1. If it is Strabismus, It Can be Diagnosed with a Cover Test
Strabismus: Ugh!
If it is Strabismus, It Can be Diagnosed with a Cover Test

2. The Obvious and the Not So Obvious
Two Big Areas
Esotropia
Exotropia
I Wonder if it should not be
Intermittent
Constant
What is the Advantage of Strabismus?

3. Press and Efficacy: Esotropia
Plus (T)NC .6 (T)AC .5 NC AC .1
Good Fusion
Family Hx
No Ambly
< 20 ^
Minus
Dense Supp
Non Concom
Dense Ambly

4. Press and Efficacy: Exotropia
Plus (T)NC .8 (T)AC .7 TNC TAC .4
Good Fusion
Family Hx
No Ambly
< 20 ^
Minus
Dense Supp
Non Concom
Dense Ambly

5. Ugly Factors No Desire To Change Anomalous Correspondence Amblyopia
Intractable Diplopia
Constancy
Non-Concomitant
Restrictions
Prior Surgery?

6. Do They Want To Change? Strabismic From Head to Toe
The Child That Did Not Want a Brother
The College Student That Wanted A Husband
Esotropes want Detail and are Willing to Give up Binocularity to Get it (Developmental)
Exotropes want the “Big Picture” Panoramic Viewing (Genetic, ABI or Functional)

7. Anomalous Correspondence
A Type of Binocularity
Develops Early---????????????
Reaction of Organism to Diplopia
Sees Double
Suspends/Suppresses
Goes into an Anomalous Fusion Cortically

8. Anomalous Correspondence
Depth
Shallow-Ignore
Deep-Ugh!
Treatment
Embed the Binocularity
Move to Harmonious Anomalous
Change to Normal Correspondence

9. Amblyopia Maples WC, Bither M
Amblyopia Maples WC, Bither M. Treating the trinity of infantile vision development: infantile esotropia, amblyopia, anisometropia. J Optom Vis Dev 2006;37:
Eccentric Fixation
Develops Early
Secret to Amblyopia (Anisometropic and Eccentric Fixation)----Fixation
0 Retino Motor Locus
Treatment-Develop Central Fixation

10. Constancy INTERMITTENT IS EASIER
The reason that Exos are easier than Esos may be that there are more Intermittent Exos
If Intermittent:
Do not Patch
Work on Binocularity where you can find binocularity and expand it. WORK BACKWARDS TO BIOUCLAR AND MONOCULAR SKILLS

11. Intractable Diplopia Late Onset Trauma Stroke Horror Fusionis
The OMD Who Saw Nothing But ID’s
Patch (Contact Lens), Blur, Suppress---

12. Non-Concomitant Pathology Prior Surgery Worse if Complications
Restrictions almost always will not have full use
Duane’s Congenital and Train other Visual Skills
Brown Can be from infection of the tendon sheath and if so, when infection controlled can decrease

13. Seven Levels of Dx and Tx
Bilateral Integration
Central Fixation
Monocular Equality
Biocular Skills
Basic Binocular Skills
Advanced Binocular Skills
Special (Perceptual/Cognitive/Executive)

14. Working the System: Testing/Demonstrate
Bilateral Skills: Anatomical Interaction
VO Star
Harmon Bimanual Circles
Standing and Seated Posture
Dry Land Swimming
Angels in the Snow
Line Roll

15. Working the System: Testing/Demonstrate
Central Fixation
Ophthalmoscopic (Visuscope)
MIT
Cover Test and Angle Lambda (Kappa) Very Gross
Past Pointing

16. Working the System: Testing/Demonstration
Monocular Equality
Fixation: Wolff Wands, VO 12* Star; Fixation Worksheet; Parquetry Blocks; Chalkboard Saccades
Saccade (Real World): See Above; Wayne Saccades; Hart Chart Challenge; Battle Ship Hart Chart
Pursuit: Wolff Wands; Marsden Ball; Head Rotations; Chalkboard Pursuits; Mechanical Rotator
Near Far-Far Near: Hart Chart, Wayne Saccade
Accommodation: Kraskin Bifocal; Monocular Rock

