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Strabismus: Ugh!

Strabismus: Ugh!. If it is Strabismus, It Can be Diagnosed with a Cover Test. The Obvious and the Not So Obvious. Two Big Areas Esotropia Exotropia I Wonder if it should not be Intermittent Constant What is the Advantage of Strabismus?. Press and Efficacy: Esotropia.

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Strabismus: Ugh!

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  1. Strabismus: Ugh! If it is Strabismus, It Can be Diagnosed with a Cover Test

  2. The Obvious and the Not So Obvious Two Big Areas Esotropia Exotropia I Wonder if it should not be Intermittent Constant What is the Advantage of Strabismus?

  3. Press and Efficacy: Esotropia Plus (T)NC .6 (T)AC .5 NC .3 AC .1 Good Fusion .1 .1 .1 .1 Family Hx .1 .1 .1 .1 No Ambly .1 .1 .1 .1 < 20 ^ .1 .1 .1 .1 Minus Dense Supp .1 .1 .1 .1 Non Concom .1 .1 .1 .1 Dense Ambly .1 .1 .1 .1

  4. Press and Efficacy: Exotropia • Plus (T)NC .8 (T)AC .7 TNC .5 TAC .4 Good Fusion Family Hx No Ambly .1 .1 .1 .1 < 20 ^ Minus Dense Supp Non Concom .1 .1 .1 .1 Dense Ambly .1 .1 .1 .1

  5. Ugly Factors • No Desire To Change • Anomalous Correspondence • Amblyopia • Intractable Diplopia • Constancy • Non-Concomitant • Restrictions • Prior Surgery?

  6. Do They Want To Change?Strabismic From Head to Toe • The Child That Did Not Want a Brother • The College Student That Wanted A Husband • Esotropes want Detail and are Willing to Give up Binocularity to Get it (Developmental) • Exotropes want the “Big Picture” Panoramic Viewing (Genetic, ABI or Functional)

  7. Anomalous Correspondence • A Type of Binocularity • Develops Early---???????????? • Reaction of Organism to Diplopia • Sees Double • Suspends/Suppresses • Goes into an Anomalous Fusion Cortically

  8. Anomalous Correspondence • Depth • Shallow-Ignore • Deep-Ugh! • Treatment • Embed the Binocularity • Move to Harmonious Anomalous • Change to Normal Correspondence

  9. AmblyopiaMaples WC, Bither M. Treating the trinity of infantile vision development: infantile esotropia, amblyopia, anisometropia. J Optom Vis Dev 2006;37: 123-130. • Eccentric Fixation • Develops Early • Secret to Amblyopia (Anisometropic and Eccentric Fixation)----Fixation • 0 Retino Motor Locus • Treatment-Develop Central Fixation

  10. Constancy • INTERMITTENT IS EASIER • The reason that Exos are easier than Esos may be that there are more Intermittent Exos • If Intermittent: • Do not Patch • Work on Binocularity where you can find binocularity and expand it. WORK BACKWARDS TO BIOUCLAR AND MONOCULAR SKILLS

  11. Intractable Diplopia • Late Onset • Trauma • Stroke • Horror Fusionis • The OMD Who Saw Nothing But ID’s • Patch (Contact Lens), Blur, Suppress---

  12. Non-Concomitant • Pathology • Prior Surgery Worse if Complications • Restrictions almost always will not have full use • Duane’s Congenital and Train other Visual Skills • Brown Can be from infection of the tendon sheath and if so, when infection controlled can decrease

  13. Seven Levels of Dx and Tx • Bilateral Integration • Central Fixation • Monocular Equality • Biocular Skills • Basic Binocular Skills • Advanced Binocular Skills • Special (Perceptual/Cognitive/Executive)

  14. Working the System: Testing/Demonstrate • Bilateral Skills: Anatomical Interaction • VO Star • Harmon Bimanual Circles • Standing and Seated Posture • Dry Land Swimming • Angels in the Snow • Line Roll

  15. Working the System: Testing/Demonstrate • Central Fixation • Ophthalmoscopic (Visuscope) • MIT • Cover Test and Angle Lambda (Kappa) Very Gross • Past Pointing

