An Overview of the Orthoptist Practical Demonstration

1. An Overview of the OrthoptistPractical Demonstration Louise.C.Corp Specialist Orthoptist

2. The Role of the Orthoptist Assess and Manage: Vision Defects (Amblyopia) Vision Screening Defects of Binocular Single Vision (Squint) Ocular Motility Defects (Diplopia) Low Vision Assessment Glaucoma Clinics Stroke Ward

3. How Do We Assess Visual Acuity?

4. Vision Assessment Cardiff Cards 6mths – 2 years Preferential Looking 2mths – 12mths

5. Vision Assessment Sheridan Gardiner Snellens Kay Pictures 2 - 3 years LogMar

6. Expectations of a baby • To be able to fix and follow small toys ( e.g. mobile whilst in their cot), lights. • Respond to facial expression ( e.g. confirmed by baby smiling, laughing, following parents face on movement ). • Baby will attempt to grasp for small toys whilst fixating on them (e.g play frame over the child whilst laying on their back on the floor) • At birth - VA approx 6/240 - Improvement rapid in first 6mths with a slower rate up until 12mths

7. “The Lazy Eye” • AMBLYOPIA - Reduced vision in one or both eyes • Refractive error • Squint • Stimulus deprivation (ptosis or cataract) • TREATMENT?

8. Managing Amblyopia Patches Glasses Fringe Maybe Not!

9. Managing Amblyopia Atropine Penalisation Blenderm

10. Vision Screening • Reception Class (4 - 5yrs) • Vision, Check for Squint, Assess BSV, Ocular Motility • Pass / Fail Criteria • Absentees offered appointment at Community Clinic or re-visit school • Referred to: Orthoptic Clinic, Hospital Optician, Consultant, High street Optician • Revisit School for Absentees • Liase with Local Opticians

11. Defects of Binocular Single VisionSquints

12. There are two types of Strabismus

13. Manifest Strabismus • Also known as HETEROTROPIA • When one eye focuses on an object, one eye deviates away from the object • Squint is caused by failure of two eyes to look at objects in a coordinated manner. Depends on the normal functioning of brain, optic nerve and twelve muscles around our eyes enabling the two images to superimpose on each other and to form a three dimensional image. • HORIZONTAL • VERTICAL • TORSIONAL

14. Horizontal • Convergent - one eye deviates inwards ESOTROPIA • Divergent - one eye deviates outwards EXOTROPIA

15. What type of squint do these patients have? RIGHT CONVERGENT SQUINT LEFT DIVERGENT SQUINT

16. Pseudo-Strabismus Pseudo-Esotropia Pseudo-Exotropia • Epicanthic folds • Wide interpupillary distance • Short interpupillary distance

17. Essential Infantile Esotropia Presents within first 6 months Signs • Angle large and stable • Nystagmus in some cases • Normal refraction for age • Poor potential for BSV • Amblyopia in about 30% • Cross fixation

18. Constant Exotropia Congenital Sensory • Presents at birth • Disruption of binocular reflexes by • acquired lesions, such as cataract • Large angle • Alternating fixation • Normal refraction for age

19. The effect of glasses The effect of accommodation

20. Ocular Motility Defects Abnormal Eye Movements

21. DIPLOPIA - HORIZONTAL & VERTICAL

22. Third Nerve Palsy • Ptosis, mydriasis and cycloplegia • Abduction in primary position • Normal abduction • Intorsion on attempted • downgaze • Limited adduction • Limited elevation • Limited depression THE PATIENT WILL SUFFER DIPLOPIA

23. Sixth Nerve Palsy Straight in primary position due to partial recovery Limitation of right abduction and horizontal diplopia Normal right adduction

24. NERVE PALSIES (III,IV,VI) Be aware in Children Present with acute onset Squint Complaining of Diplopia Limited Eye Movements Parents notice closing of one eye Urgent Referral Possible Serious Pathology More common 6th Nerve Palsy

25. Thyroid Eye Disease Elevation defect - most common Abduction defect - less common Depression defect - uncommon Adduction defect - rare

26. Right Brown`s Syndrome Normal elevation in abduction Straight in primary position Limited elevation in adduction Defect to the Superior Oblique Muscle / Tendon

27. EYE MOVEMENTS PLOTTED USING THE LEES SCREEN

28. What to refer to an Orthoptist ?? • Yes • Vision concerns – baby not fixing/following small toy / lights • Squint • Ocular Movement concerns • Poor cooperation of patient to ensure no defects • Parental Concern BE CAREFUL!! • No • Family History alone – distant relatives • If ? A squint in a child < 4 months old if obvious squint seen then refer if not ask HV to check at 6mths, if still doubtful then refer

29. Does anyone in the group have a squint? Let`s find out ???

30. The Cover Test • “An objective dissociation test to elicit the presence of a manifest or latent deviation. It relies upon the observation of the eyes whilst fixation is maintained and each eye is covered and uncovered in turn”. • Firstly, check for a manifest squint before progressing to find a latent squint.

