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Show OUP UNCORRECTED PROOF – REVISES, 09/24/12, NEWGEN appendix b clinical ex amination B.1 GENERA L CLINICAL EXAMINATION FORM 272 B.2 STRA BISMUS EXAMINATION FORM 276 B.3 NYSTAGMUS EXAMINATION FORM 277 B.4 CLINICAL PEARLS 277 B.5 OPHTHALMOLOGICAL MYTHS AND FACTS 279 • 11_Hertle_Appendix_B.indd 271 271 9/24/2012 9:35:24 PM OUP UNCORRECTED PROOF – REVISES, 09/24/12, NEWGEN B.1 GENERAL CLINICAL EXAMINATION FORM Outpatient Pediatric Ophthalmology Medical Record New Referring Physician: Annual Follow up Unknown Urgent PCP: Chief Complaint: HPI: Consult Unknown Time Patient in Office: (Location, Duration, Frequency, Severity, Associated Sign and Symptoms, Modifying Factors) Ocular HX: (Mark X if positive HX, -- if no HX) Cataracts Glaucoma Strabismus Visual Delay Retinopathy of Prematurity Amblyopia Nystagmus Retinal Disease Corneal Disease Refractive Error Other Review of Systems: PMH: (Mark X if positive HX, -- if no HX) Diabetes Arthritis Cancer Thyroid Cerebral Palsy Autism Hearing Deficit Hydrocephalus Craniofacial Disease Childhood Heart Condition Other (Normal mark X; Abnormal mark numerically the give description below) Medications: None (Mark X if none) Allergies: None (Mark X if none) __Constitutional (fever, wt loss/gain) __Gastrointestinal (diarrhea, constipation) __________________________ ________________________ __Neurological (siezures, headache) __EENT (infections, blurriness, deafness) __________________ ________ ________________________ __________________________ ________________________ __Musculoskeletal (weakness, pain) __Endocrine (diabetic, thyroid) __Hematologic (sickle cell, clotting) __Respiratory (couch, SOB) __________________________ ________________________ __________________________ ________________________ __Cardiovascular (palpitation, angina)__Genitourinary (frequency, stones) __Integumentary (rashes, lesions) __________________________ ________________________ __Psychiatric (depression, bipolar) Description: Family HX: (Mark X if positive HX & note patient relation, Retinal Detachment Glaucoma Lazy Eye Diabetes Childhood Cataracts Nystagmus Thyroid Cancer Other 272 • --if no HX) Social HX: (Mark X if positive HX, -- if no HX) Substance Use Sexual Activity Grade Level Guardian – Relation Sports Other CLINICA L EX A M INATION 11_Hertle_Appendix_B.indd 272 9/24/2012 9:35:24 PM OUP UNCORRECTED PROOF – REVISES, 09/24/12, NEWGEN Outpatient Pediatric Ophthalmology Medical Record Exam: (Mark X if Positive) Appropriate for ag e Developmentally Delayed Stereopsis: Worth 4 Dot: Color: Visual Field: Near Point of Covergence: Near Point of Accommodation: Fusional Amplitude: Accommodative Amplit ude: Exophthalmetry: Direct Ophthalmoscopy: Dynamic Retinoscopy: Glasses / Cooperative Uncooperative External: (Mark X if Normal) Head Posture Head/Face Brows Lids Lashes Lacrimal System Levator Function Margin Reflex Distance Distance Vision / OU Vision - Glasses / No Glasses Near Vision / Unresponsive/Sleeping IOP / Glasses / No Glasses Pupils @ HOTV Snellen Animal Single Crowd Line / Afferent Pupillary Defect________ __ Glasses/ Bifocal / No Glasses Motility: Distance Glasses Near No Glasses Bifocal Versions/Ductions: Fixation Preference OD / OS Nystagmus: Full No Glasses (Mark X if normal) Fixation Preference OD / OS Diagram: (Mark X if postive) Jerk R in R / L Jerk L in R / L Pendular Rotary Latent/ Manifest Latent Seesaw Glasses Jerk Up in Up / Down Jerk Down in Up / Down Decreases with Convergence Head Oscillation Iris Transillumination Null Position Nystagmus in Infancy and Childhood • 273 11_Hertle_Appendix_B.indd 273 9/24/2012 9:35:25 PM OUP UNCORRECTED PROOF – REVISES, 09/24/12, NEWGEN Outpatient Pediatric Ophthalmology Medical Record Refraction / Retinoscopy / Keratometry / / / / / Diagnostic Medications Given: Keratometry AutoRef MRef CRef CRet Vision Vision Vision Vision Slit Lamp Exam: / / / / OU - OU - Time: __Mydriacyl 1% __Cyclogyl 1% __Phenylephrine 2.5% __Fluress 0.25% __T etracaine 0.5% __Cyclogyl 2% __Pilocarpine 1% __Goniosoft 2.5% __Pilocarpine 2% __Atropine 1% (Mark X if used) OD / OS OD / OS OD / OS OD / OS OD / OS OD / OS OD / OS OD / OS OD / OS OD / OS Administered By: OU (Signature) OU - (Mark X if normal for each eye listed) OD OS Lids & Lashes Conjunctiva Cornea ANT Chamber Iris Lens Fundus Exam: (Mark X if normal for each eye listed) OD OS Vitreous Optic Nerve Vessels Macula/Fovea Periph. Retina Cup / Disc_______ 274 • Cup / Disc______ CLINICA L EX A M INATION 11_Hertle_Appendix_B.indd 274 9/24/2012 9:35:25 PM OUP UNCORRECTED PROOF – REVISES, 09/24/12, NEWGEN Outpatient Pediatric Ophthalmology Medical Record