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8/12/13 THINGS ARE NOT ALWAYS AS THEY APPEAR (Purely Practical Practice Pearls) PURELY PRACTICAL PRACTICE PEARLS ! ! ! Challenging Presentations Commonly Missed Diagnoses Practice Pearls Richard London, OD, MA, FAAO Pacific Optometry You See What You Look For Not What You Look At! THE 3- STEP TEST Questioning The 3- Step Test ! ! The Gold Standard for Diagnosis of Vertical Deviation Only Considers Single Cyclovertical Paretic Muscle ! Not overactions or tight (contracted) muscles 1 8/12/13 OBVIOUS PROBLEM ! Individual 3rd Nerve Branches Rarely Affected Problems With The Three- Step Test ! ! Does Not Account For Muscle Contractures (e.g. Tight Superior Rectus) Does Not Account For Fibrotic Change ! ! ! May Result In A False Indication That One Muscle Is Paretic Post-Operative Evaluations Misleading Multiple muscles, DVD, skew, myasthenia SOP 2 8/12/13 Congenital SOP Most Common Causes Of Positive 3-Step Test: ! ! Superior Oblique Palsy (SOP) Tight Superior Rectus ! Jampolsky Syndrome TIGHT LSR More Problems: Large Horizontal Phorias With Concurrent Small Vertical 3 8/12/13 (S (S O SO SR OD (IR ) OS IO (IO R) (S (S IR SO SR ) ) OD (IR (S O R) ) OS IO (IO IR ) ) SUPERIOR OBLIQUE PALSY NORMAL EYES OD Intorts OS Extorts ( ) Means not active (S O R) (S ) (S SO O R) ) SO SR SR EXOTROPIA Eye in action field of SR ESOTROPIA Eye in action field of SO LESSON ! ! ! Think of SOP or Tight SR (SR Contracture) Very Rare to Have Isolated 3rd N Branch ! Usually several muscles effected Head Tilt Test - Primary Overacting inferior obliques negative ! FIXATION DURESS DVDs Will Increase on Tilt to Opposite Side 4 8/12/13 NOTE HEAD POSITION FIXATION DURESS LEFT HEAD TILT LEFT HEAD TILT Congential SOP Fixating With Paretic Eye 5 8/12/13 FIXATION DURESS Facial Hypotrophy ! Patient Fixates With Paretic or Restricted Eye ! ! Secondary angle of deviation ! Rising or Falling Eye Results from strong eye dominance Rising Eye LESSON ! Always Perform Cover Test in Different Positions of Gaze and Versions ! Brown Syndrome ! ! ! ! ! ! Both CT and motilities should support the same diagnosis SO Tendon Sheath Congenital (Or Acquired - Click Syndrome ) Can Be Unilateral Or Bilateral Looks Like Paresis Of IO-Inability To Elevate In Adduction Positive Forced Duction Test Usually Binocular In Primary Gaze 6 8/12/13 OS Brown Syndrome SO Click Syndrome ! ! Brown syndrome that is associated with inflammatory conditions. Inflammation produces a nodule on the superior oblique tendon, just posterior to the trochlea, thus restricting tendon movement. Bilateral Brown: OD Bilateral Brown: OS -5! -5! BROWN OS Treatment Options OW! ! ! Steroid (Kenalog) injection if acquried Teach to point nose where looking 7 8/12/13 Lesson ! Visual Dependency If No Strabismus is Revealed With Binocular Tests, Result Following Cycloplegia is Likely Due to Attempts to Overcome Hyperopia (Increased Myodiopters) VISUAL DEPENDENCY VISUAL DEPENDENCY VISION Vision Components Required for Balance: Vestibular, Visual, Proprioception ! When Vestibular Damaged, Vision Becomes Major Contributor to Equilibrium ! VestibularProprioception A TWO-EDGED SWORD ! ! More Stability in Light; but.. In Dark or Visually Repetitive Environment Balance Suffers ! LESSON ! Co-manage To Work With Proprioception ! Usually with physical therapy (PT) Movie Theaters, Escalators, Super Markets 8 8/12/13 New or Long-Standing? ! Decompensating Phorias Long-standing Latent Deviation That Becomes Manifest Because of Diminished Compensation ! ! ! ! ! Age Illness Medication Will Be Comitant (Usually) Will Often Have Very Large Vergence Ranges Lesson ! ! ! ! Careful History of Long-Standing Intermittent Problem Check For Comitance Check Vergence Ranges Aberrant Regeneration Look Carefully For Bad Company DEVELOPMENT OF ABERRANT REGENERATION PSEUDO GRAFE SIGN LEV MR IR Trauma 3rd N 9 8/12/13 ADDUCTION ON UPGAZE Netrins Attractants and Repellants BILATERAL LID-GAZE DYSKINESIS ABERRANT REGENERATION PUPIL OD Causes Of Aberrant Regeneration ! ! ! ! Congenital Trauma Neoplasm ANEURYSM !! 