orthoptic excercises siraj safi

Orthoptic ExercisesOrthoptic Exercises

SIRAJ SAFISIRAJ SAFI

Orthoptic ExercisesOrthoptic Exercises

Orthoptic exercises may be given :Orthoptic exercises may be given : To compensate a latent strabismusTo compensate a latent strabismus To improve control of an intermittent To improve control of an intermittent

strabismusstrabismus As a pre- or postoperative measure in As a pre- or postoperative measure in

constant strabismus constant strabismus

Criteria for selectionCriteria for selection Exercise are only given to patient who Exercise are only given to patient who

have or have had Binocular Single have or have had Binocular Single Vision. Suitable patient must fulf i l l the Vision. Suitable patient must fulf i l l the fol lowing criteria:fol lowing criteria:

The examiner must be certain that normal The examiner must be certain that normal sensory and motor fusion can be achieved.sensory and motor fusion can be achieved.

The visual acuity must be equal or nearly equal.The visual acuity must be equal or nearly equal. The patient must be able to attend regularlyThe patient must be able to attend regularly A pathological cause for the strabismus must A pathological cause for the strabismus must

have been excluded.have been excluded. Patient should be intelligent and cooperativePatient should be intelligent and cooperative

Danger of Orthoptic exercisesDanger of Orthoptic exercises

Insuperable diplopia Insuperable diplopia Convergence or Accommodative spasmConvergence or Accommodative spasm Decompensation of latent strabismusDecompensation of latent strabismus

Purpose of Orthoptic exercises Purpose of Orthoptic exercises

1.1. Elimination of suppressionElimination of suppression2.2. Control of deviationControl of deviation3.3. Extension of the fusion amplitudesExtension of the fusion amplitudes4.4. Improvement of relative (fusional) Improvement of relative (fusional)

convergenceconvergence5.5. Improvement of the near point of Improvement of the near point of

convergenceconvergence

1.Elimination of Suppression1.Elimination of Suppression

Indications:Indications: Convergence insufficiency orConvergence insufficiency or Exophoria of the convergence Exophoria of the convergence

insufficiency when diplopia is not insufficiency when diplopia is not recognize on failure of convergence. recognize on failure of convergence.

In case of intermittent strabismus to In case of intermittent strabismus to control deviation. etc control deviation. etc

Methods for Elimination of Methods for Elimination of suppressionsuppression

1. Colored fi l ters:1. Colored fi l ters: Red and Green glassesRed and Green glasses A red filterA red filter Sbisa bar (Bagolini filter bar)Sbisa bar (Bagolini filter bar) Worth 4 LightsWorth 4 Lights The above should be used with spot light for The above should be used with spot light for

near and distance and with accommodative near and distance and with accommodative target in accommodative esotropia (except W 4 target in accommodative esotropia (except W 4 Lights)Lights)


These are used to recognize the second These are used to recognize the second image (diplopia) when the deviation image (diplopia) when the deviation become manifest.become manifest.

Start with Red and Green goggles so that Start with Red and Green goggles so that the patient easily recognized the two the patient easily recognized the two different images on failure. different images on failure.

Than proceed to one filter, removing it at Than proceed to one filter, removing it at intervals to obtain spontaneous diplopia.intervals to obtain spontaneous diplopia.


2. Septum:2. Septum: A card can be used as septum, holding it at 90 A card can be used as septum, holding it at 90

degree to the plane of face, resting on the nose.degree to the plane of face, resting on the nose. This can be combined with a cover test to show This can be combined with a cover test to show

both images.both images. This method is often successful in fully This method is often successful in fully

accommodative esotropia.accommodative esotropia. The septum can be made smaller or a The septum can be made smaller or a

transparent septum used until diplopia is transparent septum used until diplopia is recognized without it. recognized without it.


