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BINOCULAR VISION | PEDS | REFRACTIVE

Binocular Condition
Condition Cover Test NPC Vergence Facility Vergence Amplitude Accommodative Amplitude Binocular Acc. Facility Monocular Acc. Facility NRA/PRA MEM
Basic Exophoria Exo | D=N WNL Low BO @ D&N Low BO @ D&N WNL Fails (+) WNL Low NRA Low
Basic Esophoria Eso | D=N WNL Low BI @ D&N Low BI @ D&N WNL Fails (-) WNL Low PRA High
Convergence Insufficiency (CI) Exo, >N Receded Low BO Low BO WNL Fails (+) WNL Low NRA Low
Convergence Excess (CE) Eso, >N WNL Low BI WNL WNL Fails (-) WNL Low PRA High
Divergence Insufficiency Eso, >D WNL Low BI @ D WNL WNL WNL WNL WNL WNL
Divergence Excess Exo, >D WNL Low BO @ D Low BO @ D WNL WNL WNL WNL WNL
Accommodative Insufficiency No Pattern WNL WNL WNL Low Fails (-) Fails (-) Low PRA High
Fusional Vergence Dysfunction Low Eso or Exo WNL Low BI & BO WNL WNL Fails (+) & (-) WNL Low NRA/PRA WNL
TEST EXPECTED VALUES
Near Cover Test Ortho - 6XP
NPC 5/7cm Near 7/10cm Distance
Vergence Facility 3BI/12BO 15 cycles/min
Positive Fusional Vergence 17/21/11
Negative Fusional Vergence 13/21/13
Positive Fusional Reserve (Blur/Break/Recovery) 7-11 / 15-23 / 8-12 △
Negative Fusional Reserve (Blur/Break/Recovery) x / 5-9 / 3-5 △
Amplitude of Accomodation Minimum: 15 - (1/4)Age
Lag of Accomodation +0.25 to +0.75
Positive Relative Accomodation -2.37 (+/-1.00)
Negative Relative Accomodation +2.00 (+/-0.50)
ACA 4/1 △
Potential Amblyogenic Factors
ISOametropia Astigmatism > -2.50DC
Hyperopia > +5.00DS
Myopia > -8.00DS
ANISOametropia Astigmatism > -1.50DC
Hyperopia > +1.00DS
Myopia > -3.00DS
When to Consider Prescribing | What to Prescribe
Age Refractive Error Prescription
Hyperopia
4yo & Up > +2.50DS Undercorrect by +1.00 to +1.50DS (Full RX for Esotropia)
School-Age (5yo & up) ≥ +1.50 DS | ≥+1.00 can impact VA, while ≥1.50 can be associated with accomodative lag Full or Partial RX (Full RX for ESOTropia)
Myopia
Preschool (2-3 yo) ≥ -1.00DS Full RX
Astigmatism
3.5yo and up All types ≥ -1.50DC Full Cyl RX
5yo and up All types ≥ 0.70DC Full Cyl RX
Anisometropia
3.5yo and up ≥ 1.00DS Hyperopic Aniso RX Full Aniso
≥ 2.00DS Myopic Aniso RX Full Aniso
Associated Ambylopia Correct the Full anisometropia regardless of age
Accomodation
Amplitudes
Push-up (monocular) | Hofstetter Formula Minimum Ampltitudes (D) ≥ - ¼ (age)
Relative Accomodation
NRA | +2.00 ± 0.50D Significant if < +1.50D
PRA | -2.37 ± 1.00D Significant if < -1.50D
Dynamic Accommodation: Monocular Estimate Method
MEM: +0.33 (± 0.35D) Significant if lag > +0.75D (if large lag, r/o latent hyperopia) | Significant if there is any LEAD
Vergence
