Thursday, July 22, 2010



  1. no c/o of any symptoms from the patient but her mother noticed the deviation of the eyes since she was 5yo
  2. she never wear RX before










Dry retinoscope

wet subjective

+0.25/-0.75 X 145

+1.25/-1.00 X 150 (6/6-3 )

Pl/-0.25 X 130

+1.00/ -0.50 X 180 (6/6+3 )

Cover test

w/o RX:

with wet RX:

(done at D only)

D: Alternate ET, RE hypertropia

N: alternate ET , RE hypertropia

D: intermittent RET


(done at distance only)

Without RX :

With wet RX :

70 pd BO

32 pd BO

Other test


Hess chart. Kindly refer to the attachment.

-2                  +2         +2              -3

0                   +2         +2              -3

-2                  +2         0               -3


Alternating ET with LE as a fixating eye associated with RE hypertropia


Prescribe full wet RX with full time of wearing

TCA: 2/52


based on the hess chart above,
  1. what is the u/a muscle?
  2. what is your diagnosis based on this hess chart?


GROUP 3 :)


  1. From the hess chart on the LE eye, there is a presence of slight u/a of Inferior rectus muscle. Correct me if i'm wrong.
    And since the inner box plot of the hess chart shows shift of plot with changing shape inwards or towards medial rectus, the patient may have concommitant eso deviation severe on RE?

  2. Happy discussing...everyone must involve in this case discussion.

  3. yes zahirah..the esotropia is severe on RE and this patient always fixate with the LE. But remember that this patient has alternate esotropia.

    From the hess chart, LE IR shows u/a but i think there is another u/a muscle which is more significant to cause that deviation..

  4. yup siti.. anything else?? :)

  5. Since the patient has alternate ET, I think the u/a muscles are LLR and RLR...The patient has incomitant strabismus

  6. How to determine the severity of the tropia from the hess chart??? From what i see, the inner field of BE are quite normal, thus, does it indicate that the condition is mild??

  7. Yes nurli, I think I agree with hannan LLR and RLR is the major u/a muscle since there is and o/a in the RMR. But since, the inner field size the same and shift inwards thus shows concomittant deviation. And maybe the severity depends on the degree of deviation or shift? We can say that the inner field is shift inward by 1 box but how much deviation is shown by one box? Can someone enlighten me?

  8. -yes i also agree, obviously these two muscles are underacting.

    -1box equals to 5 degree

    -therefore the LE is deviating inward (eso) for about 5 degree, and RE a lil bit more than that (approximately 7.5, isnt it?)

    -but how much is that in prism dioptre?

  9. yes...the shape of the inner field is similar on BE but the only difference is the inward shift of the inner field..

  10. If I'm not mistaken, 7 degree approx equals to 15 pd, but it is applied in Hirschberg test...How about Hess chart???

  11. Hello everyone

    1) u/a mucle is the right and left LRM, since pt was also presented with RE hypertropia we could also see that there's a slight u/a of the SO. For this pt how much was this presented vertical deviation? is it small enough that we can ignore at this early stage? from the spectacle prescription was there any need to alter the central height on the spec? as you all know vertical deviation is not suitable for VT and if significant prism BD can be given. or do we concentrate in reducing the ET first?

    2) Since pt was diagnosed with Alternating ET at distance and near with LE as the fixating eye and wet Rx was given. In 2 months time what are we alll hoping to see other than reduced in the eso deviation?

  12. RE hyperdeviation could have possibly occur 2ndary to the horizontal deviation of the eye. I think we should be able too see reduced in the degree of hyperdeviation after 2 month. Do u by any chance have the value for vertical dev? if so we can later check and see vertical dev is secondary to presenting alternating ET or not. if not.. it should be something to be concern about.

  13. hi tikah..

    we are very sorry for not measuring the vertical deviation. Perhaps, in the next appointment, we are able to measure that. Hopefully, during that time vertical deviation also reduced when horizontal deviation reduced.

    for ur question on altering the central height, we r not very sure for the moment. can anyone answer that question?

    referring to nana's question, if im not mistaken..miss melanie once told us that prism diopter is estimated to be double. meaning that if the degree is 5, the prism diopter estimated is to be 10pd.

    pls correct me if im wrong.

  14. Does everyone agree that this is a concomitant ET? how do u know that it is concomitant? have you performed prism cover test at different gaze? if we are sure it is concomitant we can also rule out the possibility of Duane's syndrome (diffuculty in abduction) what was the result for ocular motility test? hurm? enlighten me...

  15. tiqah..
    the pt has alternate ET and RET...supposedly, RMR and LMR are the over action muscles while for vertical deviation LSO is the over action muscle instead of u said it was the u/a muscle..does anyone disagree with me???

  16. what i can see from the hess chart, the u/a muscles are LLR & LIR as well as RLR..based on the findings, this a case of RE esotropia..
    prism cover test at each gaze or diplopia test should be performed in order to give the exact diagnosis.

  17. I think the u/a muscle is RLR, LLR and LIR causing the o/a
    of RMR and LMR which resulting of the concomitant esotropia
    (severe on RE) and o/a of the RSR which is why the hypertropia is seen. I would agree with zahirah that this is a concomitant strabismus by looking at the shape of both inner box plot which are almost the same. However further examinations should be performed and I would appreciate if this group can attach some photos of this kid during the assessment to get a better idea.

    Thank you.

  18. good job my frens=)

    atikah n the rest,
    i've put in OMT result done to this pt...

    noely or ayu pls kindly attach related photos of this pt, plz..=)

    exactly rohaila,
    we have to perform Prism Cover Test at different gaze on the next TCA.

