic reasons once aetiology has
been elicited and treated if possible.
– Aim to leave eyes residually convergent to protect against over-
divergence

a) Infantile Esotropia (5 marks)

Infantile Esotropia:

• Persistent manifest deviation

• Onset in first 6mths of life
• Mostly esotropia
– Exotropia uncommon

• Stable esotropia >30dioptres (very large angled squint)

• Onset <6mths (usually 3-4 mths)
• Alternates (often fixation preference)
• Crossed fixation
– Bilateral limited abduction
– Poor prognosis for BSV

• The cause is unknown

• Infants who suffer cerebral lesions during birth are at much greater risk (30-60x)
• Associated with a range of ocular motor behaviours which occur as a result of early disruption
of the binocular vision system

DVD- Dissociated Vertical Deviation

Common in Essential Infantile Esotropia
 Condition where either eye elevates when the amount of light entering is reduced-e.g. during
cover test
 Elevated eye returns to original position when cover removed.
 Perform CT slowly
 Cover either eye in turn otherwise diagnosis could be missed
 Usually binocular but can be uniocular or asymmetrical

DVD- Dissociated Vertical Deviation (Signs)

 Eye under cover progressively elevates
 Hypertropia
 One eye may spontaneously elevate if Px fatigued, inattention, poor health
 Head tilt common
 DHD- dissociated horizontal deviation
 Develops 18mths – 3yrs
 Proof that deviation (esotropia) present before 6mths
 Bielschowsky darkening wedge test BDWT
 Neutral density filter (or Sbisa bar) placed in front of the uncovered eye, filter
gradually increased, covered eye will move back down. Decrease filter,
covered eye will move back up
 Inferior oblique o/a can occur with DVD
 IO o/a occurs gradually as eye moves to adduction
 Or DVD can look like IO o/a as the nose occludes one eye in
adduction

Accommodative esotropia with convergence excess (Intermittent)

– Esotropia may be present at both distance and near without correction

 –
Full refractive correction fully corrects the deviation at distance (BSV) but deviation
remains manifest for near (no BSV)
– Patients have high AC/A ratio (often exceeding 8:1)
– Onset 2-5 years
Remember cycloplegic refraction and full Rx for differential diagnosis!

CT – No Rx
Near – EsoT >@Dist
Distance – EsoT / EsoP < @Near

CT – Rx
Near – EsoT
Distance – EsoP / Ortho No manifest strab

Management

Full Rx prescribed initially to determine diagnosis by cover test

Needs full plus, full time wear

• Amblyopia treatment if needed- why might amblyopia be absent?

• Optical
– Bifocal specs (+2.00, increase/reduce until deviation corrected)
– CLs
– Miotic (increase depth of focus so less accomm needed) Phospholine
Iodide or Pilocarpine
• Exercises
– Deviation <25 /30 dioptres
– AC/A <8:1

Exercises- when patient old enough to recognise diplopia

– anti-suppression techniques- e.g. red filter drawing
– ‘misty’-’clear’
– Negative stereograms
– Bar reading- if BSV present at distance, can read through bar/pencil when using both
eyes, when suppressing can’t see through bar/pencil. Can also be down with
red/green glasses as shown in lecture 2

– Surgery
– <20 dioptres
– Bifocal and Orthoptic treatment
– Bilateral MR recession 3-4mm
– 20-30 dioptres
– Bilateral MR recession 5mm
– >30 dioptres
– Bilateral MR recession augmented to size of deviation

Mechanical restrictions

• Factors within the orbit that interfere with contraction or relaxation of

muscle
• Prevent free movement of globe
• Physical restraint on muscle
QUESTION TWO

A 24 year old male attends your practice. He has started a new job as a computer
programmer in the past 2 weeks. He is noted to have a large, poorly controlled
exophoria at near with reduced near point of convergence.

(i) Describe what possible symptoms he may complain of and why? (5 marks)

i. Frontal headaches, eyestrain associated with near work

ii. Blurred vision
iii. Intermittent diplopia, usually horizontal, relieved by closing one
eye
Asthenopia

(ii) Discuss the possible causes of decompensation of a heterophoria? (5 Marks)

– Optical causes
 Wrongly corrected refractive errors, poor balance of accommodation
 Ill-fitting spectacles, centres not properly set
 Aniseikonia

– Medical causes
 Poor general health- fatigue, illness
 Head trauma- tends to be temporary, loss of fusion
 Medication-anti-histamines, anti-depressants
 Alcohol!