10 8/12/13 Vascular / Ischemic Causes Of III N Palsy ! ! ! Diabetes Mellitus Hypertension Atherosclerosis COMPARISON DIABETIC III COMPRESSIVE III Pain - Precedes Diplopia Pain Usually Present Pupil Involved 15% Pupil Involved 95% No Aberrant Regeneration Aberrant Regeneration Tends Toward Older Patients Any Age Compression Lesson Pupillary Fibers CORE ! MICROVASCULAR ! ! Interactions Between Muscles That Don t Follow Normal Neurological Connections - Think Aberrant Regen Often Involves IIIN Innervated Muscles Unless Cause is Known, Worry About Aneurysm CAUSES OF SOP Palsy Or Not Palsy?: That is the Question 11 8/12/13 CAUSES OF III N PALSY When An Infant Can t Abduct ! ! Duane Retraction Syndrome Tight MR / Cross Fixation Causes of VI N Palsy Duane Retraction Syndrome Duane Retraction Syndrome (...Of Stilling-Turk-Duane) ! ! ! ! Lateral Rectus Is Misbehaving ! Likely VI N Nucleus Absent ! Likely III N Misdirection Reduced Or Absent Abduction Narrowing Of Palpebral Fissure With CoContraction Of MR And LR More Frequent In Females And Left Eye III! VI! 12 8/12/13 DUANE OD III! VI! DUANE OS XT DUANE HEAD POSTURE DUANE S OS Note Retraction 13 8/12/13 LRP or Duane? Lesson ! ! ! With Tight MR or CrossFixation ! Patch Fixating Eye and Re-evaluate Dissociated Vertical Deviation (DVD) ! ! ! ! ! Duane Patient May Be Eso, Exo, or Ortho Lateral Rectus Misbehaving Do Not Mistake For VIN Palsy in Adult No Diplopia True Hyper or Dissociated Vertical Deviations (DVD)? DVD Appears At 2 -3 Years Of Age. Even After Earlier Surgery! Most Commonly Seen in Congenital Esotropes May help control latent nystagmus (Guyton) Part of Accessory Optic System (Brodsky) Differential Diagnosis Is With Overacting Inferior Oblique, Skew Deviation 14 8/12/13 DVD OD>OS RT DVD AND PTOSIS ET WITH DVD Lesson ! ! ! If a Vertical Deviation Appears to Disregard Hering s Law - Think DV D No Pathological Implications Prescribe Prism? Characteristics of Skew Skew Deviation or Superior Obliques Palsy ! ! ! ! Associated Illnesses Shows Alternating Hyper Deviation ! Hyper on Abducting Side Hyper Eye is Intorted Lower Eye is Extorted 15 8/12/13 other potential topics References ! ! ! ! ! ! monofixation synd overacting obliques skew deviation ! ! A. Jampolsky A New Look at the Head Tilt Test In: Fuchs AF, Brandt Th, Büttner U, Zee DS, eds. Contemporary Ocular Motor and Vestibular Research. A Tribute to David A Robinson. Kushner BJ. Errors in the three step test in the dx of vertical strabismus Ophthalmology 1989, 96, 127-32 Khawan E, et al. Jampolsky Syndrome: superior rectus overaction-contracture syndrome:prevalence, characteristics, etiology and management. Binocul Vis Strabismus Q. 2000 Winter;15(4):331-42. WM Ludlam Dissociated Vertical Deviation in London R Problems in Optometry: Ocular Vertical and Cyclovertical Deviations 578-586 M C Brodsky, et al Unexplained head tilt following surgical treatment of congenital esotropia: a postural manifestation of dissociated vertical divergence Br J Ophthalmol. 2004 February; 88(2): 268–272 16