31. Detection of a manifest squint • Ensure patient is looking straight ahead • Check corneal reflection position • Hold a pen torch at 1/3m from the patients eyes (eye level) • A light is used initially as the position of corneal reflections may indicate a manifest squint (if large enough to see) • Should be central / symmetrical or both displaced slightly nasal • If a manifest squint detected, a CR will be central in the fixing eye, displaced nasal or temporal in the squinting eye

32. Continued…………….. • Hold fixation target on a level with patients eyes at a 1/3m and ask them to look at it (pen torch first) • Introduce occluder in front of one eye and watch for any in or outward movement of the other eye • If there is no movement, there is no manifest squint in that eye • Repeat with the occluder in front of the other eye • If no movement visible of the opposing eye again, then the patient DOES NOT have a manifest squint at that fixation distance in either eye • Repeat CT with an accommodative target at 1/3m • Repeat CT at 6m and far distance

34. Possible findings for Manifest Squint

35. Continued………… • Performed at 1/3m, 6m and far distance • Using accommodative/non-accommodative fixation targets • With and without glasses • With or without any Abnormal Head Posture • In 9 positions of gaze if required

36. Detection of a latent squint • Use appropriate accommodative/non-accommodative targets on a level with the patients eyes at 1/3m • Introduce occluder in front of one eye • Observe for any movement of the eye behind the occluder once it is removed • Repeat with other eye • If no movement seen, alternate the occluder from eye to eye (make sure binocularity is avoided)

37. Continued………... • This may cause the patients eyes to dissociate and a movement maybe more obvious as alternate eyes are occluded • Size and direction of movement of the occluded eye (in or out) as it is moved over to the other eye should be noted • Speed at which the eye moves back to the normal position as the occluder is completely removed should be noted (rate of recovery) – indicates strength of BSV or vision level • Repeat at 6m

38. Remember……………. • Position of eyes on appearance • Check corneal reflections first • Ensure no manifest deviation present first • Estimate size of deviation (minimal,slight,mod,mkd) and direction of deviation • Fixation targets-light,small picture or toy, 6m picture/object • Can the manifest deviation alternate or hold fixation • Diagnosing the type of movement from where the eye position has moved FROM

39. Ocular Movement Testing Practical Demonstration Let’s have a Go!

40. EOM Testing • Hold a pen torch – 1/3m from patient on eye level • Slowly move the torch in to each of the 9 gaze positions • Logical order • Use your occluder to assess ductions and versions at each gaze position • Grade any defect • Underactions, restriction, overactions, updrifts • A or V patterns • Nystagmus • Record on a diagram

41. Underactions v Restrictions/Limitations Background information: • Versions is testing both eyes open • Ductions is testing an eye uniocularly

43. Check action of Left Lateral Rectus • Patient follows torch BOTH EYES OPEN into Left Gaze or Laevoversion (Abduct the Left Eye) • Observe the Left Eye for any lack of movement • If no movement made at all – possible - 4 defect • Use occluder and cover the Right Eye • If full movement of the Left Eye into Laevoversion is seen (to abduct the eye) = Underaction of the LE in Abduction • If there is still no movement when the Right Eye is covered = Restriction of Left Abduction • Testing the Abducens VI Cranial Nerve

45. Grading • A normal version BEO movement = 0 • Sclera should be concealed by the canthus in a full horizontal movement • If the sclera is just visible ( - 1 underaction ) • Underaction / Restriction ( - 1 to - 5 ) • (- 5 ) PT UNABLE TO TAKE CENTRAL FIXATION • ( - 4 ) NO MOVEMENT BEYOND MIDLINE • ( - 3 ) 25% MOVEMENT REMAINS • ( - 2 ) 50% • ( - 1 ) 75% • ( - 5 ) EYE CANNOT REACH MIDLINE

46. Grading • Overactions • + 1 to + 4 • E.g. Inferior Oblique • + 1 Excessive elevation only in the field of main action • + 4 Maximum amount of elevation anatomically possible • + 3 and + 4 of overaction indicates an updrift on horizontal movement • +2 overaction indicates the eye has to be in an elevated position before excessive movement occurs

47. Observations • Make sure you can the corneal reflection in each eye • Make sure patients nose not obstructing corneal reflection • Watch for head movement • Ask patient about diplopia • Watch for any nystagmus (eyes shaking) • Observe pupil abnormalities • Observe lid / fissure changes

48. Thank you Louise.C.Corp Specialist Orthoptist Calderdale Royal Hospital 01422 222218 Louise.Corp@cht.nhs.uk