– Visual demand

• Demand during binocular viewing

– Close work - exophoria
– Driving for long periods – esophoria
– Night driving- dark field with little stimulus to fusion
– Use of VDU
• Demand during monocular viewing
– Occupations – microscope or jeweller’s glass

(ii) Explain what clinical tests you would undertake in order to fully examine this patient
(10 marks)

a. History- Exact nature of symptoms

b. When they occur
c. First experienced
d. Duration of episodes
 e. Can symptoms be relieved
f. General health
g. POH- previous orthoptic tx/ change in refractive error
h. Change in occupation / activities
i.
j. Convergence- use RAF rule, convergence insufficiency present if less
than 9-10cm, only maintained with effort & may require blink
k. Cover test- slight exophoria at near, no significant heterophoria at
distance
i. Note speed of recovery
(iii) Detection and measurement
a. GOI (manifest strabismus, patient blinking excessively when reading,
an uncomfortable working distance)
b. Cover/ uncover test
c. Alternate CT
d. Note recovery
e. Rapid recovery = good compensation
f. Slow recovery = decompensation probable
(iv) Cover Test
a. Direction
b. Size of deviation – estimate or prism cover test, Maddox rod/wing
c. Frequency of deviation- constant or intermittent, worse with a particular
fixation distance/fatigue
d. Recovery – very important to assess, could have large phoria that is
well compensated- no action required or could have moderate phoria
poorly compensated, may need clinical intervention
(v) Fixation Disparity
(vi) Fusional Reserves
(vii) Convergence- any fatigue?
(viii) Accommodation- binocularly & monocularly, look at pupil reactions, what
does this tell you?
(ix) Uncorrected refractive error- cycloplegic assessment to reveal full
hyperopia
(x) Stereoacuity- reduced can indicate difficulties maintain BSV in adulthood,
absent in children suggests suppression
(xi) Binocular vs monocular vision/visual acuity
(xii) AC:A Ratio

(iv) Describe how you would manage this patient Describe some simple Orthoptic
procedures which could be given to this patient to use as home exercises in the
management of this condition. (5 Marks)
 Management

Conservative Surgery

Orthoptic Exercises

Prisms

Botulinum Toxin
In EXOphoric conditions: develop CONVERGENT reserves and POSITIVE
RELATIVE CONVERGENCE
Management-
– Refraction- correct any significant refractive error, think about
accommodation
• Low levels of astigmatism similar symptoms to CI
• Correction of low hyperopia may help create clear image
– Orthoptic exercises- think about px selection
• Dots cards
• Pen to nose exercises
• Jump convergence
• Positive stereograms e.g. three cats
• Brock String
• To improve convergence & positive fusional range
• Needs regular review, treated by 6 weeks?
– Prisms
• Supplement exercises and wean off
• Exercises not successful
 • elderly, limited use of exercises

Change Visual Environment (breaks from VDU)

General health if an issue refer to gp
Refractive Modification i.e. if emmetropic over minus for exophoria

QUESTION THREE
(i) What are the main clinical features of an accommodative Esotropia with
convergence excess? (5 Marks)

a. Esotropia may be present at both distance and near without correction

b. Full refractive correction fully corrects the deviation at distance (BSV)
but deviation remains manifest for near (no BSV)
c. Patients have high AC/A ratio (often exceeding 8:1)
d. Onset 2-5 years

(ii) What are the main clinical features of a fully accommodative Esotropia? (5
Marks)

– Esotropia which occurs when accommodation is exerted to overcome

uncorrected hypermetropia
– Present at distance and near when uncorrected
– BSV present for near and distance with spectacle correction
– Eyes straight with correction- no manifest squint
– Onset between 2 and 5 years

(iii) Discuss in detail the various treatment options available for the above two
conditions. (15 Marks)

Con Ex
Full Rx prescribed initially to determine diagnosis by cover test
Needs full plus, full time wear
• Amblyopia treatment if needed- why might amblyopia be
absent?
• Optical
– Bifocal specs (+2.00, increase/reduce until deviation
corrected)
– CLs
– Miotic (increase depth of focus so less accomm
needed) Phospholine Iodide or Pilocarpine
• Exercises
– Deviation <25 /30 dioptres
– AC/A <8:1
Exercises- when patient old enough to recognise diplopia
 – anti-suppression techniques- e.g. red filter drawing
– ‘misty’-’clear’
– Negative stereograms
– Bar reading- if BSV present at distance, can read through
bar/pencil when using both eyes, when suppressing can’t see
through bar/pencil. Can also be down with red/green glasses as
shown in lecture 2.
Surgery
– <20 dioptres
– Bifocal and Orthoptic treatment
– Bilateral MR recession 3-4mm
– 20-30 dioptres
– Bilateral MR recession 5mm
– >30 dioptres
– Bilateral MR recession augmented to size of
deviation

