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Ocular Motility/Binocular Vision
Eva Lindahl C.O.M.T.
Types of Deviations
- in
- out
- up
- down
- a latent tendency of eyes to deviate that isprevented by fusion. A deviation occurs onlywhen a cover is placed over an eye; whenuncovered, the eye straightens (heterophoria)
- eye misalignment caused by extraocularmuscle imbalance; one fovea is not directed atsame object as the other. Deviation is presenteven when both eyes are uncovered (heterotropia)
X, E, H
- phoria
- stronger tropia than phoria
- manifest
X(T), E(T), H(T)
- intermittent
Muscle Abbrev. Main Actions Cranial N Testing Position
Medial Rectus
MR Adduction III
straight nasalLateral Rectus
LR Abduction VI
straight temporalSuperior Rectus
SR Elevation III
up and temporal
Inferior Rectus
IR Depression III
down and temporal
ExtortionAdductionSuperior Oblique
SO Intortion
down and nasal
DepressionAbductionInferior Oblique
IO Extortion III
up and nasal
- monocular movement of an eye outward (away from the nose)
Abnormal/Anomalous Retinal Correspondence (ARC)
- adaptation to compensate for a long-standing eyedeviation; fovea of the straight (non-deviated) eye and a non-foveal retinal point of the deviated eye work together, sometimes permitting single binocular vision despite misalignment of the eyes.
Criteria for ARC:
 1. Patient must have manifest esotropia (monocular or alternating) - hardly ever exo2. Must be the same amount of crossing all the time (no accommodation)3. The patient has the desire to fuse, but because of manifest deviation is unable to do so. If he fuses, it isabnormal.4. May or may not have amblyopia
AC/A ratio
(accommodative convergence/accommodation ratio) - numerical expression for relationship betweenthe amount both eyes simultaneously turn inward (converge) and the amount their lenses increase in power(accommodate). In normal individuals this ratio averages 5:1. Accommodative convergence is expressed inprism diopters (
), and accommodation is expressed in diopters (D).
Distance-near method : AC/A = 1/3 (n
) + interpupillary distance (in
) (Wilson p 121)
= near deviation
= primary position deviation
- increase in optical power by the eye to maintain a clear image (focus) as objects are movedcloser.
Accommodative convergence
- that portion of the range of inward rotation (toward nose) of both eyes that occursin response to an increase in optical power for focusing (accommodation) by the eyes' lenses.
Accommodative esotropia
- excessive turning of an eye inward (toward nose) caused by an overactiveconvergence response to the accommodative effort necessary to keep vision clear. Eyeglass correction forthe hyperopia relaxes accommodation, allowing eyes to remain properly aligned. Sometimes bifocals arenecessary to correct excessive inturning at near.
- monocular movement of an eye inward (toward the nose).
Afterimage Test
- evaluates retinal correspondence in a horizontal deviation. With the opposite eye occluded, themacula of each eye is marked with an afterimage using a linear light flash with the fixation point blocked.Horizontal orientation is used OD, vertical OS. Then the patient reports the composite binocular imageperceived (eyes open or closed).• Interpretation:
: a symmetrical cross with a central area void of an afterimage
esotropic ARC
: a vertical line asymmetrically displaced to the right in a crossed fashion
exotropic ARC
: a vertical line asymmetrically displaced to the left in an uncrossed fashion
Agonist, primary mover
- extraocular muscle mainly responsible for moving eye into desired position.
- a deviation which can be encouraged to hold fixation with either eye.
Alternate Cover Test
- measures the entire deviation (tropia plus phoria). Test in all appropriate positions of gazeto explore for incomitance.
, ("lazy eye") - decreased vision (two lines of vision or more) in one or both eyes without detectableanatomic damage in the eye or visual pathways. Uncorrectable by optical means (e.g., eyeglasses).Including strabismic, anisometropic, refractive, ex anopsia.
Amblyopia Ex Anopsia, amblyopia of disuse
- reduction of vision fromnot seeing or disuse
Angle Kappa -
the angle between the visual axes and the anatomic(pupillary) axes. Can be positive or negative. A slightly positiveangle kappa is physiologic due to usual foveal positioningtemporal to the anatomic axis.• If 
, the pupillary reflex will be seen on the
nasal side
 of the midline. (
type of deviation).• If 
, the pupillary reflex will be seen to the
of the midline (
type of deviation).• Use the cover - uncover test to distinguish if deviation ispseudo.
- extraocular muscle whose action opposes that of thecontracting muscle (agonist) that moves the eye.
- extraocular muscle on the fellow eye whose action
opposes the action of a contracting muscle of an eye (e.g., RSR and LSO)
- extraocular muscle whose action opposes the action of another muscle on the same eye (e.g.,MR and LR)
A/V Patterns -
eye deviations in which the deviation is more pronounced in the up or down gaze.
A pattern
- more convergent in upgaze or divergent in downgaze (10 P.D. difference necessary)• Either more eso up or more exo down
V pattern
- more convergent in downgaze or divergent in upgaze (15 P.D. difference necessary)• Either more eso down or more exo up
Bagolini lenses
- finely striated clear lenses used for evaluating retinal correspondence. The lenses are placed withthe best correction in a trial frame in a manner such that the light streak produced by viewing the target lightis oriented at 135° OD and 45° OS. The patient views a white fixation light at 20 ft or 13 in. under normalroom lighting.• Interpretation:
(orthotropia, central fusion) = 2 light streaks crossing at a light without a break in eitherline.
strabismus > 9
with NRC
= 2 separated light streaks, each passing through its own light ineither a crossed (exotropic) or uncrossed (esotropic) manner
strabismus > 9
with ARC
= 2 light streaks crossing at a light with either a 5° to 6° break inone line (esotropia) or a much larger break in one line (exotropia)
absence of binocular vision
= one light streak passing through a light
Bielschowsky Three Step Test (B3ST)
-- a test which helps isolate which of the eightcyclovertical muscles may be at fault in avertical muscle palsy
Step 1
: Determine the presence of a RHTor LHT in the primary position.
Step 2
: Determine if the HT is larger inright or left gaze
Step 3
: Determine if the HT is largerwhen measured during head tilt to theright or left.(See attached worksheet)
Binocular vision, single binocular vision
-blending of separate images seen by eacheye into one composite image
Blowout fracture
- break of bony orbital flooror walls caused by blunt trauma to eye ororbit; intraorbital contents are pushed intoone or more of the nasal sinuses
Both Eyes
- OU, Oculus Uterque
Brown's syndrome
- sheath of superior obliquemuscle that does not, or cannot, relaxwhen the eye attempts to look upward andinward, mimicking a palsy of the inferioroblique muscle. Unilateral; may becongenital or acquired.
Comitant (Concomitant)
- eye misalignment inwhich the amount of deviation remainsthe same in every direction of gaze
- erroneous perception that twodifferent objects occupy the same positionin space. Short term, leads to suppression.
Conjugate movement
- parallel movement of both eyes in same direction of gaze

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