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 -  Checklist for extraocular muscle imbalance Lecture of 0  NEXT»

This is a checklist to go through when examining a patient with a suspected extraocular muscle imbalance. The examination steps printed in bold letters are essential for every work-up and must be included in the material sent to the telementor. It is not necessary to do each part of this examination in every patient and the doctor should use his/her judgement in deciding which part of the examination is applicable to the case under discussion.

y Chief complaint:
Why did the patient come to the doctor's office or why did the parent(s) bring the child?

y Present illness:
Age of onset of the condition?
Describe symptoms and the patient complaints about his/her own or, in the case of a child, the parent's observations regarding the condition in terms of frequency, duration, precipitating factors, etc.
In case of an older child or adult, to what extent does the condition interfere with school, work, play, etc.?

y Past history:
List previous treatment including surgery, glasses, etc.

y General health:

y Family history:
Pertaining to the ocular condition

y Inspection:
Palpebral fissures?
exo- or enophthalmos?
epicanthal folds?
Anomalous head posture?
Facial asymmetry?
in cases of cyclovertical paralyses
in craniostenoses

Fixation preference?
unilateral, which eye?
Constancy of the deviation?

y Present glasses:


y Date of last cycloplegic refraction:

y Best corrected visual acuity:

y Prism cover test in primary position:
(indicate whether with or without glasses)



y Prism cover test in diagnostic positions:
An instrument such as this deviometer can be used to control the point of fixation resulting in more reproducable findings.

Image01021 Image01022

Examiner's view of the patient deviation is recorded like this

In cases of suspected cyclovertical muscle paralyses include the prism cover test with the head tilted to the right and left shoulder (Bielschowsky head tilt test)

head tilt

Right tilt Left tilt

Record vertical deviation with head tilted toward the right shoulder:
Record vertical deviation with head tilted toward left shoulder:

In the example shown above, the hyperdeviation is greater with the head tilted toward the right shoulder which would be a positive Bielschowsky test with right head tilt indicating the likelihood of a right superior oblique palsy.

y List apparently overacting or underacting muscles:

y Maddox rod test for cyclotropia:

y Sensory status:

limited to certain directions of gaze?
crossed, uncrossed, torsional, paradoxical?
Anomalous retinal correspondence?

y Fundus examination through dilated pupil:
Ex- or incyclotorsion on indirect ophthalmoscopy?

Gunter K. von Noorden, M.D.

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