Impression/Diagnosis: Plan/Treatment: Follow Up: Eyeglasses Given: __ AutoRef Sphere __CRef __CRet Cylinder Axis __MRef Add/Prism OD: _________ + _________ X ________ ______________ OS: _________ + _________ X ________ ______________ Orders: Fundus Photos Optic Nerve Macula Humphrey Visual Fields 24 -2 30 -2 Visual Evoked Potentials Swee p Flash Color D -15 EUA Peripheral Screen Pattern Optical Coherence Tomography RNFL Macula Electroretinography Standard EUA CT -Scan MRI contrast without contrast Preferential Looking Tests Sensorimotor Examination Eye Movement Recording A -Scan B -Scan Letter: (Mark X for all that apply) Dictated to Referring Physician Optic Nerve 1mm 5 mm Signatures: Technician cc: Resident Physician Nystagmus in Infancy and Childhood • 275 11_Hertle_Appendix_B.indd 275 9/24/2012 9:35:25 PM OUP UNCORRECTED PROOF – REVISES, 09/24/12, NEWGEN B.2 STRABISMUS EXAMINATION FORM 276 • CLINICA L EX A M INATION 11_Hertle_Appendix_B.indd 276 9/24/2012 9:35:25 PM OUP UNCORRECTED PROOF – REVISES, 09/24/12, NEWGEN B.3 NYSTAGMUS EXAMINATION FORM .3 NYSTAGMUS EXAMINATION FORM OCULAR MOTILITY CHART Near cAdd W -4-Dot Dist____________ Near______________ Stereo______________ Saccades_______________Pursuit_______________VOR_______________ Forced Ductions_________________________________________________ Forced Generations_______________________________________________ DIST ANCE NEAR ConvergenceAmplitude __________ ________ Divergence Amplitude __________ ________ Torsion __________ ________ Accommod Amplitude __________ ________ Anomalous Head Posture __________ _________ Ocular Oscillations Characteristics: YES NO B.4 CLINICAL PEARLS Chapter 2 Following are the clinical pearls presented throughout this volume along with the chapter and section in which they appeared. 2.1. 2.6 Clinical Pearl: Based on the research of the past 50 years, the INS in all patients is directly caused by Nystagmus in Infancy and Childhood • 277 11_Hertle_Appendix_B.indd 277 9/24/2012 9:35:26 PM OUP UNCORRECTED PROOF – REVISES, 09/24/12, NEWGEN instability in smooth pursuit damping plus a variable amount of tonic imbalance in the visual-vestibular system. Thus, INS is a motor oscillation with known motor causes, making the adjective “motor” (e.g., motor nystagmus or congenital motor nystagmus) redundant. Similarly, the terms “sensory” and “idiopathic” are both incorrect and misleading. None of these terms should be used in describing INS. 2. 4 Clinical Pearl: INS therapy is not contraindicated in patients with associated visual sensory deficits; in fact, these patients have the greatest chances for significant (i.e., life-changing) improvements in their visual function. 2. 4 . 2. 2 2.1.3.1 Clinical Pearl: Patients with INS and two static (or multiple) head postures should be examined for a latent component, FMNS or APAN. 2.1. 4 .1 Clinical Pearl: Occlude the nonpreferred eye and examine the preferred eye with the head straight and gaze in primary position over at least 5–7 minutes. A regular or irregular changing oscillation intensity and/or direction indicates APAN. 2.1. 4 .1 Clinical Pearl: Patients with INS whose measured visual acuity changes from one office visit to the next may have short periods when the nystagmus stops and acuity peaks; this is an exaggerated form of APAN. 2.1.5 Clinical Pearl: Patients who (taking advantage of their null) move their heads word to word across the line while reading (even those with high acuity) may have INS with a narrow range of gaze angles where their acuity is highest. 2.1.6 Clinical Pearl: Patients with INS whose near visual acuity is greater than distant may have INS that damps with convergence. 2.1. 8 Clinical Pearl: Point out the head tremor to the patient. If it stops, the nystagmus is that of INS; if it persists, both are more likely acquired. 278 • Clinical Pearl: Contact lenses are not contraindicated in INS and can provide better acuity than spectacles in patients whose nystagmus damps with afferent stimulation. Plano soft contact lenses can be used if no refractive correction is required. Four advantages of contacts in the INS patient are better optical quality, improvement in nystagmus foveation, move with eye to utilize eccentric gaze null, and ability to decrease light sensitivity/interference via tinting or painting. Chapter 3 3. 2.3 Clinical Pearl: To distinguish between benign (non-neurologically threatening), infantile, primary-position, jerk nystagmus, and that which is neurologically threatening, first verify that there is no periodic alternation in direction and then perform bilateral, sequential, cover-uncover testing. If the cover test causes a reversal in the nystagmus direction consistent with FMNS, the nystagmus is benign (FMNS or INS with a latent component). If not, attempt to rule out INS (by history, clinical signs [see Table 2.1], and waveforms). 