DIAGNOSIS AND TREATMENT OF STRABISMUS

Instructor:   Jeffrey Cooper, O.D., M.S.

                   Clinical Professor

                   Rm 901 Ext 4969 Available Tuesday afternoon and Thursday

                   Email cooperjsc@msn.com

                  

Required Texts:

Rutstein RP, Daum KM. Anomalies of Binocular Vision: Diagnosis and Management. Mosby Year Book, St Louis MO. (800-325-4177) ISB 0-8016-6916-2 (Buy this)

         

Texts for Additional Reading:

Caloroso E. E., Rouse M.W., Clinical Management of Strabismus, Butterworth &

Heineman, Stoneham Mass, 1993. (Excellent for treatment from an Optometric standpoint)

          Von Noorden, G.K., Binocular Vision and Ocular Motility: Theory and Management of

Strabismus, C.V. Mosby, St. Louis, 5th Edition, 1996. (Excellent from an ophthalmological prospective, great bibliograpy)

          Griffin, J., Binocular Anomalies: Procedure for Vision Therapy, Professional Press,       Chicago, 2nd Edition, 1982. (Good basic descriptions)

          Von Noorden, G., Maumence, Atlas of Strabismus, St. Louis, C.V., 4th Edition, 1983.

Schor, C. And Ciuffreda, K., Vergence Eye Movements: Basic and Clinical Aspects, Butterworth, Boston, 1st Edition, 1983. (Excellent source though dated in understanding the physiology of binocular vision)

Good WV, Hoyt CS. Strabismus Management. Butterworth-Heinemann, Boston 1996 (excellent review of all the areas of strabismus and amblyopia gives an excellent perspective from and Ophthalmological view point)

Required Readings:

The assigned readings will not necessarily correspond with the weekly lecture material. Most of the clinical material will be covered in depth in lecture. Most background theoretical material will be covered through reading assignments, with lecture limited to clinical implications and application. Since time is limited the course will stress diagnosis, and broad treatment options. Rutstein RP, Daum KM. Anomalies of Binocular Vision: Diagnosis and Management provides an excellent review of amblyopia and strabismus. Specific treatment protocols are presented in Caloroso E. E., Rouse M.W., Clinical Management of STRABISMUS. The intent of the course is to provide the student with a clinical perspective that can not be provided by a textbook. Students will be responsible for material covered in lecture and material covered in the reading assignments. Attendance and class participation may be considered in grade determination.

 

Course Objectives:

This course has been designed to review strabismus and to acquaint the student with the most recent information regarding diagnosis, etiology, treatment and sensory-motor characteristics of strabismus. The readings will provide the student with a broad literature review regarding both diagnosis and treatment. Specifically the lecture portion is designed to develop the clinical skills necessary to make a correct diagnosis and to provide the patient with the most appropriate therapeutic options. At the end of the course the student should be able to recognize the characteristics of strabismus related to life threatening diseases and the more benign forms. The reading assignments not only will reinforce this approach but also provide more specific treatment strategies.

Tests and Grading:

The purpose of grading is to: to encourage learning of the subject material, to determine the ability of the instructor to impart knowledge, to a make sure that the student has a minimal knowledge basis to care for patients, and to protect the public from poor quality care. It is my responsibility and the University’s responsibility to protect the public by making sure each student has the appropriate skills to practice Optometry. To that end each week there will be a quiz and a final at the end of the course. The quizzes cumulatively will count 50% and the final the other 50%. It is the student’s responsibility to make up missed quizzes. Missed quizzes will be given at the discretion of the instructor and will be more difficult.

