Professional Documents
Culture Documents
Catherine Qui-Macaraig, MD
UST
Why Screen?
relate survival to retinal vascular changes in the
hypertensive population
changes correlated directly with the degree of systemic
hypertension
correlated inversely with the prognosis for survival
Ophthalmic Complications
Central Retinal Artery Occlusion (CRAO)
Caused by atherosclerosis. Factors contributing to atheroma include
hyperlipidemia, hypertension and obesity.
Pathologic Changes
Arteriosclerosis – smaller vessels
diffuse fibrosis and hyalinization
Persistent Elevated BP
Sclerotic phase
Sclerotic phase
Exudative phase
Clinical findings seen in the retinal vasculature in
hypertensive retinopathy
Arteriolar narrowing (focal and diffuse)
Arterial sclerosis
Arterial tortuosity
Keith-Wagener-Barker Classification
Hypertensive ocular disease:
Hypertensive choroidopathy
Hypertensive retinopathy
Hypertensive optic neuropathy
Hypertensive choroidopathy
Young hypertensives
Zones of nonperfusion of choriocapillaries (Elschnig spots)
Focal RPE detachments, exudative RD
Hypertensive retinopathy
a. vasoconstrictive phase
b. sclerotic phase
c. exudative phase
d. complications of sclerotic phase
Hypertensive optic neuropathy
a. optic disc edema
b. optic atrophy
c. ischemic optic neuropathy
Systemic Diseases
Part 2
Catherine Qui-Macaraig, MD
Instructor, UST
AIDS and the Eye
AIDS
Retrovirus subfamily Lentivirinae
HIV-1 seen worldwide
HIV-2 western Africa
CD4 T helper cell depletion immune deficiency (infectious
diseases in the immunocompromised), polyclonal B cell stimulation
(lymphoma, kaposis sarcoma)
AIDS
Transmission:
sexual intercourse: 70%
IV drug use: 27%
Blood transfusion: 2-3%
Perinatal transmission: 1%
Diagnosis
Screening: ELISA
Definitive: Western blot
CD4 levels:
250-500 cells/mm3: oral candidiasis, disseminated TB
150-200 cells/mm3: kaposis sarcoma, lymphoma, cryptosporidiosis
75-125 cells/mm3: PCP, disseminated mycobacterium avium complex,
ulcerated herpes simplex, cryptococcosis, toxoplasmosis, esophageal
canididiasis
<50 cells: CMV retinitis
Latent reactivation
White retinal infiltrates starting peripherally (late visual complaint)
Perivascular fluffy white lesions with scattered hemorrahges
Granular lesions with few hemorrhages and central area of clearing, with atrophic retina
Low grade vitritis
CMV retinitis-
“pizza pie” retinopathy
CMV Papillitis
Pneumocystis carinii choroidopathy
Multiple white plaque
Rare visual loss
Treatment: IV pentamidine
Ocular Toxoplasmosis
retinochoroiditis
Dx IgG and IgM
In congenital-
focal choroiditis
Tx subconj or retrobulbar steroids
Toxoplasmosis
Acquired:
general malaise, lymphadenopathy, sore throat, hepatosplenomegaly
Retinochoroiditis: fluffy-white areas of small to multiple retinochoroiditis, active lesion
near an old scar, cystoid macular edema, vitritis, iridocyclitis, IOP increased
Toxoplasmosis: Active
Progressive outer retinal necrosis
Syphilis
has protean ophthalmic manifestations. CONGENITAL: Interstitial keratitis & saddle
nose
TERTIARY: Argyll Robertson pupils (small, irregular pupils reactive to near stimulus but poorly
reactive to light), Internuclear ophthalmoplegia
Interstitial Keratitis
Nonulcerative and nonsuppurative inflammation of the corneal stroma
May form stromal neovascularization if untreated
Diffuse or localized
Interstitial Keratitis
Neuro-ophthalmic manifestations
Papillitis
Optic neuritis
Optic perineuritis
Papilledema
Ocular manifestations of syphilis
A female patient aged 73 years with syphilis. Note the optic atrophy,
arteriolar narrowing, pigment loss, and clumping.
Others
Glaucoma almost always is associated with uveitic inflammation.
in congenital syphilis, interstitial keratitis is associated with adult secondary
glaucoma in 15-20% of patients.
glaucoma develops an average of 27 years after the initial episode of
interstitial keratitis has subsided.