Ocular Alignment (Phoria) Distance: 1XP (±2) | Near: 3XP' (±3)
Near Point of Convergence (NPC) Significant if > 6cm to break | Recovery within 4cm of break
Fusional Vergence
Smooth (Risley): PFV 6m (Distance): 9 (±4)/ 19 (±8)/ 9 (±4)
40cm (Near): 17 (±5)/ 21 (±6)/ 11 (±7)
Smooth (Risley): NFV 6m (Distance): x / 7 (±3)/ 4 (±2)
40cm (Near): 13 (±4)/ 21 (±4)/ 13 (±5)
Step (Prism Bar) PFV 40cm (near): 23 (±8)/ 16 (±6)
Step (Prism Bar) NFV 40cm (near): 12 (±5)/ 7 (±4)
Sensory
Stereo (Randon Dot) Significant if > 500" RDS
Stereo (Lateral Disparity) Significant if > 60"
Suppression (Worth 4 Dot) Significant if suppression or diplopia occurs
Duane Retraction Syndrome
Type 1 Esotropia in primary gaze with a compensatory head turn to the involved side
Type 2 Exotropia in primary gaze with a compensatory head turn to the uninvolved side
Type 3 Either an esotropia or exotropia in primary gaze, and will have a compensatory head turn to the involved side. The ability to adduct in this type is absent to restricted as compared to normal to mildly restricted in types 1 and 2
Count the D’s | Type 1: abDuction affected | Type 2: aDDuction affected | Type 3: abDuction and aDDuction affected
Hirschberg Test (Peds)
Light Reflex Position | Symmetric Normal
Light Reflex Position | Nasal Exotropia
Light Reflex Position | Temporal Esotropia
1mm light reflex deviation = 7° = 15∆
Spectacle Reading Add by Age | Estimate
AGE (years) ADD (diopters)
40-44 +1.00 to +1.50
45-49 +1.50 to +2.00
50-54 +2.00 to +2.25
55-59 +2.25 to +2.50
60+ +2.50 and greater
Lens Materials
Material Abbe Value Refractive Index
Glass 58.6 1.523
CR-39 58 1.498
Trivex 44 1.532
High Index 1.74 33 1.740
Polycarbonate 30 1.586
Color Vision
Color Deficiency Cone Defect Color Issue Color Perception
Protanope Missing L Cone Confuses RED, ORANGE, YELLOW, GREEN See Reddish Hues as "Very Dim"
Deuteranope Missing M Cone Confuses RED, ORANGE, YELLOW, GREEN NO Dimming of RED
Tritanope Missing S Cone Confuses BLUE & YELLOW
Protanamalous Trichromat L Cone is shifted to shorter wavelenght RED, ORANGE, GREEN all look similar Red-Weak | Red may be dimmer
Deuteranomalous Trichromat M Cone is shifted to longer wavelenght RED, ORANGE, GREEN all look similar GREEN-weak
Kollner's Rule for Disease
Outer Retina | OPL, Receptors, RPE, Ocular Media BLUE-YELLOW Defects Exceptions: Glaucoma, papilledema
Inner Retina | Ganglion Cell Layer, Optic Nerve, Visual Pathways RED-GREEN Defects Exceptions: Dominant cystoid macular dystrophy, Stargardt's
Type of Color Tests Able to Detect RED/GREEN defect Able to Detect BLUE/YELLOW defect Dicromats vs Anomalous Trichromates
Ishihara YES
HRR YES YES
Farnsworth D-15 YES YES
Nagal Anomaloscope YES YES

