maples strabismus2007

Strabismus: Ugh!Strabismus: Ugh!

If it is Strabismus, It Can be If it is Strabismus, It Can be Diagnosed with a Cover TestDiagnosed with a Cover Test

The Obvious and the Not So The Obvious and the Not So ObviousObvious

Two Big AreasTwo Big Areas

EsotropiaEsotropia

ExotropiaExotropia

I Wonder if it should not beI Wonder if it should not be

IntermittentIntermittent

ConstantConstant

What is the Advantage of Strabismus?What is the Advantage of Strabismus?

Press and Efficacy: Press and Efficacy: EsotropiaEsotropia

PlusPlus ((T)NC .6T)NC .6 (T)AC(T)AC.5.5 NC .3NC .3 AC .1 AC .1

Good FusionGood Fusion .1.1 .1.1 .1.1 .1 .1

Family HxFamily Hx .1.1 .1.1 .1.1 .1 .1

No AmblyNo Ambly .1.1 .1.1 .1 .1 .1 .1

< 20 ^< 20 ^ .1.1 .1.1 .1.1 .1 .1

MinusMinus

Dense SuppDense Supp .1.1 .1.1 .1.1 .1 .1

Non ConcomNon Concom .1.1 .1.1 .1 .1.1 .1

Dense AmblyDense Ambly .1.1 .1.1 .1 .1.1 .1

Press and Efficacy: Press and Efficacy: ExotropiaExotropia

• PlusPlus (T)NC(T)NC .8.8 (T)AC(T)AC.7.7 TNC .5 TNC .5 TAC .4 TAC .4

Good FusionGood Fusion

Family HxFamily Hx

No AmblyNo Ambly .1.1 .1.1 .1 .1 .1.1

< 20 ^< 20 ^

MinusMinus

Dense SuppDense Supp

Non ConcomNon Concom .1.1 .1.1 .1 .1.1 .1

Dense AmblyDense Ambly .1.1 .1.1 .1 .1.1 .1

Ugly FactorsUgly Factors

•No Desire To ChangeNo Desire To Change• Anomalous CorrespondenceAnomalous Correspondence• AmblyopiaAmblyopia• Intractable DiplopiaIntractable Diplopia• ConstancyConstancy• Non-ConcomitantNon-Concomitant• RestrictionsRestrictions• Prior Surgery?Prior Surgery?

Do They Want To Change?Do They Want To Change?Strabismic From Head to Strabismic From Head to

ToeToe• The Child That Did Not Want a BrotherThe Child That Did Not Want a Brother• The College Student That Wanted A The College Student That Wanted A

HusbandHusband

• Esotropes want Detail and are Willing to Esotropes want Detail and are Willing to Give up Binocularity to Get it Give up Binocularity to Get it (Developmental)(Developmental)

• Exotropes want the “Big Picture” Panoramic Exotropes want the “Big Picture” Panoramic Viewing (Genetic, ABI or Functional)Viewing (Genetic, ABI or Functional)

Anomalous Anomalous CorrespondenceCorrespondence

• A Type of BinocularityA Type of Binocularity• Develops Early---????????????Develops Early---????????????• Reaction of Organism to DiplopiaReaction of Organism to Diplopia

– Sees DoubleSees Double– Suspends/SuppressesSuspends/Suppresses– Goes into an Anomalous Fusion Goes into an Anomalous Fusion

Cortically Cortically

Anomalous Anomalous CorrespondenceCorrespondence

• DepthDepth– Shallow-IgnoreShallow-Ignore– Deep-Ugh!Deep-Ugh!

• TreatmentTreatment– Embed the BinocularityEmbed the Binocularity– Move to Harmonious AnomalousMove to Harmonious Anomalous– Change to Normal CorrespondenceChange to Normal Correspondence

AmblyopiaAmblyopiaMaples WC, Bither M. Treating the trinity of infantile vision Maples WC, Bither M. Treating the trinity of infantile vision

development: infantile esotropia, amblyopia, anisometropia. J development: infantile esotropia, amblyopia, anisometropia. J Optom Vis Dev 2006;37: 123-130.Optom Vis Dev 2006;37: 123-130.

• Eccentric FixationEccentric Fixation• Develops EarlyDevelops Early• Secret to Amblyopia (Anisometropic Secret to Amblyopia (Anisometropic

and Eccentric Fixation)----Fixationand Eccentric Fixation)----Fixation• 0 Retino Motor Locus0 Retino Motor Locus• Treatment-Develop Central FixationTreatment-Develop Central Fixation

ConstancyConstancy

• INTERMITTENT IS EASIERINTERMITTENT IS EASIER• The reason that Exos are easier than The reason that Exos are easier than

Esos may be that there are more Esos may be that there are more Intermittent ExosIntermittent Exos

• If Intermittent:If Intermittent:– Do not PatchDo not Patch– Work on Binocularity where you can find Work on Binocularity where you can find

binocularity and expand it. WORK binocularity and expand it. WORK BACKWARDS TO BIOUCLAR AND BACKWARDS TO BIOUCLAR AND MONOCULAR SKILLSMONOCULAR SKILLS