Lids/eyebrows
Chancre rarely occurs in the primary stage.
Brow loss at its temporal aspect has been reported in secondary and tertiary
syphilis.
Tarsitis or lid abscess rarely occurs in the tertiary stage.
Pseudoepitheliomatous hyperplasia, related to the gumma of tertiary syphilis.
These lesions generally are elevated, and they have an uneven surface that is either
ulcerated or crusty, which appears similar to squamous cell carcinoma or basal cell
carcinoma.
Conjunctiva
Chancre in primary syphilis
Nonspecific conjunctivitis in secondary syphilis
Gumma in tertiary/late syphilis
Scleritis/episcleritis
Nodular or diffuse
Usually present in secondary syphilis
Anterior uveitis
Unilateral in 56% of cases
Granulomatous with mutton-fat keratic precipitates on the corneal
endothelium in 50% of cases
Iris nodules
small, dilated collections of capillaries in the iris
Treponemal emboli may cause vascular tortuosity and dilatation,
which account for the iris nodules.
Posterior uveitis
Posterior uveitis (9-18%)
Panuveitis (27-47%)
Vitreal cells are typical.
Vasculitis with or without vascular occlusion, macular edema, stellate maculopathy, disciform macular
detachment, serous macular/retinal detachment (pseudohypopyon), pseudo-RP, retinal detachment, neuroretinitis,
papillitis, diffuse chorioretinitis, uveal effusion, central retinal vein occlusion (CRVO), subretinal neovascular
membrane (SNVM) formation, and retinal necrosis (big blind spot syndrome)
Syphilitic posterior placoid chorioretinitis
Present in individuals who are HIV positive
Large, flat, dry, yellowish, or gray (with baited centers); macular or juxtapapillary placoid lesions at the retinal
pigment epithelium (RPE) layer
Most new cases occur in the most populated nations: India and China
The highest rates of disease are seen in sub-Saharan Africa, the Indonesian and
Philippine archipelagos, Afghanistan, Bolivia, and Peru. In these regions case rates typically
exceed 300 cases per 100 000 per year.
In April 1993 increasing rates of tuberculosis led to the World Health Organization declaring a
global emergency.
Tuberculosis has enjoyed a resurgence, allied as it is to economic and social fractures and the
HIV epidemic.
Tuberculosis and the Eye Contemporary Issues
Globally, the most common opportunistic infection and the leading cause of death
related to HIV infection is tuberculosis.
In some areas, like New York city, as many as 19% of the cases of
tuberculosis were attributable to multidrug resistant tuberculosis.
Mortuary workers, microbiology staff, and those caring for patients with tuberculosis
should have a pre-employment chest radiograph and tuberculin test.
Mycobacteria are Gram-positive, although they are not easily stained by this method.
They are resistant to decolorization by mineral acids after staining with arylmethane dyes
such as carbol fuchsin, hence the term acid-fast.
Tuberculosis and the Eye
Pathology
Immune responses: either
1. protective- leading to resolution
of disease, or
2. tissue destroying- leading to
the pathological characteristics
of active disease
The characteristic histological lesion: caseating granuloma, which consists of a chronic, compact
aggregate of activated macrophages (epithelioid cells), some of which fuse to form multinucleate giant
cells
The body's immune system normally tags any invading bacteria with proteins that alert macrophages to
consume it. One of these proteins, C2a, then floats in the blood with no known function.
M tuberculosis manages to associate with this discarded C2a protein and use it to create a new label that
helps the bacteria adhere to the macrophage and enter it.
Once inside the macrophage, the mycobacteria multiply until the cell ruptures and the bacteria are then
released to repeat the process
Tuberculosis and the Eye
Pathology
The initial pulmonary lesion, the Ghon focus, together with the hilar lymph-
adenopathy, forms the primary complex of Ranke.
Some bacilli are disseminated through lymphatics and blood, leading in some cases
to meningeal, bone, and renal involvement.
Tuberculosis and the Eye
Standard Investigations
Chest X-Ray
Culture: Sputum / urine culture / stain for AAFB (acid and alkali fast bacilli).Ziehl
Neelsen stain or auramine-phenol fluorescent test are confirmatory
Tuberculin hypersensitivity
Mantoux
Biopsy
Reactivation tuberculosis
Tuberculosis may cause virtually any radiological abnormality and atypical pictures are
not uncommon, especially in HIV-positive and other immuno -compromised persons.
