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Basic Motility Exam Techniques
1. Basic Motility Examination
Alvina Pauline D. Santiago, MD
Pediatric Ophthalmology & Strabismus
Basic Course Lectures in Ophthalmology
Sentro Oftalmologico Jose Rizal
Philippine General Hospital 2017
2. Basic Strabismus Evaluation
• Chief complaint and History
• Vision assessment (with vision screening)
• Gross evaluation and slit lamp examination
• Refraction and need for cycloplegia
• Sensory & Motor examination (Motility
Examination)
• Dilated posterior pole evaluation
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3. Sensory Testing
• Perform before any type of monocular occlusion
• e.g., visual acuity testing, cover tests
• Must wear correct prescription
• May need to correct deviation
• Prefer to do on a second visit
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4. Sensory Testing
• Near stereoacuity
• Fly vectograph/ Titmus Fly Test
• Lang stereotest
• Random dot stereograms
• Distance stereoacuity
• Mentor BVAT
• AO vectograph
• Amblyoscope
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5. Stereoacuity tests
• Horizontal disparity
• Stimulate non-corresponding points
• Image disparity measured in sec of arc
• 40-50 sec = central or bifoveal fixation
• 80-3000 sec = peripheral fusion
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6. Titmus fly test
• Monocular cues
• Need polarized glasses
• Image displacement
may be detected by
alternate suppressors
• Turn book 90 degrees,
should be flat
From Rosenbaum & Santiago, Clinical Strabismus Management
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7. Lang Stereoacuity test
• Random dot stereogram
• No need for Polaroid
lenses
• Only for gross and low
grade stereopsis
From Rosenbaum & Santiago, Clinical Strabismus Management
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8. Random Dot Stereogram
• 2 plates of randomly
displayed dots, one plate
to each eye
• Shape of figure
displaced horizontally
relative to other plate
• No monocular cues
• Normal may fail
From Rosenbaum & Santiago, Clinical Strabismus Management
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9. Distance Stereotest
• Mentor BVAT
System
• Very good test
for assessing
control in X(T)
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
From Rosenbaum & Santiago,
Clinical Strabismus Management
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11. Sensory Testing
• Worth 4 dot
• near: tests peripheral fusion
• distance: tests central fusion
• Retinal correspondence
• amblyoscope, Bagolini lenses
• 4 pd BO test: foveal suppression
• Normal response
• conjugate saccades OU,
• slow recovery in eye without the prism
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12. Worth Dot Test
• 2 green lights
• 1 red light
• 1 white light
• Red-green glasses
• Usually red over right eye
• At 1/3 m:
• W4D separated by 6 degrees
• Tests peripheral fusion
• At 6 m:
• 1.25 degrees
• Tests central fusion
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13. Worth Dot Test Results
http://image.slidesharecdn.com
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14. Amblyoscope or Haploscope
• Measures fusional vergence
amplitudes
• Angle of deviation
• Area of suppression
• Retinal correspondence
• Torsion
• Instrument convergence
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From Rosenbaum & Santiago, Clinical Strabismus Management 1999
25. Hirschberg’s Corneal Light Reflex
• 3.5 mm pupil:
• 15 deg at pupil edge
• 30 deg between limbus
and edge of pupil
• 45 degrees at limbus
• Not a true linear relationship:
21 pd/mm decentration
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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26. Krimsky vs Modified Krimsky
• in front of deviating
eye (modified
Krimsky)
• underestimates true
angle
• better at near
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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27. LIGHT REFLEX, COVER TESTS
(Courtesy of R. Pena, MD)
MODIFIED KRIMSKY
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28. Motor Testing: Cover Tests
• Primary gaze
• Right and left gaze
• Up and down gaze
• Right and left head tilt
• Oblique gazes, occasionally
• Near: primary and down gaze
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29. Cover Tests
• Requirements:
• Appropriate correction
• Know if correction with or without prisms
• Accommodative target (above threshold)
• Distance:
• 6 m: 1/6 D of accommodation
• (approximates infinity)
• > 6 m: X(T)
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30. The Ideal Target
• Above threshold
• e.g. Snellen acuity 20/20
• present 20/50 to 20/70
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31. The Ideal Target
• With sufficient detail and contour
• Should sustain interest
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32. Toys as Targets
• One toy one look
• With detail
• May be coupled with a
light
• Sounds for tracking but
not vision testing
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33. The Ideal Target
• Maximum plus, least minus correction
• Allows minimal accommodation at 6 m
• Accommodation exerted only 1/6 Diopter,
considered zero for strabismus measurement
purposes
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38. Cover Uncover Test
• Must be performed
before alternate
cover test
• Cover test: tropia
• Uncover test: phoria
• also for fixation
preference
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https://www.youtube.com/watch?v=f5HbIZi4u70
39. Alternate Prism Cover Test
• Prisms before deviated eye
• primary vs. secondary deviation
• Unless strabismic eye is preferred for fixation
• Evaluates total deviation: manifest (tropic) and
latent (phoric)
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40. ALTERNATE PRISM & COVER TEST
Gold standard for
measuring deviation
LIGHT REFLEX, COVER TESTS
(Courtesy of R. Pena, MD)
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41. Simultaneous Prism Cover Test
• Tropia under binocular conditions
• Monofixation syndrome
• Estimate angle of deviation
• Present prism and cover simultaneously
• Absence of movement in tropic eye means correcting
prisms are accurate
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42. SIMULTANEOUS PRISM & COVER TEST
Used for monofixation
LIGHT REFLEX, COVER TESTS
(Courtesy of R. Pena, MD)