 

 

I.        REVIEW OF BINOCULAR VISION                      (Week 1)

          A. Sensory Fusion

                   1.       Simultaneous perception

                             a)       Retinal rivalry

                             b)       Luster

                   2.       Flat fusion

                             a)       Panums area

                             b)       Physiological diplopia and pathological diplopia

                             c)       Fixation disparity in respect to strabismus

                   3.       Stereopsis

                             a)       Clinical measurements

                             b)       Experimental measurements

                             c)       Monocular cues in testing

          B. Fusional Vergence

                   1.       Maddox classification

                   2.       Vergence adaptation

                   3.       SILO, float, localization, and parallax

                   4.       Findings in strabismus

          C. Sensory Stimuli Presentation

                   1.       Prisms and mirrors (stereoscopes)

                   2.       Anaglyphs

                   3.       Polaroid

                   4.       Septums

                   5.       Liquid crystal

Required Readings

          Rutstein Chapter 1, 6

Suggested Readings

          Von Noorden, Ch. 1, 2 (3-37)

 

 

 

 

II.       CLASSIFICATION OF DEVIATION

          A.       Direction (Eso, Exo, Hyper, Cyclo)

          B.       Duane’s Classification

          C.      ACA ratio effects

          D.      Temporal spatial characteristics

Required Readings:

          Rutstein

Suggested Readings

          VonNoorden, Ch. 4 & 9

III.      DIAGNOSTIC BATTERY                                           

                            

          A.       Objective angle

          B.       Subjective angle

          C.      ACA ratio

                   1.       distance - near

                   2.       gradient

                   3.       phospholine iodine

          D.      Centration point

          E.       Effect of lenses and prisms

          F.       Evaluation of responses on various fusion tests, suppression, ARC

IV.      PRELIMINARY ASSESSMENT OF STRABISMUS

          A.       History and chief complaint

          B.       Sensory responses during deviation i.e., suppression and ARC

          C.      Centration point and ranges

Required Readings:

          Rutstein pp111-131

 

 

 

V.      ETIOLOGY OF STRABISMUS

          A.       Sensory-motor (suppression)

          B.       Developmental (OEP, Gessell, psycho-optical)

          C.      Interference

                   1.       Anatomical

                   2.       Mechanical

                   3.       Innovational

    1. Phylogenic and hereditary

Required Readings:

          Rutstein Chapter 7

 

VI.      OVERVIEW OF TREATMENT OF STRABISMUS  

          A.       Prognostic factors in strabismus therapy

          B.       Vision training and surgery as treatment modalities

                   1.       Case selection

                   2.       Goals of therapy: cosmetic, performance, and symptoms

                   3.       Therapeutic results: overview of literature

          C.      Comparison of major approaches to strabismus therapy

                   1.       British orthoptic model

                   2.       Ophthalmological model

                   3.       Brock contributions

                   4.       modern optometric model

          D. Anomalous Retinal Correspondence   

                   1.       Treatment at objective angle

                   2.       Disruptive techniques

                   3.       Treatment using motoric changes

                   4.       Surgical treatment

Required Readings

Rutstein Chapter 12

Calorossa Chapter 4 –10

 

 

VII.     OCULAR MOTILITY                                                

A.       Paralytic Strabismus

          1.       Paresis vs. paralysis

          2.       Contracture and overactions

          3.       Parks 3 step method

          4.       Motor fields

B.       A-V Syndromes

C.      Paresis in

          1.       Dysthyroid

          2.       Diabetes

          3.       M.S.

          4.       Myasthenia Gravis

          5.       Tumor

          6.       Non-specific Vascular Accidents

          7.       Hysteria

Required Readings:

          Rutstein Ch 10

Suggested Readings:

          Von Noorden, Ch. 17, 18

 

VIII. SENSORY ANOMALIES ASSOCIATED WITH STRABISMUS

          Suppression

          Anomalous Retinal Correspondence

                   Harmonious ARC

                   Unharmonious ARC

                   Lack of correspondence

          Fusion

          Stereopsis

Required Readings:

          Rutstein pp 131-141

Morgan, M.W. Jr., Anomalous Correspondence Intercepted as a Motor Phenomenon, American Journal of Optometry, 38: 131, 1961.