3. Prisms:3. Prisms: If the above methods fail, prisms can be used to move If the above methods fail, prisms can be used to move

the image out of the suppression area.the image out of the suppression area. A 10 Pd vertical prism is usually successful in horizontal A 10 Pd vertical prism is usually successful in horizontal

strabismus.strabismus. Nearly all patient can appreciate diplopia the horizontal Nearly all patient can appreciate diplopia the horizontal

separation of the images in this way.separation of the images in this way. Vertical prism bar should be used so that the strength Vertical prism bar should be used so that the strength

can be reduced so that the patient can tries to maintain can be reduced so that the patient can tries to maintain the two images.the two images.

Colored filters can be used in addition if necessory Colored filters can be used in addition if necessory


4. Red Filter Drawing:4. Red Filter Drawing: A red filter is worn on the spectacles lens of the A red filter is worn on the spectacles lens of the

fixating eye and the patient is asked to draw fixating eye and the patient is asked to draw using a red pencil identical to the filter.using a red pencil identical to the filter.

The patient will see the page by both eyes while The patient will see the page by both eyes while the drawing will only be seen by the suppressed the drawing will only be seen by the suppressed eye (eye without filter). eye (eye without filter).

Children enjoy this exercise which is very Children enjoy this exercise which is very suitable for use at home.suitable for use at home.


5. Occlusion:5. Occlusion: Part time occlusion is used sometimes to Part time occlusion is used sometimes to

encourage the use of the squinting eye encourage the use of the squinting eye and to prevent suppression.and to prevent suppression.

Prisms can be used to maintain BSV Prisms can be used to maintain BSV before surgery. before surgery.

2.Exercise to aid Control of 2.Exercise to aid Control of deviationdeviation

Diplopia provide provides a stimulus to fusion and its Diplopia provide provides a stimulus to fusion and its recognition quite often results in spontaneous control of recognition quite often results in spontaneous control of the strabismus. If not this can be taught by: the strabismus. If not this can be taught by:

1. Using a prism to fuse the images, then slowly reducing 1. Using a prism to fuse the images, then slowly reducing the prism strength while the patient maintain the BSV.the prism strength while the patient maintain the BSV.

2. Working from the point of intersection of the visual axes, 2. Working from the point of intersection of the visual axes, extending to distance over which BSV is maintained by extending to distance over which BSV is maintained by moving the target towards or away from the eyes.moving the target towards or away from the eyes.

3. Using the patient accommodation to achieve control, 3. Using the patient accommodation to achieve control, either by stimulating it with detail targets in exodevition either by stimulating it with detail targets in exodevition or promoting relaxation in esodeviation , encourage the or promoting relaxation in esodeviation , encourage the patient to blur the image. patient to blur the image.

3.Extension of fusional amplitude3.Extension of fusional amplitude

Improvement of fusional amplitude Improvement of fusional amplitude enables comfortable BSV.enables comfortable BSV.

Methods:Methods: Prism bar (useful) Prism bar (useful) Major AmblyoscopeMajor Amblyoscope


1.Positive fusion amplitude:1.Positive fusion amplitude: This is increased by using prism bar base-out, This is increased by using prism bar base-out,

gradually increasing the prism strength while the gradually increasing the prism strength while the patient fuses the images. patient fuses the images.

When convergence fails, the patient should be When convergence fails, the patient should be encouraged to rejoin the diplopia with only small encouraged to rejoin the diplopia with only small reduction reduction

The Pts should be able to fuse the images The Pts should be able to fuse the images through a 40-45 pd BO at 33cm, and 20-25 pd through a 40-45 pd BO at 33cm, and 20-25 pd Bo at 6m.Bo at 6m.


Convergence must be smoothly Convergence must be smoothly maintained. In later stages of treatment maintained. In later stages of treatment the Pt should be able to fuse images when the Pt should be able to fuse images when a 2o-30 pd is introduced rejoining the a 2o-30 pd is introduced rejoining the diplopia immediately.diplopia immediately.

Relaxation should emphasized after Relaxation should emphasized after exercise exercise

Improvement of the positive amplitudes is Improvement of the positive amplitudes is indicated in exodeviations.indicated in exodeviations.