Fully acc
Management
– Must fully correct refractive error (cycloplegic refraction)- don’t
want them to accommodate
– Full time spectacle wear
– May be some amblyopia present, allow improvement to occur with
full Rx (Refractive adaptation as in Lecture 3)
– Part-time occlusion therapy if required- don’t want to dissociate
latent component (PEDIG guidelines)
– Orthoptic exercises
• <+4D, <1D cyl
• Needs to be able to read, around 7 years old
• Aims- overcome suppression & recognise diplopia, achieve
voluntary control of esotropia (Misty-Clear), improve
binocular acuity without specs (for sport or social events)

QUESTION THREE
(i) Describe in detail what is meant by the term Distance Exotropia (5 Marks)

(ii) Explain what clinical tests need to be routinely carried out in order to
monitor the signs of decompensation of this type of strabismus and why?
(10 Marks)

(iii) Discuss the management of this condition. (10 Marks)

Distance exotropia- Divergence excess

 True
 Simulated

Intermittent Distance Exotropia

• Exotropia on distance fixation (divergence excess)
• Manifest phase is associated with inattention, poor health, fatigue, alcohol and
bright light
• Look into distance-manifest and suppression occurs
• BSV for near
– Angle for near may increase with
• Prolonged disruption of fusion
• Elimination of accommodation
– i.e. simulated distance exotropia

Intermittent Distance Exotropia - Investigation

• History- px not aware of symptoms, may notice enlarged FOV, closes one
eye in sunlight
• VA-equal, unless manifest most of the time/anisometropia
– Binoc VA may be poor for distance if px using accomm to keep eyes
straight
• CT-also assess in far distance, recovery? https://www.youtube.com/watch?
v=ztrmoVbLCTQ
• OM- V pattern may be present
• NPC- monitor, reduction suggests decompensation to constant
Intermittent Distance Exotropia - Investigation
• Binocular function- fusional amplitude, stereoacuity
• Suppression – what result?
• Measurement of deviation- PCT
– 33cm, 6m & far distance
– Monitor changes in size over time
Intermittent Distance Exotropia - Investigation
True vs. Simulated
• 1 hour occlusion or +3.00DS
• If deviation at near constantly less than distance- TRUE
• If deviation at near equals distance after 1 hour-
SIMULATED
• High tonic accommodative convergence obscures the true
nature of the deviation at near
Intermittent Distance Exotropia – Management
 <15D angle
 Orthoptic exercises
  Anti-suppression & appreciation of diplopia
 Convergence exercises
 Fusional amplitude- which?
 Increase relative convergence- which?
 Refractive Correction
 correct myopia, astigmatism, anisometropia
 Refractive modification= concave lenses up to -3D
 Leave hyperopia uncorrected?
Intermittent Distance Exotropia – Management
 <15D angle
 Prisms –which base direction?
 Tinted spectacles if decompensation occurs in bright sunlight
 Occlusion therapy if required
 Surgery
 Prevent deviation from becoming constant
 Aid with cosmetic appearance when manifest
 Usually wait until px older

QUESTION FOUR

(i) Define amblyopia (1 marks)

(ii) Describe the classifications of amblyopia? (12marks)

(ii) Describe current methods for the treatment of amblyopia in childhood

(12 marks)

(i) What are the possible causes of development of amblyopia in childhood? (10marks)

(ii) Describe two methods of amblyopia treatment (after refractive adaptation) (10
marks)

(i) What problems may arise during amblyopia treatment? (5 marks)

Amblyopia - Defective visual acuity in one or both eyes, which persists after correction of refractive error and
removal of any pathological obstacle to vision

Classifications:

1. Stimulus deprivation:
• Lack of visual stimulus in early life
• Can be bilateral or unilateral
• Complete (no light) =ptosis, occlusion
 • Partial (some light)=congenital cataract, hyphaema, vitreous opacity
2. Strabismic: constant, unilateral in childhood
3. Anisometropic: most commonly hyperopes, not many myopic children (one eye has visual advantage at all
distances, usually the least hyperopic eye)
4. Ametropic: bilateral amblyopia, insuperable refractive error in BE (>+6D)
Meridional (astigmatic)
 Relatively clear image on the emmetropic axis
 Blurred image along the more ametropic axis
5. Idiopathic
 No refractive error
 Normal BSV
 Small suppression scotoma detected with 4dioptre prism
* More than one type can occur in a patient e.g. strabismic & anisometropic

