Orthoptics evlauation and its test includes accomodation and convergence

1. ORTHOPTICS INTRODUCTION &
INDICATIONS
PRATYUSH DHAKAL

2. INTRODUCTION
 WHAT IS AN ORTHOPTIC EVALUATION
 It is a systemic and step by step phenomenon of evaluation of the efficacy of
eye muscles during normal binocular eye movements to maintain binocular
fusion.
 It leads to an idea of Accomodative, Vergence or Fusional Vergence
Anomalies and provides a guideline to treat the causes and rectify it by
practice of some orthoptic exercises accordingly.

3. INDICATIONS
 Basic questions to be answered..
 Whether the patient has binocular single vision.
 Whether the patient has diplopia
 Whether the patient has suppression.
 Ocular alignment and status of accomodation.

4. INDICATIONS
MAIN C/O OF PATIENTS
 HEADACHE
Detailed history should be taken..
 Duration
 Whether it persists for few minutes or continues for long
hours.

5. INDICATIONS
 Time of Onset
 Is the headache associated only during reading time or
any sort of near work.
 During watching system for continuously.
 Increases while going out in sun, associated with pain
around eyebrows.
 How it gets relieved

6. INDICATIONS
 INTERMITTENT BLURRING OF VISION DURING
READING
 The patient complains of sudden blurring of vision after
1-2 hours of reading.
 Gets worsened after stressful work.
 Associated with headache.

7. INDICATIONS
 INTERMITTENT DIPLOPIA
 Cases of intermittent diplopia should be ruled out as a
need for orthoptic evaluation.
 As it indicates an Intermittent Divergent Squint.

8. INDICATIONS
 DIFFICULTY TO FOCUS AT DISTANCE & NEAR
SIMULTANEOUSLY
 Some patients complains of difficulty to focus at a near
object immediately after looking at a distant object.
 This might gives an indication of accomodative defect.
 We need to check the accomodative facility after doing
NRA & PRA and MEM findings.

9. INDICATIONS
 BLURRING OF VISION MORE AT DISTANCE THAN
NEAR
 This may be a case of Divergence Insufficiency.
 It should be always ruled out with Divergence Paralysis
where the patient will have the same problem for
distance & near both.
 Sometimes the patient complains of an inward turning of
eyes during distance vision.

10. INDICATIONS
 SPLITTING OF IMAGES WHILE MOVING AN OBJECT
FORWARD
 This is a case of Convergence Insufficiency.
 Fusional Vergence needs to be checked to rule out
Fusional Anomalies along with convergence insufficiency.
 Accomodative component should also be ruled out.

11. INDICATIONS
 INWARD TURNING OF EYES & FATIGUE WHILE
READING
 This may indicate a case of Accomodative Excess or
Convergence excess.
 May lead to accomodative spasm or may be a case of
Pseudomyopia.
 Parents often complain that the child is doing lot of
mistakes while writing.

12. INDICATIONS
 CLINICAL SIGNS..
 We will get a varying reflex in this situations.
 Normally a case of pseudomypia.
 Patient will accept a high minus.
 Due to over accomodation.
 MEM value will show a low value or lead in
accomodation.

13. indications
 Gross reduction in Near Vision.
 Patient finds difficult to read the N6 line.
 If it is a convergence excess then NFV will be low, but we
will get a normal MEM value or a little high MEM.

14. ORTHOPTIC EVALUATION
STEP BY STEP

15. Orthoptic evaluation
WORTH 4 DOT TEST
 Habitual Correction
 Red-green goggles
 Both for distance
and near.

16. Orthoptic evaluation
 3 green RE-Suppression
 2 red LE-Suppression
 5 lights - Diplopia

17. ORTHOPTIC EVALUATION
 MADDOX ROD TEST for detection of distance
phoria

18. Orthoptic evaluation
 MADDOX ROD – PHORIA
 Patient’s Habitual Correction.
 RE-Maddox Rod.
 Fixation light or pen torch.
 Both distance and near.
 Measure vertical and lateral phoria.
 Increasing prisms kept infront of
other eye till orthoposition.