DRY EYES

Tear Breakup Time (TBUT)
Result TBUT
Normal ≥ 10 seconds
Abnormal < 10 seconds
Schirmer's Tear Test
Type Strip Wet Length
I (without anesthesia) ≥ 15mm
II (with anesthesia) > 10mm
Phenyl Red Thread
Dry Eye Status Wet length
Severe Dry Eye <10mm
Borderline Dry Eye ≤ 19mm
Normal >20 mm

  • DEWS II Treatment and Management Guide

    Step 1:

    • Education regarding the condition, its management, treatment and prognosis
    • Modification of local environment
    • Education regarding potential dietary modifications (including oral essential fatty acid supplementation)
    • Identification and potential modification/elimination of offending systemic and topical medications
    • Ocular lubricants of various types (if MGD is present, then consider lipid-containing supplements)
    • Lid hygiene and warm compresses of various types

  • Step 2: If above options are inadequate consider:

    • Non-preserved ocular lubricants to minimize preservative-induced toxicity
    • Tea tree oil treatment for Demodex (if present)
    • Tear conservation
    • Punctal occlusion
    • Moisture chamber spectacles/goggles
    • Overnight treatments (such as ointment or moisture chamber devices)
    • In-office, physical heating and expression of the meibomian glands (including device-assisted therapies, such as LipiFlow)
    • In-office intense pulsed light therapy for MGD
    • Prescription drugs to manage DED
    • Topical antibiotic or antibiotic/steroid combination applied to the lid margins for anterior blepharitis (if present)
    • Topical corticosteroid (limited-duration)
    • Topical secretagogues
    • Topical non-glucocorticoid immunomodulatory drugs (such as cyclosporine)
    • Topical LFA-1 antagonist drugs (such as lifitegrast)
    • Oral macrolide or tetracycline antibiotics

  • Step 3: If above options are inadequate consider:

    • Oral secretagogues
    • Autologous/allogeneic serum eye drops
    • Therapeutic contact lens options
    • Soft bandage lenses
    • Rigid scleral lenses

  • Step 4: If above options are inadequate consider:

    • Topical corticosteroid for longer duration
    • Amniotic membrane grafts
    • Surgical punctal occlusion
    • Other surgical approaches (eg tarsorrhaphy, salivary gland transplantation)
Tear Osmolarity
Dry Eye Status Osmolarity
Normal <308 mOsm/L, or an inter-eye difference of <8 mOsm/L
Abnormal >308 mOsm/L, or an inter-eye difference of >8 mOsm/L
Inflammatory Dry Eye
Test Result Indication MMP-9 Level
Red Strip + Blue Strip Positive MMP-9 ≥ 40 ng/ml
Blue Strip Negative MMP-9 ≤ 40 ng/ml

ANTERIOR SEGMENT

LASIK / PRK CRITERIA
Factors Criteria
Age | Stability Age 18 years or older
Stable refraction of at least one year’s duration
Refractive Error Myopia ≤ -12.00 diopters
Astigmatism ≤ 5.00 diopters
Hyperopia ≤ +6.00 diopters
Ocular contraindications | Warnings Keratoconus | Herpetic keratitis | Corneal dystrophy or degeneration | Cataract |Glaucoma | Corneal Scarring | Lagophthalmos | Severe dry eye | Severe Blepharitis | Uveitis
Medical Contraindications | Warnings Diabetes mellitus | History of keloids |Pregnancy or lactation | Autoimmune disease | Immunosuppression or immunocompromised status
Van Herick Angle Grading System
Angle Grade Anterior Chamber Depth as a Fraction of Corneal Thickness
1 < 1/4
2 = 1/4
3 > 1/4 to < 1/2
4 ≥ 1
Implantable Collamer Lens (ICL) Criteria
Type of ICL Criteria | indicated for adults 21-45 years of age
Visian ICL To correct myopia ranging from -3.0 diopters to -15.0 diopters with less than or equal to 2.5 diopters of astigmatism at the spectacle plane
To reduce myopia ranging from greater than -15.0 diopters to -20.0 diopters with less than or equal to 2.5 diopters of astigmatism at the spectacle plane
Anterior chamber depth (ACD) 3.00 mm or greater is required for implantation.
Stable refractive history within 0.5 diopter for 1 year is required prior to implantation.
Visian Toric ICL For the correction of myopic astigmatism with spherical equivalent ranging from -3.0D to ≤ -15.0D (in the spectacle plane) with cylinder (spectacle plane) of 1.0D to 4.0D.
For the reduction of myopic astigmatism with spherical equivalent ranging from greater than -15.0D to -20.0D (in the spectacle plane) with cylinder (spectacle plane) 1.0D to 4.0D.
With an anterior chamber depth of 3.00 mm or greater, when measured from the corneal endothelium to the anterior surface of the crystalline lens
A stable refractive history (within 0.5D for both spherical equivalent and cylinder for 1 year prior to implantation)
The Visian TICL is intended for placement in the posterior chamber (ciliary sulcus) of the phakic eye.
Contraindications
Anterior chamber depth < 3.00 mm
Anterior chamber angle less than grade II determined by gonioscopic examination
Pregnancy or nursing
Not meeting appropriate endothelial cell density as determined by an age-dependent minimum (range 1900- 3875 cells/mm2)
Pregnancy or nursing

