History and Refractive Status - Clinical Binocular Vision Fall 2026

True

True or False:

Case History is an integral part of the eye exam

Can help you diagnostically as well as coming up with a treatment plan

How can case history be helpful in a vision exam?

-Complications with birth?

-Premature or Full term?

-Birthweight

-APGAR

What birth history should be asked during eye exam on patient with strabismus complaints?

-Fam Hx?

-Onset of Strabismus (Acute, chronic, congenital)

-Frequency of the Eye Turn

-Progression of the Deviation

-Previous Treatments/Success

-Symptoms

What other components of the case history is important to ask patients with strabismus during an eye exam?

-Diplopia

-HA

-Blurred vision

-Asthenopia

-Reduced depth perception

What symptoms are commonly reported by individuals with strabismus?

-Mobility problems?

-Head turn?

-Eye rubbing?

-Changes in visual behavior (no longer like reading but they used to)

What questions are important to ask patients who complain of strabismus in their pre-verbal child?

Yes

Should you gauge the patients/parents attitude towards the deviation and treatment options when a strabismus presents?

Yes

Should you ask patients if they have cosmetic concerns when strabismus presents?

-Cosmesis

-Second opinion

-Signs/Symptoms suggesting strabismus

-Complaints of visual discomfort

-Positive Fam Hx

What are common chief complaints when patients present with strabismus?

-covering one eye in bright sun

-head turns/tilts/tips

-excessive blinking/rubbing eyes

-diplopia

-asthenopia

-reduced vision

What are the signs/symptoms that can suggest strabismus and are common chief complaints?

-Monocular or binocular

-Frequency?

-Distance or near?

-Orientation of the images?

-Changes during the day or associated with fatigue?

-Anything to eliminate (turn, tip, tilt, close an eye)

-What and how was this first noticed?

-Associated signs or symptoms (dizziness, ask neurological questions)

-Gotten better or worse over time? Stable? Progressive?

-Previous hx of treatment?

When a patient complains of DOUBLE VISION, what questions must you ask the patient to get a better dx and management plan for the diplopia?

refractive error

What is a common etiological factor in strabismus and amblyopia?

Yes

Is correcting refractive error an important part of proper management of strabismus and amblyopia?

Yes

Is correcting refractive error for a patient with strabismus/amblyopia an easy step that can be completed in a primary care setting?

Yes

Does increasing amounts of astigmatism increase the odds ratio for exotopia?

>1.5D

_____ amount of astigmatism will 2.5x the chance of developing exotropia

0.25

Anisometropia of ____D can lead to a 2x greater chance of developing exotropia

Yes

Does increasing amounts of anisometropia increase the odds ratio for exotropia?

Yes

Does increasing amounts of anisometropia increase the odds ratio of esotropia?

true

True or False:

As hyperopia increases, the odds ratio for esotropia also increases

122

For a patient with a SE of +5.00 or more, there is a _____x greater chance of developing esotropia

-amblyopia

-strabismus

-preverbal children

When do we want to take objective measurements of refractive error?

objective measurements are more reliable

Which is more reliable?

Objective or subjective measurements of refractive error

-Dry Ret

-Damp Ret

-Wet (Cycloplegic) Ret

-Near (Mohindra, Dynamic) Ret

-Autorefraction

What are the OBJECTIVE ASSESSMENTS of refractive error?

-Not controlling accommodation

-Not scoping on axis

What are common sources of error in retinoscopy readings?

-Astigmatism increases with increasing eccentricity

-Spherical component decreases with increasing eccentricity

Why is scoping on axis so important?

Increases

Astigmatism (increases/decreases) with increasing eccentricity

decreases

Spherical component (increases/decreases) with increasing eccentricity

-Introduce prism over the fixating eye

-Perform retinoscopy out of the phoropter to better align yourself with the deviating eye

-Occlude eyes as needed

How to scope on axis in strabimic patients?

-Monocular (occlude the fellow eye)

-Completely dark room

-50cm

-Have patient fixate on the light

-+1.25 is subtracted from the sphere power

How to perform Mohindra Retinoscopy?

If you cannot use a cycloplegic agent on a child

When is Mohindra Retinoscopy useful?

modified

We use _____ MEM to assess refractive error

-50cm

-Grab attention of the child

-Child will be looking at you

-Neutralize the reflex with loose lenses or a lens bar

-DO NOT TAKE OUT WORKING DISTANCE

How to perform modified MEM to assess refractive error?

anti-cholinergics

Cycloplegic agents are _________

Block ACh (inhibit parasympathetic nerve impulses)

What is the function of anti-cholinergics?

-Flushed skin

-Confusion/irritability

-Dry mouth and mucous membranes

-Mydriasis and decreased accommodation

What are the side effects of the anti-cholinergics?

-Tropicamide

-Cyclopentolate

-Atropine

What cycloplegic agents can we use for a wet retinoscopy?

4-6 hours

What is the DOA of Tropicamide?

Up to 24 hours

What is the DOA of Cyclopentolate?

7+ days

What is the DOA of Atropine?

3-6hours

When is ma cycloplegia of atropine?

Atropine

Side effects are most common with which anti-cholinergic agent

1%

What is the dosage of cyclopentolate to use in children >1 yo?

0.5%

What is the dosage of cyclopentolate to use in children

No -- need phenyl or tropicamide

Does cyclopentolate provide the needed mydraisis for DFE?

30 min

How long after instillation of cyclopentolate before you can check refractive status?

-Strabismus

-Amblyopia

-Hyperopes

-Latent hyperopia suspect

-High esophoria

-Lag of accommodation

-VA problems

-Symptoms inconsistent with manifest RE

-Uncooperative or non-cooperative

-New patients

When should you use cycloplegic agents to check refractive status?

Yes

Does tropicamide do an adequate job esp when determining refractive error?

2 drops seperated by 5 min

Many studies suggest ___ drops of tropicamide are equal to cyclopentolate

true

True or False:

Young children can be poor responders to subjective refraction

larger

Amblyopic patients may have a (smaller/larger) just noticeable difference than typical 0.25D used in subjective refraction

true

True or False:

The identification and treatment of RE is very important to initial dx and management of strabismus and amblyopia