Methods for Amblyopia correction:

Occlusion Therapy:
• Principal treatment for amblyopia
• Patch the non-amblyopic eye
• Adhesive patch stuck to the peri-orbital rim or to the spectacles (possible allergy to patch)
1. Total occlusion , excluding all light and form, e.g. adhesive occluders, opaque black contact lens
2. Total occlusion, excluding form. But allowing the passage of some light. This is an opaque material
adherent to the spectacle lens such as blenderm tape or frosted glass.

US Paediatric Eye Disease Investigator Group (PEDIG) Guidelines

• Moderate amblyopia 6/12 to 6/24 no difference in patching 2 hours vs 6 hours (plus 1
hour of near visual activities)
• Severe amblyopia 6/30 to 6/120 no difference in patching 6 hours vs full time (plus 1
hour of near visual activities)
Cycloplegic drugs:
• Atropine 0.5% or 1% ointment, once daily or alternate days
• As effective (and well tolerated) as patching for moderate amblyopia (6/12 to 6/30) in children 3 to 7
years
• Advantages:
 Not cosmetically obtrusive
 Compliance not an issue once drops are in
 Disadvantages
 Less easy to monitor for occlusion amblyopia of the normal eye
 Systemic side effects- confusion, flushing, dry mouth

Optical Penalisation
Principal is to blur the vision of the non-amblyopic eye to stimulate vision in the amblyopic eye
3 types
1. Distance penalisation
• use the amblyopic eye for distance fixation. Prescribe optimum correction for distance for amblyopic
eye, overcorrect non-amblyopic eye (more plus) can still see at near
• Most commonly used
•
2. Near penalization - use the amblyopic eye for near fixation. Cycloplegic used in the non-amblyopic eye,
plus lens (up to +3D) used in the amblyopic eye

3. Total penalisation
• use the amblyopic eye for all distances
• Very high plus lens (occasionally very high minus lens) used in the non-amblyopic eye to blur at all
distances
• Gross amblyopic

Active Therapy

• Some suggest treatment more effective if patient undertakes detailed visual task
• Simple reading/writing/puzzles
• Video games, virtual reality systems
• Some use filters so that some parts of the scene seen by only the amblyopic eye-
need it to work to complete the task
 • Competition to improve “bad” eye
• Perceptual learning tasks, attempts to improve amblyopia in adults, early research
stages, results are promising
• Encourages connectivity between R & L neuronal pathways

Possible causes of Amblyopia in children:

1. Deprivation of Form vision

• Complete if no stimulus reaches fovea (ptosis)
• Partial if defocused image reaches fovea (congenital cataract)
• Can be unilateral or bilateral

2. Abnormal binocular interaction

• Binocular competition: involved in all unilateral amblyopia, not in
bilateral
• Incompatible images formed on the fovea
• Neurones from the two eyes compete for control over cortical
connections during developmental period - better eye gains control, at
expense of neurones of affected eye

Problems of Amblyopic treatment:

• Occlusion amblyopia - over eager patching, total occlusion, atropine, younger

infants
• Intractable diplopia - patient brought out of suppression, cease occlusion
immediately
• Dissociation of intermittent or latent strabismus- occurs where poor motor fusion,
weak BV
• Reoccurrence of amblyopia- tail off treatment, more likely to reoccur if stop
patching abruptly
• Compliance & follow up

QUESTION TWO

A 74 year old male reports for an eye examination in your optometry practice.
He complains of vertical diplopia of sudden onset. He informs you he is a type
2 diabetic which is currently unstable.

i) What clinical tests would you use to examine this patient and what would be
your expected findings and diagnosis? (12 Marks)
ii) Discuss how your results and findings would determine whether this was an
acquired or congenital/longstanding condition and whether it is unilateral or
bilateral. (8 Marks)

In the case of this patient, what are suitable management and treatment
options? (5 Marks)

QUESTION ONE

A 38 year old female reports for an eye examination in your optometry practice. She
complains of vertical diplopia for both near and distance fixations. On motility testing
she is noted to have an underacting left superior oblique weakness.

I. What main clinical tests would you undertake to examine this patient and briefly
discuss your expected findings. (12 Marks)
II. Discuss how you would determine whether this condition is
congenital/longstanding or recently acquired. (8 Marks)
In both case scenarios, outline the management and treatment of this patient. 5 marks

4. A 38 year old female reports for an eye examination in your optometry practice. She
complains of vertical diplopia for both near and distance fixations. On motility testing she
is noted to have an underacting left superior oblique weakness.

