Presented By:Tehseen JavaidMuhammad Amin

1. CONCOMITANCE / INCOMITANCE

2. ABNORMAL HEAD POSTURE

3. HESS CHART

DEFINITIONS

CONCOMITANT DEVIATION:

Angle of deviation remain same in all directions of gaze and there is no limitation of ocular movements.

INCOMITANT DEVIATION:

Angle of deviation varies in different position of gazes and there is limitation of ocular movements.

Secondary angle of deviation is greater than primary deviation

DIFFERENCIAL CRITERIA COMITANT DEVIATION INCOMITANT DEVIATION

OCCURANCE More common Less common

ONSET Usually congenital Usually acquired

DEVIATION Primary angle is equal to secondary angle

Secondary greater than primary angle

MOVEMENT No limitation Limitation

AHP None Present

DIPLOPIA None Amblyopia

CAUSE Hereditary

Uncorrected refractive error

Usually injuryVascular diseases

DEPTH PERSCEPTION None due to suppression

Present when do AHP

INCOMITANT DEVIATION

NEUROGENIC MYOGENICMECHANICAL

3RD NERVE PALSY6TH NERVE PALSY4TH NERVE PALSYDOUBLE ELEVATOR PALSY DOUBLE DEPRESSIVE PALSY

Myasthenia gravis Chronic

Progressive External Ophthalmoplegia

Orbital myositis

Brown syndromeDuane syndromeOrbital injuryThyroid eye disease

INVESTIGATION CONGENITAL ACQUIRED

PRESENTATION Unacceptablecosmetic appearance symptoms of decompensation,Unaware of AHP.

Diplopia and occasionally pain

OCULAR MOTILITY Often full muscle sequlae

Muscle sequlae not fully developed

DURATION Longstanding Recent

BINOCULARFUNCTION

Extended vertical fusion range

Normal fusion range

ABNORMAL HEAD POSTURE:

AHP is a motor adaptation and it is adapted in the

interest of comfortable vision

COMPONENTS OF AHP:

Face turn towards right or left side

Chin up or down

Head tilt towards right or left shoulder

ASSESMENT OF AHP:

Compare ear is more visible

Check whether eyes are level

Observe chin from side

CAUSES OF AHP:

OCULAR CAUSES•Obtain BSV•Maintain BSV•Overcome symptoms•Improve visual acuity•Protect eyes•Separate diplopia in paralytic strabismus•Nystagmus

NON OCULAR CAUSES:•Shyness•Habit•Deafness•Mental developmental delay•Arthritic condition•Non ocular torticollis(Contracture of

Sterno- mastoid muscle.

How to confirm either AHP is ocular or non ocular?

EXAMINATION OF COMPONENTS OF AHP

FACE TURN:

CHIN ELEVATION OR DEPRESSION

HEAD TILT

AHP IN PARALYTIC CONDITIONS:NEUROGENIC PALSIES:

3rd nerve palsy

Complete

Incomplete(divisional or isolated)

4th nerve palsy

6th nerve palsy

MECHANICAL PALSIES:

Brown syndrome

Duane’s syndrome

AV PATTERNS:

A eso or V exo

A exo or V eso

NYSTAGMUS:

1:Dissociation of the eyes by either :

• Red and green goggles in case of hess

• The mirror in case of lees screen

2:Foveal projection inn the presence of normal retinal correspondence :

3:Herring’s law and sherrington’s law:

• Explain the development of muscle sequlae.

1:Diagnosis of:

U/a or o/a of eom.

Mechanical or neurogenic palsy

Congenital/long standing

Acquired/recent palsy

2:planning of surgery and post-op effects of surgery

3:Monitoring of surgery

Full muscle sequlae will include :

E.g :sr u/a = io o/a

:Ir o/a = so u/a

What is the direction of the deviation eg: Eso, exo, hyper, hypo?

What is the size of the deviation?

Is the deviation concomitant or incomitant ?

Is there a smaller field ?

Which is the affected muscle(s) or nerve(s) ?

Has the muscle sequelae spread to produce concomitance ?

Is the aetiology mechanical or neurogenic ?

Is there an a or v pattern ?