3. 2.3 Clinical Pearl: If the results of an alternate-cover test indicate a benign, infantile, primary-position, jerk nystagmus (i.e., it causes a reversal in the nystagmus direction consistent with FMNS or INS with a latent component), perform the test again but in far adduction of the fixating eye (e.g., far left gaze when the left eye is occluded). If the nystagmus again reverses (i.e., becomes jerk left in left gaze with left eye occluded), it is INS with a latent component. Repeat the test in adduction of the other eye fixating. If the nystagmus remains in the direction of the fixating eye, it may be either FMNS or INS with a large latent component. CLINICA L EX A M INATION 11_Hertle_Appendix_B.indd 278 9/24/2012 9:35:26 PM OUP UNCORRECTED PROOF – REVISES, 09/24/12, NEWGEN Chapter 4 4 . 2.1.3 “Cultured” Clinical Pearl: Based on the observation that head nodding is compensatory in the SNS, if further research on the eye movements of the “SN-like” nystagmus associated with brainstem gliomas demonstrates that no head nodding is exhibited by these patients, the presence of deliberate, compensatory head nodding is an indication of SNS and is benign. Chapter 5 5.1.1. 2 Clinical Pearl: When the preferred fi xating eye is kept in abduction, the nystagmus is most probably IN, not FMN. Caveat: It might still be FMN if the patient has exotropia or an angle kappa. Chapter 7 7. 2.1 Clinical Pearl: When performing simultaneous nystagmus and strabismus surgery, the procedure is determined by a combination of moving the eccentric null (straightening the head) using the preferred eye and correcting the remaining strabismus using the nonpreferred eye. 7. 2. 2 Clinical Pearl: Determination of the amounts of recession and resection needed to rotate the eyes using bilateral recession and resection of the horizontal recti (A-K procedure) may be best accomplished by dividing the total amount of surgery (indicated by the curve given in Dell’Osso and Flynn, 1979) in two and applying those equal amounts to the two antagonist muscles. B.5 OPHTHALMOLOGICAL MYTHS AND FACTS Listed next are ophthalmological myths that were prevalent in the literature and, in some cases, still taught, repeated, or even published. The factual data contradicting each are also listed. Myth: Nystagmus causes the eyes to oscillate across the intended line of regard (i.e., fixation direction). Facts: Nystagmus slow phases take the eyes away from the intended line of regard (target being fi xated) and the eyes are returned by either a foveating saccade (for pendular waveforms) or a foveating fast phase (for jerk waveforms). Myth: Extraocular muscle surgery to correct anomalous head positions does not improve the nystagmus or visual acuity. Facts: Nystagmus surgery of the extraocular muscles to center eccentric INS “nulls” not only corrects anomalous head positions but also broadens the range of gaze angles with highest acuities, may increase the peak acuity, and shortens the target acquisition time; all of which improve visual function. Myth: If there is no anomalous head position or no nystagmus damping with convergence, nothing can be done to improve the nystagmus. Facts: Improvement of INS waveforms, and therefore, visual function, is possible by the tenotomy and reattachment procedure, which broadens the range of gaze angles with highest acuities, may increase the peak acuity, and shortens the target acquisition time; all of which improve visual function. Myth: Patients with afferent visual sensory deficits and nystagmus cannot be helped by nystagmus surgery. Facts: All INS patients can profit from the therapeutic improvements in visual function resulting from the proper extraocular muscle surgery, and those with the poorest acuities may profit the most (i.e., receive the largest percent increases in the direct outcome measures affecting visual function). Myth: After surgery to correct anomalous head position by centering an eccentric nystagmus null, the null often returns at some intermediate lateral gaze angle. Facts: Eye-movement data verify that adequate surgery, determined by that data, permanently repositions an eccentric INS null to primary position. However, insufficient surgery, determined by measurement of the anomalous head position, can result in the patient using the partially centered null by adopting a head turn that is less than preoperatively. Nystagmus in Infancy and Childhood • 279 11_Hertle_Appendix_B.indd 279 9/24/2012 9:35:26 PM |