(i) What main clinical tests would you undertake to examine this patient and briefly
discuss your expected findings. (7 Marks)
(ii) Discuss how you would determine whether this condition is
congenital/longstanding or recently acquired. (12 Marks)
(iii) In both case scenarios, outline the management and treatment of this patient.
(6 Marks)

QUESTION ONE

A 69 year old male reports for an eye examination in your optometry practice. He
complains of vertical diplopia of sudden onset after a fall and a knock to the back of the
head.

I. What clinical tests would you use to examine this patient and what would be
your expected findings and diagnosis? (12 Marks)
II. Discuss how your results and findings would determine whether this was an
acquired or congenital/longstanding condition and whether it is unilateral or
bilateral (8 Marks)
 III. In the case of this patient, what are suitable management and treatment options?
(5 Marks)

QUESTION FOUR

A previously unexamined six year old presents to your optometry practice with
a Right Convergent Squint. He is noted to be moderately hyperopic. Answer
all the following questions:

(i) What clinical tests would you undertake to investigate this patient?
(15 Marks)
With all esodeviations, need to do cycloplegic refraction to find full extent of
hyperopia
Then do cover test with the full Rx for differential diagnosis
CT without Glasses CT with Glasses (distance and near)

• History & symptoms

• Refractive error
• VA
• CT/Size of Deviation
• OMB
• Grades of BV
Children
• Infrequent as suppression usually occurs, parents more likely to
report eye turning in/out or apparent poor vision
• Clumsiness, poor judgment of distance
• May close one eye
• May get distressed if squint is manifest
• May complain of headaches/sore eyes/diplopia but much more
likely to suppress in childhood
If strabismus reported by parents/carers you need to ask:
• Duration- new/longstanding?
• Constancy- constant/intermittent
• Which eye/alternating?
• Worse with particular tasks-e.g. looking at near object/in
bright sunlight?
• Family history, strabismus, amblyopia, hyperopia?
• Full term birth/premature < 32 weeks, low birth weight (5x
more at risk of esotropia), any orbital trauma during birth
delivery, forcep/vacuum assisted delivery (VI nerve palsy)

If strabismus reported by parents/carers you need to ask:

 Previous treatment, spectacles, occlusion, eye exercises, surgery
 General health- fatigue, poor general health, nausea/vomiting,
headaches, general malaise, growth/weight changes, thyroid
disorders, diabetes, Down syndrome, Cerebral Palsy, Gross
Developmental Delay
  General observation of px- head turns, tilts, dragging a leg, facial
palsy, proptosis, ptosis, lid retraction?
 Detects type of strabismus
 Estimate size of deviation or measure size with prism cover test (PCT)
 Measure with and without refractive correction
 Near and distance fixation, far distance fixation
 Think about target, accommodative (budgie stick), non-accommodative
(pen-torch)
VA

(ii) Discuss your management of this patient if:

(a) He had potential for Binocular Single Vision (6 Marks)
(b) He had no potential for Binocular Single Vision (4 Marks)

QUESTION THREE

(i) Name the ocular muscles supplied by the 3 rd cranial nerve (3 marks)
MR, IO, SR, IR

(iii) Detail the signs and symptoms associated with a sudden onset of a complete third nerve
palsy in adulthood and what tests you would use to confirm the diagnosis? (12 marks)

Symptoms
– Pain around eye
– Headache
– Sudden & rapid onset of palsy
– Diplopia (if ptosis partial or absent)
– Dilated pupil

Ophthalmic & Orthoptic Investigation

• Pupil reactions- is it dilated? How well does it react? Anisocoria?
• Accommodative palsy- check near monocular VA
• Check integrity of other cranial nerves- IV, VI, V (trigeminal nerve-check
corneal sensitivity)
• Cover test- affected eye will be exotropic, intorted and hypotropic= DOWN
and OUT
• GOI- Ptosis?

Ophthalmic & Orthoptic Investigation

 • Ocular movement- underaction of all muscles controlled by 3 rd nerve (SR, IR,
IO, MR) overaction of the synergistic muscles of the unaffected eye, further
sequelae not formed if newly acquired
• Measurement of deviation
• HESS chart- permanent record to monitor change/improvement

• If 3rd nerve palsy suspected, (sudden, onset of diplopia with pain) must be
referred as a medical emergency
• Needs urgent neurosurgical investigation
• May be an aneurysm of posterior communicating artery which if left untreated
is fatal.