Intractable DiplopiaIntractable Diplopia

• Late OnsetLate Onset• TraumaTrauma• StrokeStroke• Horror FusionisHorror Fusionis• The OMD Who Saw Nothing But ID’sThe OMD Who Saw Nothing But ID’s• Patch (Contact Lens), Blur, Patch (Contact Lens), Blur,

Suppress---Suppress---

Non-ConcomitantNon-Concomitant

• PathologyPathology• Prior Surgery Worse if Complications Prior Surgery Worse if Complications • Restrictions almost always will not have Restrictions almost always will not have

full usefull use• Duane’s Congenital and Train other Duane’s Congenital and Train other

Visual SkillsVisual Skills• Brown Can be from infection of the Brown Can be from infection of the

tendon sheath and if so, when infection tendon sheath and if so, when infection controlled can decrease controlled can decrease

Seven Levels of Dx and Seven Levels of Dx and TxTx

• Bilateral IntegrationBilateral Integration• Central FixationCentral Fixation• Monocular EqualityMonocular Equality• Biocular SkillsBiocular Skills• Basic Binocular SkillsBasic Binocular Skills• Advanced Binocular SkillsAdvanced Binocular Skills• Special Special

(Perceptual/Cognitive/Executive)(Perceptual/Cognitive/Executive)

Working the System: Working the System: Testing/DemonstrateTesting/Demonstrate

• Bilateral Skills: Anatomical Bilateral Skills: Anatomical Interaction Interaction – VO StarVO Star– Harmon Bimanual CirclesHarmon Bimanual Circles– Standing and Seated PostureStanding and Seated Posture– Dry Land SwimmingDry Land Swimming– Angels in the SnowAngels in the Snow– Line RollLine Roll

Working the System: Working the System: Testing/DemonstrateTesting/Demonstrate

• Central FixationCentral Fixation– Ophthalmoscopic (Visuscope)Ophthalmoscopic (Visuscope)– MITMIT– Cover Test and Angle Lambda (Kappa) Cover Test and Angle Lambda (Kappa)

Very GrossVery Gross– Past Pointing Past Pointing

Working the System: Working the System: Testing/DemonstrationTesting/Demonstration

• Monocular EqualityMonocular Equality– Fixation: Wolff Wands, VO 12* Star; Fixation Fixation: Wolff Wands, VO 12* Star; Fixation

Worksheet; Parquetry Blocks; Chalkboard SaccadesWorksheet; Parquetry Blocks; Chalkboard Saccades– Saccade (Real World): See Above; Wayne Saccades; Saccade (Real World): See Above; Wayne Saccades;

Hart Chart Challenge; Battle Ship Hart ChartHart Chart Challenge; Battle Ship Hart Chart– Pursuit: Wolff Wands; Marsden Ball; Head Pursuit: Wolff Wands; Marsden Ball; Head

Rotations; Chalkboard Pursuits; Mechanical RotatorRotations; Chalkboard Pursuits; Mechanical Rotator– Near Far-Far Near: Hart Chart, Wayne SaccadeNear Far-Far Near: Hart Chart, Wayne Saccade– Accommodation: Kraskin Bifocal; Monocular RockAccommodation: Kraskin Bifocal; Monocular Rock

Working the System: Working the System: TestingTesting

• Biocular Skills: In My Opinion-The Key Biocular Skills: In My Opinion-The Key to Effective Amblyopic and Strabismus to Effective Amblyopic and Strabismus TherapyTherapy

• SuppressionSuppression• Anomalous CorrespondenceAnomalous Correspondence• Double but MORE THAN Double-Double but MORE THAN Double-

Equally RealEqually Real• ““The one I am attending” The one I am attending”

BiocularBiocular

• Tests (Anomalous Correspondence-Tests (Anomalous Correspondence-Press)Press)

• Bagolini LensesBagolini Lenses• Polarized VectogramPolarized Vectogram• AmblyscopeAmblyscope• Worth Four DotWorth Four Dot• Maddox Rod with Red LensMaddox Rod with Red Lens• Hering-Bielschowsky After ImageHering-Bielschowsky After Image


• Tests (Suppression)Tests (Suppression)– Bagolini LensesBagolini Lenses– KeystoneKeystone– Brock StringBrock String– Quoits (Cross)Quoits (Cross)– Binocular RefractionsBinocular Refractions– Physiological DiplopiaPhysiological Diplopia– Retinal RivalryRetinal Rivalry– OthersOthers


• Basic BinocularBasic Binocular– Tons of TestsTons of Tests– RetinoscopyRetinoscopy– PhoriasPhorias– VergencesVergences– TelebinocularTelebinocular– StereoStereo

The Intermittent Trope Can The Intermittent Trope Can you get Stereo?you get Stereo?