19. Orthoptic evaluation
 NEAR POINT OF CONVERGENCE
 Maintaining fusion
 Pentip or Fixation target in RAF
 Target double
 Subjectively & Objectively
 Should be checked recurrently
 To see if there is a recede of
NPC

20. ORTHOPTIC EVALUATION
 AMPLITUDE OF ACCOMODATION
 Normally with a RAF rule
 First binocularly then monocularly
 Binocularly-Accomodative response
with convergence
 Hofster Formula= 18.5 – (0.3 * Age)

21. Orthoptic evaluation
TESTS DONE
 PUSH UP
 NEGATIVE LENS TO BLUR

22. ORTHOPTIC EVALUATION
PUSH UP
 N6 target
 Move the target
 Target should be blur
 Note in dioptre

23. Orthoptic evaluation
 NEGATIVE LENS TO BLUR
 N6 target @ 40cm
 Monocularly
 Subjective correction
 Add minus lenses
 Report to blur

24. Orthoptic evaluation
NEGATIVE RELATIVE ACCOMODATION
 N6 target given
 Add plus lens binocularly
 0.25 – 0.50 clicks
 Note first sustained blur
 Normal value of NRA is +2.50 DS

25. Orthoptic evaluation
POSITIVE RELATIVE ACCOMODATION
 N6 target given
 Add minus lens binocularly
 0.25-0.50 clicks
 Note first sustained blur
 PRA value related with NFV
value measured in Step Vergence test.

26. Orthoptic evaluation Some basic terms
NFV : NEGATIVE FUSIONAL VERGENCE
It measures the amount of divergence of the patient’s eyes to maintain binocular
fusion in
presence of a stimulus (minus lens)
PFV : POSITIVE FUSIONAL VERGENCE
It measures the amount of how much the patient’s eyes converge to maintain fusion
in presence of a stimulus( plus lens)

27. Orthoptic evaluation
DYNAMIC RETINOSCOPY
 With static correction
 Dynamic card attached to
to retinoscope
 Room light on
 Fixate on dynamic card or read aloud
 Strongly active accomodation.

28. Orthoptic evaluation
DYNAMIC RETINOSCOPY (Contd..)
 Neutralise both the meridians
 Static – Dynamic = Lag of accomodation.
 +0.25 to +1.00 normal
 Above +1.00D – lag
 Minus - lead

29. Orthoptic evaluation
ACCOMODATIVE FACILITY
 Dynamics of accomodative response
 N6 target given
 Flippers close to eyes
 Flip when target clears
 First plus lens side kept
 Select according to NRA PRA value.

30. Orthoptic evaluation
ACCOMODATIVE FACILITY
 Flipper or accomodative rock
 Monocularly and binocularly
 No. of flips per minute is noted
 Monocularly 12cpm for +/- 1.50D

31. Orthoptic evaluation
STEP VERGENCE TEST
 Horizontal prisms arranged together in increasing steps.
 First Base-In then Base-Out
 For distance and near both
 6/60 or 6/36 fixation target
 Base-in for Near (NFV value) correlated with PRA value.

32. Orthoptic evaluation
FUSIONAL RANGE
 Fusional Range(Synaptophore)
 Abduction and adduction
 Fusion slide
 +7 to -10 degree

33. Orthoptic evaluation
AC/A RATIO
Ratio of Accomodative Convergence and Accomodation.
AC/A Ratio = IPD(cm) + W.D in mt*(Near phoria –Distance
Phoria)

34. Orthoptic evaluaTION
BROCK STRING
 Look at the 1st bead -
V shape
 2nd bead – X shape
 3rd bead – A shape

35. Orthoptic evaluation
LIFE SAVER CARD
CAT CARD

36. ORTHOPTIC EVALUATION
ACCOMODATIVE HART CHART

37. Orthoptic evaluation
TAKE HOME MESSAGE
 ‘’Giving a proper orthoptic treatment and
follow up report results in rapid cost
effective and permanent improvement in
visual skills”