Negative fusion amplitude:Negative fusion amplitude: A prism bar is used base-in.A prism bar is used base-in. Indicated in esodeviations Indicated in esodeviations Pt with esophorai of the divergence weakness type often Pt with esophorai of the divergence weakness type often

have a very poor negative fusion amplitude at 6m.have a very poor negative fusion amplitude at 6m. Even 1-2 pd is sufficient to disrupt BSV , and Even 1-2 pd is sufficient to disrupt BSV , and

improvement of the amplitude is difficult.improvement of the amplitude is difficult. These Pt can be helped at home exercise with prism bar These Pt can be helped at home exercise with prism bar

or Fresnel prism.or Fresnel prism. Advising them to start by fixing on an object at Advising them to start by fixing on an object at

intermediate distance , gradually increasing the fixation intermediate distance , gradually increasing the fixation distance once fusion is maintaineddistance once fusion is maintained

4.Improvement of relative (fusional) 4.Improvement of relative (fusional) convergenceconvergence

Improvement of the relative convergence is not Improvement of the relative convergence is not same as the fusional amplitudes, which utilized same as the fusional amplitudes, which utilized all the three components of convergence all the three components of convergence (Accommodation, fusional and proximal)(Accommodation, fusional and proximal)

When ever the amount of accommodation is When ever the amount of accommodation is changed accommodative convergence is either changed accommodative convergence is either exerted or relaxed but if accommodation is exerted or relaxed but if accommodation is constant, relative convergence can be exerted constant, relative convergence can be exerted or relaxed while maintaining a static amount of or relaxed while maintaining a static amount of accommodation.accommodation.


Positive relative convergence:Positive relative convergence: Convergence is exerted in excess of Convergence is exerted in excess of

accommodation.accommodation. This component is improved in This component is improved in

exodeviations so that relative exodeviations so that relative convergence can be used to control the convergence can be used to control the strabismus whilst the correct amount of strabismus whilst the correct amount of accommodation is exerted to give clear accommodation is exerted to give clear vision at all distances.vision at all distances.


Negative relative convergence:Negative relative convergence: Convergence is relaxed in relation to the Convergence is relaxed in relation to the

amount of accommodation exerted.amount of accommodation exerted. The negative amplitude is increased in The negative amplitude is increased in

esodeviations so that sufficient amount of esodeviations so that sufficient amount of accommodation can be used for clear accommodation can be used for clear vision at all distances without associated vision at all distances without associated convergence. convergence.


The purpose of improving relative The purpose of improving relative convergence is therefore to:convergence is therefore to:

Improve the binocular visual acuity. Improve the binocular visual acuity. (the (the level of VA achieved while BSV Is maintained)level of VA achieved while BSV Is maintained) \ \

To allow the continued use of clear BSV. To allow the continued use of clear BSV.


Methods: Methods: Many of the exercises used are based on the Many of the exercises used are based on the

physiological diplopia. physiological diplopia. (Should be taught) (Should be taught) Stereogram Cards:Stereogram Cards: The cards are printed with two figures , by The cards are printed with two figures , by

looking or fixing in front of the card uncrossed looking or fixing in front of the card uncrossed diplopia is obtained, resulting in four figures.diplopia is obtained, resulting in four figures.

The distance of the near fixation target or card The distance of the near fixation target or card can be adjusted until the innermost figure fuse to can be adjusted until the innermost figure fuse to give a central figure common to both eyes, with give a central figure common to both eyes, with two peripheral figures each seen by Lt. and Rt. two peripheral figures each seen by Lt. and Rt. Eye. Eye.


The same effect is obtained by fixing on a The same effect is obtained by fixing on a distance target beyond the card , distance target beyond the card , obtaining crossed physiological diplopia of obtaining crossed physiological diplopia of the figures. the figures.

Start with simple cat card.Start with simple cat card. Those with esodeviations find crossed Those with esodeviations find crossed

physiological diplopia easier and those physiological diplopia easier and those with exodeviations have less difficulty with exodeviations have less difficulty appreciating it in the uncrossed position. appreciating it in the uncrossed position.

The card with the drawings of two incomplete cats are held at arm’s length and the Pt fixates the pencil in between. The distance of the pencil is adjusted until the two middle cats fuse into a complete cat with two incomplete cats on either side.