17. Working the System: Testing
Biocular Skills: In My Opinion-The Key to Effective Amblyopic and Strabismus Therapy
Suppression
Anomalous Correspondence
Double but MORE THAN Double-Equally Real
“The one I am attending”

18. Biocular Tests (Anomalous Correspondence-Press) Bagolini Lenses
Polarized Vectogram
Amblyscope
Worth Four Dot
Maddox Rod with Red Lens
Hering-Bielschowsky After Image

19. Working the System: Testing
Tests (Suppression)
Bagolini Lenses
Keystone
Brock String
Quoits (Cross)
Binocular Refractions
Physiological Diplopia
Retinal Rivalry
Others

20. Working the System: Testing
Basic Binocular
Tons of Tests
Retinoscopy
Phorias
Vergences
Telebinocular
Stereo

21. The Intermittent Trope Can you get Stereo?
If Stereo
Demonstrated with Peripheral Targets Brock Stereo Motivator or Quoits on a Window
Build Ranges
Ramp
Step
Ability as measured by Accuracy as measured by the Speed and Stamina of the Patient A Ass
Speed means both Fast AND Slow
Minimal Differences (Quoits and 1 ^ difference)

22. Rules of Engagement ”Where the Eye looks and were the Brain thinks it looks is different”
Start Were They Are and Go Where They Ain’t
Start Slow and Start Low
Synapses that Fire Together Continue to Fire Together
Analyze the Procedure: All VT is Bio-Feedback
Patient & Therapist MUST BE involved
Know What you are Attempting to Accomplish
Be Enthustatic
Accomplishment is the Best Reward

23. Working the System: Therapy
Central Fixation
Pleoptics
Ophthalmoscopic Bleaching
Fixation/Saccade/Pursuit
Smaller and Smaller
MIT
Eye Hand Activities

24. Working the System: Therapy
Bilateral Skills
Yoked Prisms with Motor Activities
Line Roll
Line Walk
Harmon (Lowman) Board
Harmon Circles
Van Orden Circles

25. Working the System: Therapy
Monocular Equality (Biocular & Binocular)
Monocular Disassociated Binocular (MDB) Marsden Ball
MDB Pointers
AN 12 pointed Star MDB
Kraskin Bifocal Rock MDB
Modified Modified UpDegrave MDB

26. Working the System: Therapy
Biocular
Squinchel
Marsden Ball
Physio Diplopia
Quoits
Brock String
12 Pointed Star

27. Working the System: Therapy
Binocular Esotrope
Luster
Gross/Peripheral/Moving Targets
Give Me 5 on the Balance Board
Touch my Fingers
Top Clear/Bottom Clear/Both Clear (= Blur)
Quoits-Suppression and Fusion
Keystone without Detail
Encourage Periphery
Motor Activities

28. Working the System: Therapy
Extotropes
Rx (+) and tend to be poorer academic achievers
“Take This Job and Shove It” “ I Quit”
High Sx: See COVD-QOL Checklist
Functional or Nerve/Muscle Damage
Needs “Orthoptics”: Fixations, Pursuits, Vergence, ACCOMMODATION
Get Stereo; Let Stereo Go; Regain Stereo
See 1/See 2

29. Skeffington’s Model Exotropia
Divergence Excess Needs + at Near (Cooper, NO!)
Sympathetic and Parasympathetic-Exos Peripheral Dominant
Social and Biological Clash
Myopia/Esotropia
Hyperopia (Normal Refraction)/Exotropia

30. Working the System: Therapy
Esotropes
Minimal +; Monocular (-) Followed by Low +
Tend to be High Achievers (Bull Dogs) Low Sx
Want their own Way (Spoiled?-Indulgent Parents)
Will tell you what they think you want to hear
Developmental or SERIOUS PATHOLOGY
Ah, Ha is Needed. That is how you do it