  • CORNEAL ENDOTHELIAL SURGERIES

    Corneal Procedure | Brief Description

  • DMEK

    Descemet’s Membrane Endothelial Keratoplasty | Corneal transplant consisting of Descemet’s membrane and endothelium.

  • DSEK / DSAEK

    Descemet’s Stripping Endothelial Keratoplasty | Corneal transplant consisting of posterior stroma, Descemet’s membrane and endothelium.

    Note:  DSAEK is the Automated, microkeratome-assisted version of DSEK 

  • DWEK / DSO

    Descemetorhexis Without Endothelial Keratoplasty

    • Also referred to as Descemet’s Stripping Only

    Technically not a corneal transplant. Rather, centrally located compromised endothelial cells are removed so that “healthy” peripheral cells can migrate centrally

  • PKP (PK)

    Penetrating Keratoplasty | Full thickness corneal transplant

Scheie Gonioscopy Grading System
Angle Grade Visible Structures
I Iris root NOT visible
II Ciliary body NOT visible
III Posterior trabecular meshwork (PTM) NOT visible
IV No visible angle structures
Shaffer Gonioscopy Grading System
Angle Grade Degree Width Interpretation
4 45°-35° Wide open
3 35°-20° Wide open
2 20° Narrow
1 ≤10° Extremely narrow
0 0° Angle closed in part or all of circumference
Anterior Chamber Cell/Flare
Grade Cell Flare
0.5+ 1-5 cells None
1+ 6-15 cells Faint
2+ 16-25 cells Moderate (iris and lens details clear)
3+ 26-50 cells Marked (iris and lens details hazy)
4+ >50 cells Intense (fibrin or plasmoid aqueous)
Use 1×1 mm slit beam
Spaeth Gonioscopy Grading System
Iris Insertion A – Anterior to Schwalbe’s line
B – Between Schwalbe’s line and scleral spur
C – sCleral spur visible
D – Deep, ciliary body visible
E – Extremely deep, >1 mm of ciliary body visible
Angular Approach 0° to 50°
Peripheral Iris R– Regular | F- Flat
S – Steep
C – Concave
B – Bowed anteriorly
P – Plateau
Pigmentation
0 | None
1+ | Just visible
2+ | Mild
3+ | Moderate
4+ | Dense
Causes of Whorl Keratopathy
Drug Causes CHAIR-T
C-Chloroquine
H-Hydroxychloroquine
A- Amiodarone
I-Indomethacin
R-Rhopressa
T-Tamoxifen
Systemic Causes Fabry Disease
Keratoconus Associations
Keratoconus systemic Associations T-DOME
T-Turner Syndrome
D-Down Syndrome
O- Osteogenesis Imperfecta
M-Marfan Syndrome
E- Ehlers-Danlos Syndrome