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43. Prism Under Cover Test
• For Dissociated Vertical Deviation
• Evaluate one eye at a time
• Prism and cover presented to the same eye
• Separate true hypertropia by using BU prism
neutralization in other eye
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44. PRISM UNDER COVER TEST
Used for DISSOCIATED
VERTICAL DEVIATION (DVD)
LIGHT REFLEX, COVER TESTS
(Courtesy of R. Pena, MD)
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46. Techniques in Finding Strabismus
• Bruckner test
• Spielmann
translucent occluder
From Rosenbaum & Santiago, Clinical Strabismus Management
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47. Other Tests
• Red glass test
• Maddox rod
• horizontal, vertical
• torsional
• Parks 3-step test for isolated cyclovertical muscle
palsy
• 3rd step is Bielschowsky maneuver
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49. Parks 3-step Test
Left Hypertropia
1. Of 8 cyclovertical
muscles: 4
LSO, LIR, RSR, RIO
2. Of 4 cyclovertical
muscles: 2
increase on R gaze: LSO,
RSR
3. Of 2 cyclovertical
muscles: 1
increase of L tilt: LSO
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57. Tests of Muscle Function
• Forced duction test
• Force generation test
• Saccadic velocity analysis
• EMG
• Dynamic MRI
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58. Indications
• Incomitant deviation
• Limited ocular rotation
• Distinguish between restriction and paresis/palsy
• Distinguish between paresis and palsy
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59. Passive Forced Duction
• Some indications:
• Trauma
• Endocrine
• Postoperative restriction of
motility
• Longstanding deviation with
secondary contracture
• Congenital restrictions
• Brown
• Duane
• Transposition procedures
• Orbital diseases
• Tumors
• Inflammation
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60. Advantages
• Help in deciding between treatment options
• Monitor improvement of paretic muscles
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61. Tests of Muscle Function
• Paresis vs. restriction
• Forced duction test
• Force generation test
• Saccadic velocity analysis
• Differential intraocular pressure
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62. EMG: Electromyography
• Limitations:
• may record activity even if muscle still paretic
• response suppressed by GA
• still used in some cases of Duane syndrome and
Botulinum injection
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63. Passive Forced Duction
• Children > 7 yrs, adults
• Topical anesthetic
• Cover one eye: ensures
fixation
• Look as far as possible in
the direction of limited
ocular rotation
• Provide fixation target
• Watch out for “falling
off” of eye
#BasicMotilityExam
(c) APSantiago 2017
63
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
64. Passive Forced Duction
“Can the forceps rotate the eye further
than the patient can using maximal
innervation in that gaze field?”
• Grasp limbus opposite the side of limited gaze
• Tenon’s and conjunctiva fused in one layer
• limits stretching/tearing of conjunctiva
• provides firm grasp
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70. Intraoperative Forced Duction Testing
• Perform routinely to feel “normal”
• Perform esp after resections
• may be ortho in primary
• overcorrection in certain gazes
• Perform after transpositions
• Intraoperative adjustable suture
• Perform after removing suspected restrictions
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72. Pitfalls: Forced Duction
• Patient apprehension
• Errors in technique
• “Falling off”
• Failure to proptose for rectus or retropulse globe for obliques
• Succinylcholine (Anectine)
• Posterior restrictions
• Co-contractions
• Co-existing paresis and restriction
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73. Active Force Generation
• Apply a counteracting force
• Using the same grasp on
limbus
• Counter-traction to feel
resistance
• WOF: corneal abrasion,
conjunctival hemorrhage
#BasicMotilityExam (c) APSantiago 201773From Rosenbaum & Santiago, Clinical Strabismus Management 1999
74. Active Force Generation
• Differential IOP
• Paresis vs. palsy
• Combined paresis and restriction
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75. FDT, FGT, Diagnosis
Diagnosis Forced Duction Force
Generation
Mechanical
restriction
Restricted Normal
Muscle palsy Free Absent
Paresis &
restriction
Free Weak
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Common pitfall: mild paresis
Correlate with saccadic velocity analysis
76. Saccadic Velocity Analysis
• Study eye movement velocity
• muscle activity
• return of muscle function
• EOG : problem when testing vertical saccades
• Infrared
• Scleral search coil
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77. Office Saccadic Velocity
• Look at 2 separate targets
• At least 20 deg movement sufficient
• Compare
• briskness of agonist and antagonist
• with fellow eye
• Bring the eye where muscle has
• maximum function
• full unrestricted motion From Rosenbaum & Santiago, Clinical
Strabismus Management 1999
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78. Pitfalls: Saccadic Velocity
• Errors in technique
• failure to bring eye
where muscle is still
functioning
• Pharmacologic
• Fatigue
• Time of day
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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79. Clinical Applications:
Saccadic Velocity Analysis
• Paralytic Strabismus
• Restrictive Strabismus
• Lost or slipped muscles
• Neurologic Disorders
• Myasthenia Gravis (MG)
• normal then weakens; use
with Tensilon
• Progressive External
Ophthalmoplegia (PEO)
• general slowing
• Inter-nuclear
ophthalmoplegia (INO)
• slowed adduction
• normal abduction
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80. Slowed Saccadic Velocities
• LR palsy abduction
• SO palsy downgaze
• Moebius horizontal
• Myasthenia normal then slows
• Slipped/Lost reduced 20-50%
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81. Magnetic Resonance Imaging
• Cross-sectional area
• Applications:
• EOM palsy
• EOM heterotopy
• Severed/extirpated muscles
• Entrapment
• Mass
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82. Normal coronal section
From Rosenbaum & Santiago, Clinical Strabismus Management 1999
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