(iii) In the case of a patient who has presented to you in practice with a sudden onset
of complete 3rd nerve palsy, what are the suitable management and treatment
options available? (10 marks)

 If pt presents to your practice with suspect signs of 3 rd nerve palsy,

urgent referral to A&E, assume aneurysm of posterior communicating
artery until proven otherwise
 Send letter with pt

• Emergency referral to A&E

• Neurological investigation required-treat underlying condition
• Spontaneous recovery - may occur depending on the cause
(microvascular 95% vs tumour/aneurysm 16-36%) 1
• SYMPTOMS (DIPLOPIA)– PRISMS, little use unless palsy is mild,
OCCLUSIVE CL (if ptosis is absent)
• PHOTOPHOBIA –constriction of pupil with pilocarpine 0.1% x 2 daily,
suggest sunglasses
• SURGICAL –must be delayed 9-12 months until stable in acquired
palsies® correct exotropia first. Not great success for any field of BSV,
usually require occlusive CL

Muscles affected SR, MR, IR, IO, Levator

QUESTION THREE
(i) Discuss the characteristics and investigation of a 49 year old male presenting
with a fourth nerve palsy. (15 marks)

History & Symptoms

• Symptoms much worse in acquired than congenital
• Image tilt is important feature
• Px c/o vertical diplopia, worse in down gaze (e.g. when reading)
– SO known as the ‘reading muscle’, px may c/o having to hold
book higher
 – Varifocals/bifocals contraindicated

AHP / Diplopia
• head tilt to unaffected side, possibly face turn to unaffected side & chin
depression
CT
• hypertropic & slightly esotropic, may show excyclotropia
• Increases on near vision
• Do with/without AHP
• Measure size of deviation (prism bar) for accurate record
• Only slight hyper in PP if bilateral palsy
• Presume the condition is bilateral until proven otherwise in acquired
(usually due to trauma), can be asymmetric
• Extorsion present in acquired bilateral palsies (not congenital)
• Adapt to the retinal extorsion in congenital palsies
OM
• u/a of affected SO, o/a of contralateral IR
• Muscle sequelae will be formed in congenital, not in acquired
• o/a of ipsilateral IO, u/a contralateral SR
• Greatest hyperdeviation seen when eye looks up & in due to muscle
sequelae, o/a of IO
Binocular function
• large vertical fusional range in congenital (10 ^D or more!)
• Suggestive that condition is longstanding
• Suppression in congenital?
Hess Chart / Field of BSV
• Hess is smaller for affected eye in acquired, congenital, more equal in size
due to muscle sequelae

Bielschowsky Head Tilt Test (BHTT)

• PP shows a hyper deviation of affected eye

• +ve BHTT tilt head towards affected side, vertical deviation increases
• Tilt head towards unaffected side, vertical deviation will decrease

(ii) Describe how your management of this patient would differ if the deviation was
longstanding or recently acquired. (10 marks)

IN ADULTS
Where congenital palsy has decompensated
• Need to be sure it is congenital decompensating over acquired (DD-see table)
• Referral to orthoptist for confirmation of diagnosis
• Vertical prism may alleviate symptoms, start with Fresnel prism and then
incorporate into glasses when stable
• Avoid bifocals/varifocals, will prefer to read in primary position rather than
downgaze where deviation is maximum. SVN best solution.

acq
Referral to GP/orthoptics/ophthalmology for further investigation
 • Requires urgent referral (not medical emergency like 3 rd nerve) to investigate
neurological cause, medical work up & CT scan
• Treat underlying cause (e.g. diabetes/hypertension)
• Wait for spontaneous recovery of diplopia 9-12 months
• Prisms- for small angles/ Fresnel for temporary fix
• Occlusion (to remove diplopia)

• If not resolved after 9-12 months

• Incorporate prism into glasses and monitor for 3 months
• If still symptomatic- surgery
– Ipsilateral IO recession
– Contralateral IR recession
• Surgery for torsion
– Harado-Ito/ Fell’s procedure- SO tendon placed further anteriorly and
laterally- increases intorsion

• Longstanding
• Need to investigate source of decompensation- soon referral if you think it is due
to general health issue, microvascular incident etc
• Routine if decompensation likely due to loss of fusion with change in
task/age/muscle weakness/presbyopia etc
• May only need conservative treatment of prisms which can be incorporated into
lenses
• This may be sufficient to regain comfortable BSV. Surgery is only indicated if
patient complains of symptoms and the deviation is too large to control
• Also indicated if decompensation likely or large head posture is present
• Clinically should determine if well compensated or not, this will then indicate if
referral is needed