Tuberculous phlyctenulosis
An elevated infiltrate is seen at the limbus with a fornix-based leash
of blood vessels.
responds well to topical corticosteroids.
Tuberculosis and the Eye
Ocular Manifestations
Phlyctenular conjunctivitis, which may occur in some children
within 1 year of the primary infection, consists of small, multiple,
yellow or grey conjunctival nodules near the limbus, with a sheaf of
dilated vessels.
Tuberculous interstitial keratitis
has a prolonged course and leaves residual dense opacification.
The central cornea usually is not affected.
Tuberculous choroiditis
symptoms usually are blurred vision and floaters.
This patient had a 2-month history of decreased vision and presented with a large
choroidal infiltrate.
Systemic TB was proved by culture of Mycobacterium tuberculosis. B.
The lesion responded dramatically to systemic antituberculous medications.
Fundus Photo- multiple vascular lesions associated with vitreous hemorrhage
Choroidal Tubercles
Latent choroidal tubercle in a patient with multidrug resistant TB.
Tuberculous Retinitis
Vitritis, focal retinitis with cicatrization, focal satellites, arteritis
and venous engorgement.
Tuberculous Retinitis
fA shows focus of retinitis as a hypofluorescent area with venous
dilatation.
Hyperfluorescent areas are satellite lesions
Tuberculous Retinitis
Later phases show hypofluorescent area with diffuse
hyperfluorescent borders with further diffusion of contrast from
leaking veins.
Tuberculosis of the eye
Tuberculosis patients are frequently referred to ophthalmology
because the anti-TB meds (e.g. ETHAMBUTOL and ISONIAZID)
may cause a OPTIC NEUROPATHY.
Case: Ethambutol toxicity in a 43 y/o
Ethambutol was initiated at a dosage of 15 mg/kg per day.
3 months later, the patient had lower extremity neuropathy,
and
2 weeks after developed a rapidly progressive, severe
decrease in vision
OD 20/200 OS CF
Hollenhorst plaques
[= cholesterol emboli] are typically asymptomatic & located at
bifurcations; do not produce downstream ischemic effects
CRAO
Pallid swelling of the retina
Usually due to AS
Giant cell arteritis is a cause in the elderly
Cherry red spot at center due to choroidal perfusion
CRVO
CRVO
Usu in HPN or gl
Dilated tortuous veins
Retinal edema
Hemorrhages and cotton-wool spots
Secondary NV Gl in ischemic type
More in DM smokers, hyperviscosity syn, CRF, hyperlipidemia
Visual Field Loss
Automated Perimetry
chiasmatic field defects
because nasal retinal fibers [= temporal fields] decussate in the chiasm, all
chiasmatic field defects respect the vertical meridian
all chiasmatic field defects tend to be variations on theme of
bitemporal hemianopsia
anterior, retrochiasmatic pathway pathology
Produces asymmetric or incongruous, homonymous
hemianopsias
Pediatric Ophthalmology
Catherine Qui-Macaraig, MD
UST
Cardinal Santos Medical Center
American Eye Center
10 warning signs of treatable eye disease in the
newborn and infant.
These first three of the ten warning signs of significant eye
disease in infancy and childhood have the most serious
implications and most require early definitive
treatment. Fortunately, they are rare!
Cataract - 1 in 250
Glaucoma - 1 in 10,000
Retinoblastoma - 1 in 20,000
Congenital Cataracts
2 Drooping Lid
Lump or swelling of lids with or without redness, heat, or pain (signs of
inflammation)
- this can be a sign of cellulitis, tumor, hemangioma, etc.
- occlusion of the pupil can cause amblyopia - immediate treatment is
indicated.
5 Crossed Eyes
Intermittently crossed eyes persisting after the 2 to 4 months of age should be evaluated by an
ophthalmologist to establish a diagnosis and plan treatment. Crossing can require surgery, done in
some cases as young as 4 months.
Other crossing can require treatment with spectacles. Eyes that deviate constantly should be evaluated
immediately!
immediately!
6 Nystagmus
Dancing Eyes "Dancing eyes" which move from side to side, in a rotary pattern, or
up and down.
