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J.W. Global Hospital & Research Centre, Mount Abu & Global Hospital & Institute Of Ophthalmology, Abu Road Strabismus Clinic Patient Name ………………………………………….Age……Sex M / F Father’s Name……………………………………………………………… Address…………………………………………………………………….. ……………………………………………………………………………… Phone no ……………………………………………………………………... CRN…………………………..IRN…………………………….. ……… Consultant…………………………………………………………………. Infantile Esotropia, Basic Esotropia, Accommodative Esotropia (Refractive, Partial Refractive, NonReftractive, Mixed), Microtropia, Secondry Esotropia (Residual, Consecutive), Esophopria ---------------------------------------------------------------------------------------------------Basic Exotropia, Infantile Isotropic, Intermittent (Basic, True Divergence Excess, Simulated Divergence Excess, High AC/ A Ratio), Secondary Exotropia (Residual, Consecutive), Sensory Exotropia, Exophopria -----------------------------------------------------------------------------------------------------Hypertropia R/L , Hypertropia L/ R , -----------------------------------------------------------------------------------------------------Patterns A, V, X, Delta ------------------------------------------------------------------------------------------------------Superior Oblique Normal /Over Action /Under Action Inferior Oblique Normal /Over Action /Under Action ------------------------------------------------------------------------------------------------------DVD Right Eye/ Left Eye / Both Eyes -----------------------------------------------------------------------------------------------------Amblyopia Eye/ Left Eye / Both Eyes -----------------------------------------------------------------------------------------------------DRS 1; 2; 3, Brown Syndrome, Double Elevator Plasy Third Nerve Palsy, Forth Nerve Palsy, Sixth Nerve Palsy History 1. Age of onset 2. Whether constant or intermittent? 3. Whether Diplopia present? 4. Drug Allergy Page1 Right Eye Left Eye Vision Unaided Power of Glasses RE LE Add Under Atro / Homatro/ Cyclopent Vision Corrected Cycloplegic Refraction Near Point of Convergence Near Point of Accommodation IPD Motor Examination Head Posture Movements - Normal / Restricted Inferior Obligue -Normal / Over Action / Under Action Superior Obligue -Normal / Over Action / Under Action Nystagmus Orthoptic Examination RE/ LE / Alternate / Eccentric Fixation Moddox Wing(Near) Moddox Rod ( 6 Mtr +PBCT) Prism Bar Cover Test (PBCT) PBCT For Distance PBCT For Near PBCT For Near With + 3.0 D PBCT In Nine Positions of Gaze AC/ A Ratio (Gradient Method) Normal / High / Low Fusional Amplitude Convergence Divergence Steriopsis Distance Near Sensory Examination Worth’s Four Dot Test BSV / RE Suppression / RE Suppression / Diplopia / ARC Baggloini’s Test BSV / RE Suppression / RE Suppression / ARC Randot Dot Steroacuity Page 2 Anterior Segment: Posterior Segment: Force Duction Test Force Generation Test Management 1. Glasses 2. Orthoptic 3. Surgical Anesthesia LA/ GA Right Eye Medial Rectus Recession …………… Left Eye Medial Rectus Recession …………… Medial Rectus Resection …………… Medial Rectus Resection …………… Lateral Rectus Recession …………… Lateral Rectus Recession …………… Lateral Rectus Resection … Lateral Rectus Resection … Inferior Oblique Recession Inferior Oblique Recession Superior Oblique Weakning Superior Oblique Weakning
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