• Acquired
• Urgent referral to ophthalmology
• Should NOT prescribe prisms to this patient
• Needs medical investigation of blood count/pressure, test for blood sugars,
neuroimaging
• Neuro-imaging is required in younger patients, neoplasm common cause in younger
px, vascular in older px
• A period of observation is given to allow time for spontaneous recovery and treatment
of underlying cause
• Observation period of 9 – 12 months. Fresnel prisms given to maintain single vision
during this time

QUESTION ONE
(i) Discuss the characteristics and investigation of a 52 year old female presenting
with diplopia and a sixth nerve palsy with a longstanding moderate hypermetropic
correction of +7.50DS right and left. (15 marks)
(ii) Describe how your management of this patient would differ if the deviation was
longstanding or recently acquired. (10 marks)

HISTORY- birth trauma? Forcep/vacuum assisted delivery

Full medical history
May complain of horizontal diplopia, worse on distance vision
MEDICAL INVESTIGATION- MRI/CT scan blood count & diabetic test, fundus check for
papilledema/optic neuritis
OPHTHALMIC/ORTHOPTIC INVESTIGATION- DD congenital esotropia & Duane’s
retraction syndrome
MEASUREMENT OF DEVIATION- cover test
HESS/LEES CHART

OCULAR POSTURE
• Esotropia (greater at distance), check with and without AHP
ABNORMAL HEAD POSTURE
• What type?
MUSCLE SEQULAE
• u/a of LR
• O/a of contralateral synergist ?
• Contracture of ipsilateral antagonist ?
• Secondary inhibition of contralateral antagonist ?

• CHARACTERISTICS
• Esotropia, D>N (may be phoric at near)
• AHP- turn face to affected side (no chin element or tilt)
• Px will complain of horizontal diplopia worse in the distance (due to convergence
effect at near)
• Muscle sequelae likely only u/a LR, o/a MR if recent onset

• INVESTIGATION
• Visions D&N
• CT w & w/o AHP (PCT)
• Refraction (have current glasses prism incorporated?) Hyperopia correction should
reduce esotropia (if an accommodative tropia present)
• OM- note maximum diplopia
• Versions and ductions
• Hess chart
• Determine if longstanding or acquired by case history

• Longstanding
• Need to investigate source of decompensation- soon referral if you think it is due
to general health issue, microvascular incident etc
• Routine if decompensation likely due to loss of fusion with change in
task/age/muscle weakness/presbyopia etc
• May only need conservative treatment of prisms which can be incorporated into
lenses
• This may be sufficient to regain comfortable BSV. Surgery is only indicated if
patient complains of symptoms and the deviation is too large to control
• Also indicated if decompensation likely or large head posture is present
• Clinically should determine if well compensated or not, this will then indicate if
referral is needed

• Acquired
• Urgent referral to ophthalmology
• Should NOT prescribe prisms to this patient
• Needs medical investigation of blood count/pressure, test for blood sugars,
neuroimaging
• Neuro-imaging is required in younger patients, neoplasm common cause in younger
px, vascular in older px
• A period of observation is given to allow time for spontaneous recovery and treatment
of underlying cause
• Observation period of 9 – 12 months. Fresnel prisms given to maintain single vision
during this time
QUESTION ONE
Answer all sections:
 Discuss the 2 laws that govern the development of extra ocular muscle
sequelae.

(8 Marks)
 Describe the full muscle sequelae that occur in ocular neurogenic palsies
indicating which law is responsible for each sequelae in turn.

(7 Marks)
 How may longstanding incomitant strabismus be distinguished from recently
acquired incomitant strabismus?

(10 Marks)

QUESTION FIVE
A cycloplegic refraction of a six-year-old child reveals:
RE +2.00DS 6/6
LE +4.00DS 6/12
Left esotropia (20) is present without this prescription and there is an esophoria
(6) when this prescription is worn.
Clearly outline a programme for the further investigation of this patient and describe
what your management of this case would be. (25 Marks)

• Diagnosis= fully accommodative esotropia with strabismic and anisometropic

amblyopia
• Case History
– Onset, duration, worse with certain tasks/ when tired, GH, birth history,
POH, FOH, symptoms from child
• Refraction
– Prescribe full Rx, full time wear
– Only when refracted do we know it is fully accomm
• Cover test- check at distance and near to ensure it is not convergence excess
• OM- concomitant – same in all directions of gaze, rule out 6 th nerve palsy/duanes
• Assess BSV- sim perception, fusion (motor & sensory), stereopsis- HOW? What
tests and expected results