The Pt is asked to try and see the cats clearly; to converge for the pencil distance and relax accommodation , i.e. positive relative convergence in exodeviations


Bar- Reading:Bar- Reading: It is based on crossed physiological It is based on crossed physiological

diplopia.diplopia. Print of larger size than the near binocular Print of larger size than the near binocular

visual acuity is selected. visual acuity is selected. The Bar is held at the centre of the page The Bar is held at the centre of the page

by the examiner. by the examiner. The book is held at 33cm. The book is held at 33cm. The patient head should be kept static.The patient head should be kept static.


Purpose of Bar- Reading:Purpose of Bar- Reading: To exercise maintenance of BSV when To exercise maintenance of BSV when

readingreading To improve relative positive or negative To improve relative positive or negative

convergence with the use of lensesconvergence with the use of lenses


1.To exercise Negative relative 1.To exercise Negative relative convergence:convergence:

Concave lenses are used to increase the Concave lenses are used to increase the amount of accommodation exertedamount of accommodation exerted

Large print is used initially, but the size of Large print is used initially, but the size of print is reduced as the BVA improvesprint is reduced as the BVA improves

Hypermetropes may be taught to bar read Hypermetropes may be taught to bar read without their spectacles if the correction is without their spectacles if the correction is +3 DS and no astigmatism. +3 DS and no astigmatism.


2. Positive relative convergence with 2. Positive relative convergence with Bar-reading: Bar-reading:

Additional convex lenses are used to relax Additional convex lenses are used to relax accommodation.accommodation.

Convergence remains static for the distance of Convergence remains static for the distance of the page.the page.

Bar- reading is little used to improve positive Bar- reading is little used to improve positive relative convergence and is mainly of value in relative convergence and is mainly of value in improving the near BVA in Accommodative improving the near BVA in Accommodative esotropia.esotropia.


Remy Separator:Remy Separator: This test is based on foveal projection instead of This test is based on foveal projection instead of

physiological diplopia.physiological diplopia. It consist septum which rest on the nose.It consist septum which rest on the nose. Transparencies are placed in the holder at the other end Transparencies are placed in the holder at the other end

of the apparatus.of the apparatus. The transparencies present either simultaneous or The transparencies present either simultaneous or

fusion targets.fusion targets. The patient looks through the transparencies and The patient looks through the transparencies and

relaxed his convergence, causing the images to fall on relaxed his convergence, causing the images to fall on the fovea, when they should appear superimposed or the fovea, when they should appear superimposed or fused.fused.

If they are seen clearly, negative convergence is If they are seen clearly, negative convergence is exercised.exercised.

Mainly used for esodeviation but have very limited value. Mainly used for esodeviation but have very limited value.

5. Improving the near point of 5. Improving the near point of convergenceconvergence

Smooth convergence :Smooth convergence : when an accommodative target moved when an accommodative target moved

slowly towards the nose.slowly towards the nose. Jump convergence:Jump convergence: When looking from near target to distance When looking from near target to distance

target and again to near target. Can be target and again to near target. Can be done with the help of prism.done with the help of prism.


Dot Card:Dot Card: A series of small circles is spaced out along a line drawn A series of small circles is spaced out along a line drawn

the length of a card some 30 cm long.the length of a card some 30 cm long. Method:Method: The patient should fixate the furthest dot and should The patient should fixate the furthest dot and should

obtain crossed physiological diplopia of the line and the obtain crossed physiological diplopia of the line and the closer dots.closer dots.

He then fixate each dot in turn, fusing the images .He then fixate each dot in turn, fusing the images . The more remote dots and line then appear as The more remote dots and line then appear as

uncrossed diplopia.uncrossed diplopia. The patient can also be asked to look at one dot and The patient can also be asked to look at one dot and

then into the distance and back again to exercise jump then into the distance and back again to exercise jump convergence.convergence.

Nose

DOT CARD

Pin-push up exercise for NPCPin-push up exercise for NPC

THANK YOUTHANK YOU

orthoptic excercises siraj safi

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