 

 

VIII.    ESO DEVIATION

          A.       Classification

          B.       Incidence

          C.      Characteristics

A.       Vision Training

          1.       Monocular skills training

                   a)       indications

                   b)       techniques

          2.       Binocular skills training

                   a)       sequencing fusion, stereopsis, lustre, bi-ocular training

                   b)       bi-ocular/anti-suppression therapy

                             1)       indications, significance sequencing

                             2)       specific techniques,

                             3)       binasal occlusion: case selection, methodology, results

                   c)       central fusion training

                             1)       space training vs. instrument training

                             2)       techniques: instruments, space training, prism application

                   d)       peripheral stereopsis

                             1)       rationale

                             2)       techniques and sequencing

                   e)       finishing techniques: high level visual skills development

          3.       Lens application in constant esotropia

          4.       Prognosis

B.       Surgical Intervention

          1.       Early surgery

          2.       Later surgery

C.      Combined surgical and vision training

Required Readings:

          Rutstein Ch 8

Articles

          Archer, Steven M., Helverston, Eugene M., Miller, Kathleen K., Ellis, Forrest D.:

          Stereopsis in Normal Infants and Infants With Congenital Esotropia; American J.

          of Ophthamology, 101: 591-596, May 1986.

          Burian, H.M., Normal and Anomalous Correspondence, In Allen, J.H., Editor:

          Strabismus Ophthal. Symposium I., St. Louis, C.B. Mosby Co., p. 130, 1930.

          Helverston, E.M. and Von Noorden G.K., Microtropia: A Newly Defined Entity",

          Arch. Ophthal., 78: 272, 1967.

         

          Scheiman, M., et al: Surgical success rates in infantile esotropia. J. Amer. Optom.

          Assoc. 60 (1); 22-31, 1989.

          Scheiman, M., Ciner, E.; Surgical success rates in acquired comitnat, partially              accommodative and nonaccommodative esotropia. J. Amer. Optom. Assoc.

                   58 (7) 556-561.

 

 

 

IX.      EXO Deviation                                                       

          A.       Classification

          B.       Incidence

          C.      Characteristics

          A.       Brock/Flax therapeutic model

                   1.       Monocular skills training

                             a.       nature of monocular skills; pursuits, saccadics, accommodation,                                                     visual-motor skills

                             b.       indications for therapy

                             c.       therapeutic techniques

                   2.       Sequencing binocular therapy

                             a.       peripheral stereopsis

                                      1) rationale

                                      2) techniques and sequencing

                             b.       fusion training in space and instruments

                             c.       final stages of treatment: development of

                                      1) freedom between accommodation and convergence

                                      2) ability to maintain alignment with reduced effort and attention,                                       even in the absence of fusion cues

                   3.       Lens application in intermittent exotropia

                   4.       Prognosis

          B.       Alternative treatment

                   1.       Occlusion

                   2.       Minus overcorrection

                   3.       Diplopia awareness

                   4.       Surgery for alignment

                   5.       Overcorrective surgery

 

 

Required Readings:

          Rutstein Chapter 9

Cooper, J Medow., Major Review: Intermittent Exotropia: Basic and Divergence Excess Type, Binocular Vision and Eye Muscle Surgery 8(3):185-216, 1993.

Cooper, J., and Duckman, R., Convergence Insufficiency: Incidence, Diagnosis, and Treatment",Journal of American Optometric Association, 49:(6) 673-680, 1978.

 

 

 

 

X.      HYPER Deviation                                                            

          A.       Classification (Concomitant, DVD, Paralytic)

          B.       Incidence

          C.      Characteristics

          Required Reading

          Calorossa Chapter 16

XI.      SPECIAL FORM OF STRABISMUS                    

          A.       Duane's syndrome

          B.       Brown's superior sheath tendon

          C.      Strabismus fixus

          D.      Fibrosis of the muscle

          E.       Endocrine myopathy

          F.       Cyclic heterotropia

 

 

XII.     ALTERNATIVE TREATMENT AND OTHER TYPES OF STRABISMUS  

          A.       Vertical strabismus

          B.       Biofeedback as a treatment modality

          C.      Management of non-comitant strabismus

          D.      Horror fusionis and intractable diplopia

          E.       Management of strabismus in infants and pre-schoolers

                   1)       lenses, binasals, gross motor, fusion, prisms, environmental guidance

                   2)       miotics

                   3)       early surgery

Suggested Readings

          Von Noorden, Ch. 19, 20, 21

          Calarossa 17