• Management

  • Rod chromatism (poor VA and photophobia)

    • Tinted lenses (red and amber) to obtain low scotopic luminance transmittance but decreased visibility in short wavelengths

  • Acquired defects should be directed to cause

  • Inherited defects: counseling, career limitations

• Cover Test

  • Fusion: both eyes are looking at the same target at the same time

  • Alignment

    • Orthophoria (ortho): “normal”, both eyes fixate on the same spot even after you break fusion

  • Misalignment

    • Tropia (strabismus): manifest deviation of the line of sight of one eye

      • The LOS of one eye is directed toward the object and the LOS of the other eye is directed elsewhere

      • If the eye is misaligned outward it is called exotropia

        • Will move in when the other eye is covered

      • If the eye is misaligned inward it is called esotropia

        • Will move out when the other eye is covered

      • If the eye is misaligned upward it is called hypertropia

        • Will move down when the other eye is covered

      • If the eye is misaligned downward it is called hypotropia

        • Will move up when the other eye is covered

    • Patient may have symptoms such as double vision, eye strain, headaches, fatigue, and reduced stereo

    • Phoria: latent deviation of the LOS

      • Eye aligned except when fusion is disrupted

  • Bruchner: observe the red reflex from the retina with the ophthalmoscope to detect leukocoria, strabismus, or anisometropia

  • Hirschburg: use the transilluminator to find the corneal light reflex

    • To see 1 mm, patient must have 22 diopters

  • Krimsky: perform Hirschburg and line up the corneal light reflex with prism

  • Cover Test: objective test to determine the presence, amount, and direction of misalignment

    • Unilateral cover test (cover-uncover): detects tropia

    • Alternating cover test: to detect phoria and measure amount of tropia

  • Procedure

    • Unilateral

      • Distance: patient fixates on a letter that is one line larger than the best VA of the worst eye

      • Near: patient uses a fixation stick with a small accommodative target

        • Done at 40 cm or working distance

      • Important to come from the nose

      • Clinician covers OD and watches OS for movement; then covers OS and watches OD for movement

        • Presence of movement indicates strabismus or tropia

    • Alternating

      • Patient still fixates a target

      • Clinician covers OD for 2 sec, then swings cover paddle from one eye to next

      • Do NOT allow patient to view with both eyes at the same time

        • Presence of movement on alternating but not on unilateral indicates phoria

        • If there is movement on both unilateral and alternating, it is a tropia (tropia trumps a phoria)

        • If there is no movement on both unilateral and alternating, check with 4 BI and 4 BO and there should be equal and opposite movements

  • Measuring magnitude

    • Prisms deviate the image towards the apex

      • ‘Exos’ need the image sent OUT---- use base IN

      • ‘Esos’ need the image sent IN---- use base OUT

      • ‘Hypers’ need the image sent UP---- use base DOWN

      • ‘Hypos’ need the image sent DOWN---- use base UP

    • Procedure

      • Put the prism behind the cover paddle and place in front of the eye at the same time

        • For eso and exo, put prism in front of either eye

        • For hyper and hypo, put prism in front of deviated eye

      • Move occluder to other eye without allowing binocular fixation

      • Increase prism amount without allowing binocular fixation until movement stops=neutrality

      • Continue to increase amount until the direction of the movement reverses

      • Record amount of prism that resulted in neutrality before reversal

  • Recording

    • O rthophoria (lack of manifest or latent deviation)

      • Horizontally ortho

      • Vertically ortho

      • Ortho both horizontally and vertically

    • Magnitude: prism diopters

    • Direction: exo (X), eso (E), hyper, hypo*

      • Only name the hypo eye if it also has a horizontal constant tropia

    • Laterality: right (R), left (L), alternating (A)

      • Note the fixation preference

    • Frequency: constant (C) or intermittent (I)

      • If intermittent, write down percentage

    • Nature: comitant or incomitant

      • Use 9-gaze test or Park’s 3-step test

    • Also note: Testing distance, cc or sc

    • Normal: Distance 1 XP + 2 Near 3 XP + 3

  • Duane’s Classifications

    • Basic: <8 Δ difference between distance and near

    • Distance vs. Near Deviations

      • Convergence Insufficiency

        • Exo at near > distance

      • Convergence Excess

        • Eso at near > distance

      • Divergence Insufficiency

        • Eso at distance > near

      • Divergence Excess

        • Exo at distance > near

• Blood Pressure

  • Important to do routine bp measurements:

    • Elevated blood pressure increase the risk of coronary heart disease, stroke, and kidney failure

    • “Silent killer” since you cannot tell by the way you feel

    • Patients will often seek eye care before other health care

    • HTN can result in significant visual morbidity

  • Risk Factors for HTN

    • Smoking, high cholesterol, obesity, diabetes, age (elderly), family history, race (African-Americans), gender (male) and stress

  • Systolic pressure: ventricular contraction

  • Diastolic pressure: ventricular relaxation

  • Korotkoff Sounds

    • Phase 1: appearance of clear taping sounds (systolic)

    • Phase 2: swishing of sounds

    • Phase 3: increase clear sounds, increase intensity

    • Phase 4: abrupt muffling of sounds (diastolic I)

    • Phase 5: complete disappearance of sound (diastolic II)

    • Auscultatory gap: early, temporary disappearance of sound between phase 1 and 2 that can cause serious underestimation of systolic (or overestimation of diastolic pressure)

  • Procedure

    • Patient should be seated and relaxed with legs uncrossed

    • Patient’s arm should be slightly bent, resting on the arm rest with palm up and unrestricted baring of arm

    • Palpate for systolic pressure

      • Place cuff ~1’’ above antecubital crease

      • Palpate the radial artery at wrist using fore finger and middle finger

      • Inflate cuff to ~30mmHg above level at which the pulse disappears

      • Note reading and deflate cuff

    • Place diaphragm over brachial artery between the crease and the lower edge of the cuff

    • Inflate cuff to 30 mmHg above systolic (determined by palpation)

    • Deflate at a rate of 2-3 mmHg/sec

    • Listen for phase 1 sound (regular tapping sound)

      • Note reading: systolic pressure

    • Continue deflation and listen for phase 5 (complete disappearance of sound)

      • Note reading: diastolic pressure

    • If sounds are too weak, ask patient to open and clench fist ~10x or inflate cuff quickly

      • Repeated inflation will cause venous engorgement and decrease sounds

    • Deflate cuff and remove

    • Record: systolic/ diastolic, arm used, posture, time of day, and cuff size if other than regular

  • Sources of Error

    • Falsely High

      • Brachial artery below heart level

      • Asucultatory gap (diastolic)

      • Cuff too small

      • Anxiety or fear

      • Isolated sources: anxiety, stress, recent exertion, pain, caffeine

    • Falsely Low

      • Brachial artery above heart level

      • Asucultatory gap (systolic)

      • Cuff too large

      • Deflating too rapidly

Hypertension Classification

Pressure	Normal BP	Pre-hypertension	Stage I	Stage II
Systolic Diastolic	< 120 < 80	120-139 80-89	140-159 90-99	> 160 > 100

Referral Guidelines

Initial Screening Blood Pressure (mmHg)
Systolic	Diastolic	Follow-Up Recommended
<130	<85	Recheck in 2 yrs
130-139	85-89	Recheck in 1 yr
140-159	90-99	Confirm within 2 months
160-179	100-109	Evaluate or refer to source of care within 1mo
180-209	110-119	Evaluate or refer to source of care within 1 wk
> 210	> 120	Evaluate or refer to source of care immediately