  19. salam..
    first of all, i hope all of u can now differentiate between the concomitant strabismus and incomitant strabismus..Good job girlz ;)

    Duane syndrome might become differential diagnosis, but, there is no reported in restraction of globe on abduction as well as there is no narrowing of palpebral fissure on attempted adduction.

    for OMT, we have put it, but due to some technical problem, it cannot be displayed..but we will try to show it.. sorry for that..

    and..referring to nazaryna question..he3..I'm not sure about that ;D

    perform Prism Cover Test at different's gonna be interesting :)

  20. i did try to upload the pic many times but fail. we r very sorry for that.

  21. nurli: u can try to compress the pic 1st b4 uploading them..try to use msword to edit them..gud luck!!!
    erm..good job my frenz..
    yes, i'm agreed with zahirah and hannan..i think the u/a muscles are LLR and RLR. if i'm not mistaken there are also slightly u/a of LLR and LIR.. that is why the o/a muscle is obviously on RMR.. Correct me if i'm wrong.. since the shape of inner box is shift inward, so i can say that it is concomitant deviation.. from the hess chart, it also shows is true?

  22. testing testing!!!

    Weieeeeee...i make it! found the password in my 10000 mail.

    Sure, u r waiting for me rite?

    Well everyone has discussed a lot on this case...what should i comment next...emmm..

  23. yup aida! well done..:D

  24. where are other? Sob, Azuwan n few more

  25. sorry for the late post..
    this is the link to the pictures of this patient but not so clear...
    wait for norli to post the clear one...

    OMT test...

  26. exactly aida, thats true..

    from the cover test itself shown right hypertropia.

    is it because of vertical deviation secondary to large horizontal deviation?

    any comment?

  27. referring to atikah's concern on altering pt spectacle's central height, i think she herself had answered that question.

    most probably the vertical deviation would be resolved once horizontal deviation is taken care of so there's no need to alter spec's central height.

    but pls anyone enlighten me on ur conclusion of pt having RE hypertropia, i'm a bit unclear on that matter.

  28. i think the presenter should reveal the real diagnosis now. and the management plan as well.

    Everyone is agreed with the same diagnosis. What is the plan for the next visit?

    Let say

  29. according to lecture given to us by Miss Melanie, orthoptist form S’pore

    Indication for Surgery
    1) increasing tropic phase with diminished fusion control
    2) poor fusion recovery on cover uncover test
    3) XT is manifest >50% of waking hours
    4) XT > 20PD

    Does the patient has all of these?

  30. i think everyone has agree that the hess chart shows under action of RLR which cause overaction of RMR.

    from the hess chart, inner box of both RE and LE show equal degee of inward deviation. thus, we can say that this is concomitant esotropia.

    from the hess chart,we also can see that RE shows more inward deviation than LE. thus, esotropia is more severe on the RE.

    from the history taking, mother noticed that her doughter's eyes deviate inward since she was 1 yo. thus, i can say that this is infantile esotropia.

  31. this case still need to undergo further follow up & investigation b4 we come to conclusion right? so what is your next management for this patient?
    how about azuwan's list criteria for surgery management, do the patient fulfill that criteria? should be noticed that surgery is the last option to choose.
    my suggestion is to rule out all these test b4 u come to diagnose the pt:
    1) do evaluation of eye alignment
    -direct observation
    -hirschberg & kappa test
    -krimsky test
    -bruckner test
    2)comitance testing
    -cover test in 9 position
    all above just my suggestion to be considered in order to confirm the status..might be some of the test not been done yet.. if i'm wrong..correct me..=)

  32. hi...sorry for the late coming...

    from the hess chart, I agree with u all, LLR and RLR are the u/a muscle and o/a in the RMR...

    and she was diagnosed as infantile eostropia...

    INFANTILE ESOTROPIA is a condition which da strabismus : ~manifest within the first year of life (*as her mother noticed that her doughter’s eyes deviate inward since she was 1 yo)

    ~ it is almost always esotopic (from the hess chart we can said she has RE esotropia)

    ~ large angle of squint (we can see it from PCT)
    ~ hyperopia (we can see it from refraction)
    ~ alternate fixation (it showed from cover test)
    ~ become unilateral if amblyopia develop (no sign)
    ~ nystagmus (no sign)

  33. and i think the vertical deviation is secondary to large horizontal deviation (esotropia)...

  34. nurlizawati1, are you sure, from the history taking, her mother noticed that her doughter’s eyes deviate inward since she was 1 yo??...

    because i look at her file just now, from the history taking, the mother noticed that her doughter’s eyes deviate inward since she was 5 yo??...

    misunderstood??...huhuhu~wrong diagnosis made...

  35. correction, the mother noticed that her daughter's eye deviate inward since she was 5 yo..diagnosis for infatile esotropia is totally wrong~

    I agree with nurhidayah1 that the vertical deviation is secondary to large horizontal deviation because after wearing the correction, the vertical deviation is almost gone..

    for azuwanmusa, patient does not has all that criteria.. remember, surgery is the last choice! :)

  36. sorry...wrong info! heeee :)

  37. based on the hess chart result, the u/a of muscle are RLR, LLR and LIR. u/a of LLR leads to o/a of RMR. This condition cause the pt has alternate ET. From the hess chart,we can conclude that the deviation is concomitant strabismus.

    It also show that, there is R hyperT.I agree with chenur and nurhidayah1 that R hyperT might be secondary to ET.



Related Posts Plugin for WordPress, Blogger...