POSTERIOR SEGMENT

Fundus Lens Correction Factor
Fundus Lens Correction Factor
60 D 1x
78 D 1.1x
90 D 1.3x
Superfield 1.5x
To correct for lens magnification | When assessing vertical disc diameter, the size measured at the slit lamp should be multiplied by the appropriate correction factor according to the fundus lens.
Age-Related Macular Degeneration (AMD)
Stage Findings
Early (1) Numerous small drusen (<63 microns, “hard”) OR
(2) Intermediate drusen (≥63 microns but <125 microns, “soft”)
Intermediate (1) Many small or intermediate drusen OR
(2) Any drusen of large size (≥125 microns)
Advanced Wet AMD or center involving geographic atrophy or CNVM (Wet ARMD)
NOTE | 124 micron is the average diameter of retinal vein at the optic disc margin
Macular Holes (MH)
Stage Signs
1 Impending macular hole, loss of foveal depression
Stage 1A | Loss of the foveal contour and a lipofuscin-colored spot
Stage 1B | Characterized by a lipofuscin-colored ring
2 Full thickness break < 400µm in size
3 Full thickness break ≥ 400 µm in size
4 Stage 3 Macular Hole with a complete posterior vitreous detachment
Central Serous Chorioretinopathy (CSCR) vs. Pigment Epithelial Detachment (PED
CSCR PED
Neurosensory detachment Serous fluid BELOW the RPE
Serous fluid ABOVE the RPE
Neovascularization Classification
Type Anatomical Location
Type 1 CNVM (occult) Sub-RPE CNVM
Type 2 CNVM (classic) Subretinal CNVM (superficial to the RPE)
Type 3 (RAP) Neovascularization that develops within the neurosensory retina an progresses posteriorly into the subretinal space
Known as retinal angiomatous proliferation
Nonproliferative diabetic retinopathy (NPDR) Proliferative diabetic retinopathy (PDR)
Stage Findings Stage Signs
No DR No findings of DR Mild PDR NVD | NVE | Vitreous Hemorrhage
Mild Microaneurysms only High-risk PDR NVD > ⅓ disc area | Any NVD with vitreous hemorrhage | NVE > ½ disc area with vitreous hemorrhage
Moderate Microaneurysms and dot-blot hemorrhages in 1-3 quadrants | Venous beading ≤ 1 quadrant | No IRMA
Severe 4-2-1 Rule: Micro-aneurysms and dot-blot hemorrhage in 4 quadrants | OR | Venous beading in 2 quadrants | OR | IRMA in 1 quadrant
Proliferative diabetic retinopathy (PDR)
Stage Signs
Mild PDR NVD | NVE | Vitreous hemorrhage
High-risk PDR NVD > ⅓ disc area | Any NVD with vitreous hemorrhage | NVE > ½ disc area with vitreous hemorrhage
Clinically Significant Macular Edema (CSME)
CSME (1) Retinal thickening within 500 microns of the foveal center AND/OR
(2) Hard exudates within 500 microns of the foveal center and with adjacent retinal thickening AND/OR
(3) Retinal thickening at least one disc diameter in size, part of which is within one disc diameter of the foveal center
Hypertension Retinopathy Grading System (Based on the Keith-Wagner-Barker classification)
Grade Signs
1 Mild, generalized constriction of retinal arterioles
2 Definite focal narrowing of retinal arterioles PLUS AV nicking
3 Grade 2 PLUS flame-shaped hemorrhages PLUS cotton-wool spots PLUS hard exudates
4 Severe Grade 3 retinopathy PLUS papilledema or retinal edema

  • Choroidal Melanoma Mnemonic

    TFSOM-DIM | To Find Small Ocular Melanoma Doing IMaging

  • T

    Thickness >2mm

  • F

    Fluid (Subretinal)

  • S

    Symptoms

  • O

    Orange pigment

  • M

    Melanoma hollow on ultrasound

  • DIM

    DIaMeter >5 mm on fundus photography

  • Angioid Streaks Mnemonic

    PEPSI-HAM

  • P

    Pseudoxanthoma elasticum

  • E

    Ehlers-Danlos syndrome

    Newer research suggests that angioid streaks may not be associated with Ehlers-Danlos Syndrome 