• If StereoIf Stereo– Demonstrated with Peripheral Targets Brock Stereo Demonstrated with Peripheral Targets Brock Stereo

Motivator or Quoits on a WindowMotivator or Quoits on a Window

• Build RangesBuild Ranges• RampRamp• StepStep• Ability as measured by Accuracy as measured Ability as measured by Accuracy as measured

by the Speed and Stamina of the Patient A Assby the Speed and Stamina of the Patient A Ass• Speed means both Fast AND SlowSpeed means both Fast AND Slow• Minimal Differences (Quoits and 1 ^ Minimal Differences (Quoits and 1 ^

difference)difference)

Rules of EngagementRules of Engagement”Where the Eye looks and were the Brain thinks it looks ”Where the Eye looks and were the Brain thinks it looks

is different”is different”

• Start Were They Are and Go Where They Ain’tStart Were They Are and Go Where They Ain’t• Start Slow and Start LowStart Slow and Start Low• Synapses that Fire Together Continue to Fire Synapses that Fire Together Continue to Fire

TogetherTogether• Analyze the Procedure: All VT is Bio-Analyze the Procedure: All VT is Bio-

FeedbackFeedback• Patient & Therapist MUST BE involvedPatient & Therapist MUST BE involved• Know What you are Attempting to AccomplishKnow What you are Attempting to Accomplish• Be EnthustaticBe Enthustatic• Accomplishment is the Best RewardAccomplishment is the Best Reward

Working the System: Working the System: TherapyTherapy

• Central FixationCentral Fixation– PleopticsPleoptics

• Ophthalmoscopic BleachingOphthalmoscopic Bleaching• Fixation/Saccade/PursuitFixation/Saccade/Pursuit• Smaller and SmallerSmaller and Smaller

– MITMIT– Eye Hand ActivitiesEye Hand Activities


• Bilateral SkillsBilateral Skills– Yoked Prisms with Motor ActivitiesYoked Prisms with Motor Activities

• Line RollLine Roll• Line WalkLine Walk• Harmon (Lowman) BoardHarmon (Lowman) Board

– Harmon CirclesHarmon Circles– Van Orden CirclesVan Orden Circles


• Monocular Equality (Biocular & Monocular Equality (Biocular & Binocular)Binocular)

• Monocular Disassociated Binocular Monocular Disassociated Binocular (MDB) Marsden Ball(MDB) Marsden Ball

• MDB PointersMDB Pointers• AN 12 pointed Star MDBAN 12 pointed Star MDB• Kraskin Bifocal Rock MDBKraskin Bifocal Rock MDB• Modified Modified UpDegrave MDBModified Modified UpDegrave MDB


• BiocularBiocular– SquinchelSquinchel– Marsden BallMarsden Ball– Physio DiplopiaPhysio Diplopia– QuoitsQuoits– Brock StringBrock String– 12 Pointed Star12 Pointed Star


• Binocular EsotropeBinocular Esotrope– LusterLuster– Gross/Peripheral/Moving TargetsGross/Peripheral/Moving Targets

• Give Me 5 on the Balance BoardGive Me 5 on the Balance Board• Touch my FingersTouch my Fingers• Top Clear/Bottom Clear/Both Clear (= Blur)Top Clear/Bottom Clear/Both Clear (= Blur)• Quoits-Suppression and FusionQuoits-Suppression and Fusion• Keystone without DetailKeystone without Detail• Encourage PeripheryEncourage Periphery• Motor ActivitiesMotor Activities


• ExtotropesExtotropes– Rx (+) and tend to be poorer academic Rx (+) and tend to be poorer academic

achieversachievers– ““Take This Job and Shove It” “ I Quit” Take This Job and Shove It” “ I Quit” – High Sx: See COVD-QOL ChecklistHigh Sx: See COVD-QOL Checklist– Functional or Nerve/Muscle DamageFunctional or Nerve/Muscle Damage– Needs “Orthoptics”: Fixations, Pursuits, Needs “Orthoptics”: Fixations, Pursuits,

Vergence, ACCOMMODATIONVergence, ACCOMMODATION– Get Stereo; Let Stereo Go; Regain StereoGet Stereo; Let Stereo Go; Regain Stereo– See 1/See 2See 1/See 2

Skeffington’s ModelSkeffington’s Model

• ExotropiaExotropia– Divergence Excess Needs + at Near Divergence Excess Needs + at Near

(Cooper, NO!)(Cooper, NO!)– Sympathetic and Parasympathetic-Exos Sympathetic and Parasympathetic-Exos

Peripheral DominantPeripheral Dominant– Social and Biological ClashSocial and Biological Clash– Myopia/EsotropiaMyopia/Esotropia– Hyperopia (Normal Hyperopia (Normal

Refraction)/ExotropiaRefraction)/Exotropia


• EsotropesEsotropes– Minimal +; Monocular (-) Followed by Low +Minimal +; Monocular (-) Followed by Low +– Tend to be High Achievers (Bull Dogs) Low SxTend to be High Achievers (Bull Dogs) Low Sx– Want their own Way (Spoiled?-Indulgent Want their own Way (Spoiled?-Indulgent

Parents)Parents)– Will tell you what they think you want to hearWill tell you what they think you want to hear– Developmental or SERIOUS PATHOLOGYDevelopmental or SERIOUS PATHOLOGY– Ah, Ha is Needed. That is how you do itAh, Ha is Needed. That is how you do it

maples strabismus2007

Health & Medicine