• Management
• Can manage in practice, monitor VA every 4-6 weeks
• Ensure VA is improving. Measure using a crowded test (e.g. Keeler crowded
letters)
• Refer to orthoptist for occlusion therapy once plateau in VA. (less than one
line improvement at consecutive visits) (refractive adaptation 18 weeks), not
urgent referral as straight with specs,
• PEDIG – amblyopia therapy, part time occlusion as moderate amblyopia and
don’t want to dissociate strabismus

– Moderate amblyopia 6/12 to 6/24 patch for 2 hours with 1 hour of near
visual activities
– Atropine therapy, optical penalistion other alternatives discussed
– HOW WOULD YOUR MANAGEMENT DIFFER IF NOT FULLY
ACCOMMODATIVE OR IF CONVERGENCE EXCESS PRESENT?

 Hess Chart

1. Which is the affected eye? The chart with the small field is the abnormal
one.
 2. Is the field compressed? If compressed, consider mechanical causes
otherwise neuro.
 3. what is the deviation in the pp? Look at the central dot
 4. Which muscle is underacting? The greatest negative or inward
displacement  represents the primary underaction
 5. Which muscle is overacting or any other sequelae? The muscle with
positive or outward displacement indicates an overaction.

• Link between convergence and accommodation

• Plus lenses help esophoria/esotropia, minus lenses help exophoria/exotropia
• Orthoptic exercises
– Positive or near stereograms work positive fusional reserves
(convergence problems/ exophorias)
– Negative or distance stereograms work negative fusional reserves
(divergence problems/ esophorias)

• Know where the greatest actions of muscles occur

• Amblyopia, treatment methods, occlusion therapy, atropine, optical
penalisation, recommended guidelines
• Types of esotropia/exotropia, investigation, clinical diagnosis (differential
diagnosis), management and treatment options
• Remember- congenital/infantile tropias are present before 1 year, all else are
childhood tropias
 • Vasa nervorum= small network of blood vessels helping to supply the nerves
• Supplies inner aspect of nerve, pupil fibres lie on the periphery of the
nerve
• Vasa nervorum vulnerable to occlusive disease (e.g. from diabetes)
• Nerve fibres that influence pupil constriction on the periphery of the nerve are
less susceptible to ischaemic disease, but they are more susceptible to injury
by compression by the posterior communicating artery

• Full ophthalmic & medical history

• Symptoms- nature, when, sudden/gradual, change, worsening, relief?
• Type of diplopia, horiz, vert, torsional?
• Associated event before symptoms? Associated symptoms = eye pain, pain
on eye movement?
• Changes throughout the day?
• Method to overcome diplopia?
• AHP- is this new or longstanding? New will look uncomfortable and obvious,
longstanding will look natural for px
• Facial asymmetry or facial injury
• Obvious deviation
• Anisocoria
• Ptosis, lid retraction, proptosis/exophthalmos
• Difficulty in speech, hearing or locomotion
• VA N&D
• CT- do with and without head posture, check for recovery-important
• OM-
• versions and ductions,
• note pain, where diplopia/ deviation of axis is greatest (this
indicates u/a muscle), observe reflexes
• CT in 9 positions
• Note any changes with lid or globe
• Measurement (PCT)
• Hess chart
• Field of BSV

• Sudden onset complete third nerve palsy with pupil involvement

– Intracranial aneurysm until proven otherwise
• Signs of serious underlying cause e.g. progressively expanding lesion- px
who presents with progression and/or numerous palsies
• Significant head trauma
• Myasthenia gravis
• Microvascular-diabetes, high blood pressure
• Demyelinating disease- MS
• All need medical work up, often urgent/emergency referral

con
Children
Aim is to restore/stabilise BSV, prevent symptoms, improve cosmetic appearance of
squint/ improve postural problems
– Surgery indicated
• To reduce AHP
• If decompensation in PP occurs or is likely
• If Manifest strab. with potential for motor and sensory fusion
Adults
– Wait for spontaneous recovery?
– Conservative- prisms (small vert deviations), advise on AHP, occlusion
for temporary relief of diplopia
– Surgery
Acq
Adults & Children
• Investigate and treat cause
• Observation- wait for spontaneous recovery 9-12 months
• Relieve symptoms- prisms, AHP, occlusion
• Surgery