  • P

    Paget's disease

  • S

    Sickle cell anemia or other hemoglobinopathy

  • I

    Idiopathic

  • H

    Homocystinuria

  • A

    Acromegaly

  • M

    Marfan syndrome

OPTICE NERVE | NEURO

Papilledema
Grade Severity Findings
1 Very early Blurring of nasal disc margin, normal temporal disc margin
2 Early Obscuration of all borders. Elevation of the nasal border. Complete peripapillary halo
3 Moderate Obscurations of all borders. Increased diameter of optic nerve head. Obscuration of one or more segments of major blood vessels leaving the disc. Peripapillary halo-irregular outer fringe with finger-like extensions.
4 Marked Elevation of the entire nerve head. Obscuration of all borders. Peripapillary halo. Total obscuration on the disc of a segment of a major blood vessel.
5 Severe Dome-shaped protrusions representing anterior expansion of the optic nerve head. Peripapillary halo is narrow and smoothly demarcated. Total obscuration of a segment of a major blood vessel may or may not be present. Obliteration of the optic cup.
Brain Lobe Lesions w/ Associated VF Defect | P.I.T.S
Brain Lobe Lesion Visual Field Defect
P- Parietal lobe I-Inferior VF defect
T-Temporal lobe S-Superior VF defect
APD (afferent pupillary defect)
Grade Pupil Response
1+ Weak initial constriction followed by greater redilation
2+ Initial pupillary stall followed by greater redilation
3+ Immediate pupillary dilation
4+ No reaction to light
Glaucoma Grading Scale
Stage Findings
Mild or Early Optic nerve abnormalities consistent with glaucoma but NO visual field abnormalities on any visual field test.
OR abnormalities present only on short-wavelength automated perimetry or frequency doubling perimetry
Moderate Optic nerve abnormalities consistent with glaucoma AND visual field abnormalities in ONE hemifield and NOT within 5 degrees of fixation.
Advanced, Late, Severe Stage Optic nerve abnormalities consistent with glaucoma AND glaucomatous visual field abnormalities in BOTH hemifields AND/OR loss within 5 degrees of fixation in at least one hemifield
Classic Thyroid Eye Disease (TED) Signs
Class Findings (NO SPECS)
0 No physical signs or symptoms
1 Only signs, no symptoms
2 Soft tissue involvement
3 Proptosis
4 Extraocular muscle involvement
5 Corneal involvement
6 Sight loss (optic nerve involvement)
Cranial Nerves
Nerve Origination Purpose Innervation
I - Olfactory Cerebrum Olfaction/Smell Sensory
II - Optic Cerebrum Vision Sensory
III - Oculomotor Midbrain Eye Movement, Pupillary Constriction, Accommodation Motor
Divisions: Superior/Inferior
IV - Trochlear Midbrain Eye Movement with Superior Oblique Motor
V - Trigeminal Pons Corneal & Facial Sensation, Mastication Sensory & Motor
Branches: V1-Ophthalmic, V2-Maxillary, V3-Mandibular
VI - Abducens Pontomedullary Region Eye Movement with Lateral Rectus Motor
VII - Facial Pontomedullary Region Facial Expression, Taste, Anterior 2/3 of Tongue, Lacrimation, Salivation Sensory & Motor
Braches: Posterior Auricular, Temporal, Zygomatic, Buccal, Mandibular, Cervical
VIII - Vestibulocochlear Pontomedullary Region Hearing, Equilibrium Sensory
IX - Glossopharyngeal Medulla Oblongata Taste, Posterior 1/3 of Tongue, Swallowing, Salivation, Sensory Information from Carotid Sinus Sensory & Motor
X - Vagus Medulla Oblongata Taste, Swallowing, Palate Elevation, Speech, Slowing Heart Rate Sensory & Motor
XI - Accessory Medulla Oblongata & Cervical Spinal Cord Head Turning, Shoulder Shrugging Motor
XII - Hypoglossal Medulla Oblongata Tongue Movement Motor