This can be a sign of eye (vision) disease, or serious disease of the brain and should be
evaluated by an ophthalmologist soon.
Vision Screening
The purpose of vision screening is to identify chldren with one or more
of the following conditions:
1) Decreased vision in one or both eye(s) (below an arbitrary standard)
2) Eye conditions which could lead to decreased vision in one or both eye(s)
3) Strabismus (crossed or wall eye)
4) Other eye related conditions such as: ptosis (droopy lid), nystagmus (dancing
eyes), head tilt, etc.
each eye should see at least 20/40 with no more than 2 lines
difference between the two eyes (OD 20/20 OS 20/40) is failure
Observe for:
eye crossing
crossed or "wall" eye
nystagmus (dancing eyes)
droopy lid
head tilt
Amblyopia
Definition: Reduced vision in one eye or occasionally both
eyes caused by pattern vision deprivation or abnormal binocular
interaction for which no causes can be detected by physical
examination of the eye and which in appropriate cases is
reversible by therapeutic measures (from von Noorden).
Strabismic Amblyopia
Constant use of the left eye causes suppression of the right eye
which produces amblyopia.
strabismus
Angle Kappa
The angle bet visual and central pupillary line
A nasally centered pupillary light reflex gives the appearance of exotropia and is
physiologic.
A temporally displaced pupillary light reflex gives the appearance of esotropia and is
uncommon, occurring in some cases of very high myopia.
Extraocular Muscles
Spiral of Tillaux
The line of insertion where the rectus muscles insert in sclera gradually farther from the limbus
beginning with the medial rectus at 5.5mm (range 3.0 to 6.0mm), inferior rectus 6.5mm, lateral rectus
6.9mm and superior rectus 7.7mm.
7.7mm.
It is also the line of insertion of posterior Tenon's capsule which then proceeds to the limbus as
the episclera fused with the underlying sclera.
Recti
The rectus muscles are each 40mm long.
They receive innervation on the global surface at the junction of the middle and
posterior 1/3 of the muscle.
The pulleys are located on the orbital surface at the junction of the middle and
posterior 1/3 of the globe. The pulleys are fibromuscular structures that act as
functional origins of recti
Superior Oblique
The superior oblique (S.O.) is made up of a 30mm muscle, and 30mm tendon with the trochlea
between.
The S.O. has its functional origin in the trochlea. This unique structure allows an 8mm increase
in the trochlear insertion distance in upgaze and an 8mm decrease in distance between the S.O. insertion
and trochlea in downgaze.
Action
Blood Supply
A long posterior ciliary artery travels from the back of the eye in sclera
beneath the horizontal recti.
The oblique muscles do not contribute to the blood supply of the anterior
segment of the eye.
Anterior Ciliaries
EOM Innervation
lateral rectus
innervated by the sixth cranial nerve.
The nucleus is located in the brain stem and the nerve is uncrossed.
superior oblique
innervated by the fourth cranial nerve which crosses to reach the muscle.
The nerve passes through the "stiff" tentorium making it susceptible to the
shearing force produced by brain oscillation in closed head trauma.
third cranial nerve
Innervates
the medial rectus
superior rectus
inferior rectus
inferior oblique
levator palpebri.
Muscle Fibers
At least two types of muscle fibers are present - they differ in several
parameters
By innervation: multiple - single
By action: slow - fast
By layer: global - orbital
Normal pattern of stretch and active contraction
Contracted/overlapping/
"stiff" muscle occurs with chronic, unopposed contraction, i.e. M.R. in chronic VI N
palsy -- "lost" contracted M.R. and after injection of local anesthetics -- as in diplopia
after cataract.
Multiple fascial layers and fat compartments
Multiple fascial layers as seen with a limbal incision
Evaluation
Cardinal Gazes
Cardinal Gazes
Hirschberg Test
Krimsky
Cover Test
Cover-uncover Test – shows a manifest deviation e.g.
esotropia
Accomodative Esotropia
Leukocoria
Catherine O. Qui-Macaraig, M.D.
