J.W. Global Hospital & Research Centre, Mount Abu

Global Hospital & Institute Of Ophthalmology, Abu Road

Strabismus Clinic

Patient Name ………………………………………….Age……Sex M / F

Father’s Name………………………………………………………………

Address……………………………………………………………………..

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Phone no ……………………………………………………………………...

CRN…………………………..IRN…………………………….. ………

Consultant………………………………………………………………….

Infantile Esotropia, Basic Esotropia, Accommodative Esotropia (Refractive, Partial Refractive, NonReftractive, Mixed), Microtropia, Secondry Esotropia (Residual, Consecutive), Esophopria

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Basic Exotropia, Infantile Isotropic, Intermittent (Basic, True Divergence Excess, Simulated Divergence Excess, High AC/ A Ratio), Secondary Exotropia (Residual, Consecutive), Sensory Exotropia, Exophopria

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Hypertropia R/L , Hypertropia L/ R ,

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Patterns A, V, X, Delta

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Superior Oblique Normal /Over Action /Under Action

Inferior Oblique Normal /Over Action /Under Action

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DVD Right Eye/ Left Eye / Both Eyes

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Amblyopia Eye/ Left Eye / Both Eyes

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DRS 1; 2; 3, Brown Syndrome, Double Elevator Plasy

Third Nerve Palsy, Forth Nerve Palsy, Sixth Nerve Palsy

History

1. Age of onset

2. Whether constant or intermittent?

3. Whether Diplopia present?

4. Drug Allergy Page1

Right Eye / Left Eye
Vision Unaided / Power of Glasses
RE
LE
Add
Vision Corrected
Cycloplegic Refraction / Under Atro / Homatro/ Cyclopent
Near Point of Convergence
Near Point of Accommodation
IPD

Motor Examination

Head Posture

Movements - Normal / Restricted

Inferior Obligue -Normal / Over Action / Under Action

Superior Obligue -Normal / Over Action / Under Action

Nystagmus

Orthoptic Examination
Fixation / RE/ LE / Alternate / Eccentric
Moddox Wing(Near)
Moddox Rod ( 6 Mtr +PBCT)
Prism Bar Cover Test (PBCT)
PBCT For Distance
PBCT For Near
PBCT For Near With + 3.0 D
PBCT In Nine Positions of Gaze
AC/ A Ratio (Gradient Method) Normal / High / Low
Fusional Amplitude / Convergence
Divergence
Steriopsis / Distance
Near

Sensory Examination

Worth’s Four Dot Test BSV / RE Suppression / RE Suppression / Diplopia / ARC

Baggloini’s Test BSV / RE Suppression / RE Suppression / ARC

Randot Dot Steroacuity

Page 2

Anterior Segment:

Posterior Segment:

Force Duction Test

Force Generation Test

Management

1. Glasses

2. Orthoptic

3. Surgical

Anesthesia LA/ GA

Right Eye / Left Eye
Medial Rectus Recession ……………
Medial Rectus Resection ……………
Lateral Rectus Recession ……………
Lateral Rectus Resection … / Medial Rectus Recession ……………
Medial Rectus Resection ……………
Lateral Rectus Recession ……………
Lateral Rectus Resection …
Inferior Oblique Recession / Inferior Oblique Recession
Superior Oblique Weakning / Superior Oblique Weakning