  16. Working the System: Testing/Demonstration • Monocular Equality • Fixation: Wolff Wands, VO 12* Star; Fixation Worksheet; Parquetry Blocks; Chalkboard Saccades • Saccade (Real World): See Above; Wayne Saccades; Hart Chart Challenge; Battle Ship Hart Chart • Pursuit: Wolff Wands; Marsden Ball; Head Rotations; Chalkboard Pursuits; Mechanical Rotator • Near Far-Far Near: Hart Chart, Wayne Saccade • Accommodation: Kraskin Bifocal; Monocular Rock

  17. Working the System: Testing • Biocular Skills: In My Opinion-The Key to Effective Amblyopic and Strabismus Therapy • Suppression • Anomalous Correspondence • Double but MORE THAN Double-Equally Real • “The one I am attending”

  18. Biocular • Tests (Anomalous Correspondence-Press) • Bagolini Lenses • Polarized Vectogram • Amblyscope • Worth Four Dot • Maddox Rod with Red Lens • Hering-Bielschowsky After Image

  19. Working the System: Testing • Tests (Suppression) • Bagolini Lenses • Keystone • Brock String • Quoits (Cross) • Binocular Refractions • Physiological Diplopia • Retinal Rivalry • Others

  20. Working the System: Testing • Basic Binocular • Tons of Tests • Retinoscopy • Phorias • Vergences • Telebinocular • Stereo

  21. The Intermittent Trope Can you get Stereo? • If Stereo • Demonstrated with Peripheral Targets Brock Stereo Motivator or Quoits on a Window • Build Ranges • Ramp • Step • Ability as measured by Accuracy as measured by the Speed and Stamina of the Patient A Ass • Speed means both Fast AND Slow • Minimal Differences (Quoits and 1 ^ difference)

  22. Rules of Engagement”Where the Eye looks and were the Brain thinks it looks is different” • Start Were They Are and Go Where They Ain’t • Start Slow and Start Low • Synapses that Fire Together Continue to Fire Together • Analyze the Procedure: All VT is Bio-Feedback • Patient & Therapist MUST BE involved • Know What you are Attempting to Accomplish • Be Enthustatic • Accomplishment is the Best Reward

  23. Working the System: Therapy • Central Fixation • Pleoptics • Ophthalmoscopic Bleaching • Fixation/Saccade/Pursuit • Smaller and Smaller • MIT • Eye Hand Activities

  24. Working the System: Therapy • Bilateral Skills • Yoked Prisms with Motor Activities • Line Roll • Line Walk • Harmon (Lowman) Board • Harmon Circles • Van Orden Circles

  25. Working the System: Therapy • Monocular Equality (Biocular & Binocular) • Monocular Disassociated Binocular (MDB) Marsden Ball • MDB Pointers • AN 12 pointed Star MDB • Kraskin Bifocal Rock MDB • Modified Modified UpDegrave MDB

  26. Working the System: Therapy • Biocular • Squinchel • Marsden Ball • Physio Diplopia • Quoits • Brock String • 12 Pointed Star

  27. Working the System: Therapy • Binocular Esotrope • Luster • Gross/Peripheral/Moving Targets • Give Me 5 on the Balance Board • Touch my Fingers • Top Clear/Bottom Clear/Both Clear (= Blur) • Quoits-Suppression and Fusion • Keystone without Detail • Encourage Periphery • Motor Activities

  28. Working the System: Therapy • Extotropes • Rx (+) and tend to be poorer academic achievers • “Take This Job and Shove It” “ I Quit” • High Sx: See COVD-QOL Checklist • Functional or Nerve/Muscle Damage • Needs “Orthoptics”: Fixations, Pursuits, Vergence, ACCOMMODATION • Get Stereo; Let Stereo Go; Regain Stereo • See 1/See 2

  29. Skeffington’s Model • Exotropia • Divergence Excess Needs + at Near (Cooper, NO!) • Sympathetic and Parasympathetic-Exos Peripheral Dominant • Social and Biological Clash • Myopia/Esotropia • Hyperopia (Normal Refraction)/Exotropia

  30. Working the System: Therapy • Esotropes • Minimal +; Monocular (-) Followed by Low + • Tend to be High Achievers (Bull Dogs) Low Sx • Want their own Way (Spoiled?-Indulgent Parents) • Will tell you what they think you want to hear • Developmental or SERIOUS PATHOLOGY • Ah, Ha is Needed. That is how you do it

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