Pediatric Ophthalmology
University of Santo Tomas
Department of Ophthalmology
Leukocoria
“white pupil”
Any white tissue mass behind a clear lens obscuring the pupil and
occurring in infants or young children
Always consider RETINOBLASTOMA
Retinoblastoma
The most common ocular malignant tumor of childhood
Currently with a 90% long-term survival rate
Unilateral in 70%
Retinoblastoma: Incidence
11 cases per million children < 5 years or
1 case per 18,000 live births
Most common age at diagnosis: 18months
Retinoblastoma: Inheritance
Rb gene: for regulation of cell division
An inactivating mutation of both maternal and paternal alleles of
chromosome 13q14
Knudson Hypothesis: 2 hit theory
- 2 independent mutational events
Inheritance (cont’d.)
60% unilateral nonhereditary-present later
40% with a heterozygous germline mutation which is inherited from an
affected parent (10%) or occurs around time of conception
Second tumorigenic mutation occurs by chance alone
Retinoblastoma: histopathology
Flexner-wintersteiner rosettes
fleurettes
Clinical Presentations of Retinoblastoma
Leukocoria
Strabismus
+ family history
Inflammation with tumor hypopyon
Glaucoma
Hyphema
Preseptal cellulitis
Nystagmus
Retinoblastoma: Diagnosis
Unilateral, with classic fundus picture
Calcification by CT/US
Retinoblastoma on CT Scan
Intra-lesional calcifications
Retinoblastoma on B-scan Ultrasonography
B-scan at low gain to show endophytic mushroom shaped lesion and foci of
calcification
Histology
Less differentiated tumors do not have increased metastatic potential
Important Reminders
When a fundus can’t be seen in a young child, pre-operative imaging (CT
or b-scan) is essential
Always suspect retinoblastoma
Retinoblastoma: Natural History
Small mass that later fills the eye
Spreads to brain by local extension
Blood-borne metastases to bone, bone-marrow
Retinoblastoma: Treatment
Enucleation
Radiation
Chemotherapy
Cryotherapy
Photocoagulation
Radioactive plaques
Enucleation
Procedure of choice for unilateral tumors
Use blunt tipped scissors
Do not pass needles through sclera
Grasp muscle stump for fixation instead
Obtain as long a stump of optic nerve as possible
Radioactive Plaque
Minimizes radiation to normal tissue
Disadvantages:
incomplete treatment
high dose to local sclera
significant lens irradiation for anterior ones
difficulty placing posterior ones
Chemotherapy
VP-16, VM-26, carboplatin
In combination with laser generated hyperthermia
Factors Affecting Visual Outcome
Tumor size
Tumor location-macula
Treatment modality- chemo and focal tx
Complications
Amblyopia
Prognosis
SURVIVAL RATES:
No violation of lamina cribrosa: >90%
Beyond lamina cribrosa: 60%
+ transection site: <20%
PHPV
Fibrovascular stalk emanating from optic nerve to ciliary processes and posterior
lens capsule
PHPV
Iridohyaloid vessels over superotemporal aspect of iris dip behind to anastomose
with vascularized mass behind behind the lens
Coloboma of the Choroid
Absence of tissue that may occur through abnormal fusion of the optic fissure
Often associated with microphthalmia
Coat’s Disease
Idiopathic, unilateral (80%)
Male predilection (3:1)
Telangiectatic and aneurysmal dilatation of retinal vessels with massive subretinal
exudate
Ocular Toxocariasis
Invasion of the eye by the dog roundworm Toxocara canis
Most commonly confused with retinoblastoma
Presents as a hazy yellow-white mass
Toxocara cont’d.
Cataract is common
Aqueous humor cytology can differentiate the two conditions
Treatment is with antihelminthics like thiabendazole
RETINOPATHY OF PREMATURITY
(RETROLENTAL FIBROPLASIA)
Catherine Qui-Macaraig, MD
Instructor
DEPARTMENT OF OPHTHALMOLOGY
UNIVERSITY OF SANTO TOMAS
ROP STAGE 5
RETINOPATHY OF PREMATURITY
INCIDENCE & BIRTH WEIGHT*
1,000-1251 g(2lb 3-2lb 13oz) 47%
750-999g(1lb 10oz-2lb 2oz) 78%
<750g(1lb 10oz) 90%
85% of children who have some form of ROP develop, with no intervention, fully
vascularized retina without the severe sequelae of retinal detachment.
*Palmer EA, Flynn JT et al. Incidence and early course of retinopathy of prematurity. Ophthalmology. 1991; 98:1628-40
DIAGNOSTIC PROCEDURE
INDIRECT OPHTHALMOSCOPY
best procedure to visualize the PERIPHERAL
RETINA
in ROP
INDIRECT OPHTHALMOSCOPY
THANK YOU!
Retina
Catherine Qui-Macaraig, md
UST, CSMC, American Eye Center
Anatomy: Retina
Thin
Transparent
LAYERS:
Outer RPE and Bruch’s membrane
Inner sensory retina
In between is Subretinal space in retinal detachments
Special points of attachment: optic disc and ora serrata
Retina Function
Layers of the Retina
(1) retinal pigment epithelium;
(2) rods and cones;
(3) external limiting membrane;
(4) outer nuclear layer;
(5) outer plexiform layer;
(6) inner nuclear layer;
(7) inner plexiform layer;
(8) ganglion cell layer;
(9) nerve fiber layer;
(10) inner limiting membrane
Layers of the Retina
All vertebrate retinas are composed of three layers of nerve cell bodies and two layers of
synapses. The outer nuclear layer contains cell bodies of the rods and cones, the inner nuclear
layer contains cell bodies of the bipolar, horizontal and amacrine cells and the ganglion cell layer
contains cell bodies of ganglion cells and displaced amacrine cells. Dividing these nerve cell
layers are two neuropils where synaptic contacts occur.
photoreceptor density in the human retina (x 1000
cells/mm2)
Vitreous
Choroid
Choroid
densely pigmented and richly vascularized layer that nourishes the outer
retina and RPE
high blood flow --> heat dissipation
orange color of posterior segment
Macula
The whole foveal area including foveal pit, foveal slope, parafovea
and perifovea is considered the macula
the most essential part of the retina for human vision
macula lutea
yellow pigmentation
This pigmentation is the reflection from yellow screening pigments,
xanthophyll carotenoids zeaxanthin and lutein present in the cone
axons of the Henle fibre layer
thought to act as a short wavelength filter, additional to that
provided by the lens
protective mechanisms for avoiding bright light and especially
ultraviolet irradiation damage
Berlin's edema or commotio retinae
macular edema secondary to blunt trauma to the globe.
CME
central retinal artery occlusion
of “cherry-red spot”
The perifoveal edema (white opacification) does not extend beyond the
macula because of the reduced concentration of ganglion cells in the extramacular
retina. Marked pallor of the optic disc is present.
retinal tear
The pigment epithelium and choroid visible through the retinal break have
an orange-red color.
The retina surrounding the tear has lost its transparency because of edema
and underlying fluid.
Fluorescein Angiography
Side Effects
Nausea, vomiting
anaphylactoid reaction 91%)
anaphylactic reaction (less than 1%)
Indocyanine Green Angiography
Water soluble dye
high peak absorption and emission allowing fluoresecnce through
pigment and hemorrhage
detection of choroidal neovascularization beneath hemorrhage
Common uses of diagnostic imaging technology
Choroidal neovascularization
Chorioretinal inflammatory conditions
Subretinal fluid accumulation
Retinal perfusion abnormalities
Macula edema
Vitreomacular interface changes
Electroretinogram
Electroretinogram
Diffuse electrical response generated by retina
a wave - negative waveform; photoreceptor response
b wave- positive waveform; Muller and bipolar response
Electroretinogram
Photopic ERG - patient ligt adapted state to suppress rod response
then elicit ERG response with bright white flash *cones)
Scotopic EG - patient is dark adapted for 45 minutes to evoke
response from rods
ERG
Electro-oculogram
Electro-oculogram
Symptoms suggestive of retinal dse.
Distortion- image magnification/minification-wavy lines
-lesions of macula or ON
Flashes of light- retinal traction/ migraine
Floaters- syneresis/ blood, pigment, or inflammatory cells
Abrupt or progressive loss of peripheral visual field
Abrupt or progressive dimming of vision
Thank you!
Neuro-ophthalmology
catherine qui-macaraig, md
UST, CSMC, American Eye Center
Pupils: Direct Pupillary Light Reflex
- dim lights
- ask patient to fix in the distance
- shine light on test eye
Horner's pupil
as accentuated after administration of topical cocaine.
A true Horner's pupil does not dilate with cocaine. Cocaine blocks the reuptake of
norepinephrine
Ocular Motility
Cardinal Gazes
Cover Testing
Cardinal Gazes
Cover Test
Cover-uncover Test – shows a manifest deviation e.g. esotropia