Good Hope, Heartlands, and Solihull Eye Clinics

Orthoptic Department

Kathryn Coulthard

The Orthoptic Department

The department treats conditions such as squint, double vision, and lazy eyes.

If a child or adult has a squint, double vision, or specific types of reduced vision or abnormal eye co-ordination, they will be assessed by the Orthoptist. The aim of orthoptic tests is to:

  • establish if there is a squint and type of squint is present
  • assess vision
  • test the ability to use the eyes together (binocular vision)
  • carry out and monitor treatment for lazy eye and squint


Children may be seen at their local Health Centre or Nursery School or School. This service varies across the country, but a child's G.P., Health Visitor or School Nurse, will be able to advise on the local service available. Children seen in the hospital are referred by their G.P. or other medical personnel.

Adults are seen in a hospital setting and will be referred by their G.P. or other medical personnel.


What is a squint?

Helpful article  A squint is the condition when the right and left eye look in different directions. So, while one eye seems to look straight ahead, the other will appear to look left or right, or up or down see.

a squint...each eye looks in a dfferent direction

a squint...each eye looks in a different direction


Lazy eye (amblyopia)

Visual development occurs rapidly in the early years of life and continues until approximately 7 - 8 years of age.

If the back of the eye and the brain do not receive a clear focused image during this time of visual development, vision will be reduced. Hence the term 'lazy eye'. If treatment is not given before age 7-8y, the affected eye will never see perfectly. See However, many older children do benefit from treatment Arch 11.

See links


Acute onset diplopia, for professionals

  • AO 14 ;  in children Eye 19 ;   Adults  Eye 20
  • 50% isolated, 10% mechanical, 10% higher function such as INO, 5% decompensated, 5% monocular, 5% normal, 5% multiple muscle
  • 25% microvascular, 15% decompensated, 10% trauma, 10% or less in order reducing frequency..each MS, tumour, HZ, CVA, thyroid, aneurysm, age, monocular
  • scan patients
    • 3rd crainial nerve any age>>>medical reg on call
    • isolated lesion,
    • atypical,
    • no microvascular risk factors
    • trauma,
    • progression
  • of those scanned (1/3)
    • 111n and with pupil ...
      • 2/3 PC Aneurysm and
      • 1/3 orbit mass; pupil spared ...pituitary
  • Myasthenia 
    • ( Anti-acetylcholine Receptor Binding Antibody) Myasthenia antibodies...always test for thyroid at same time; Acetylcholine receptors antibodies and Anti musk antibodies ...results take 4 weeks
    • 30% thymoma
    • Variable ptosis, diplopia, muscle weakness, slow walking, worse at end of day
    • ptosis worse prolonged upgaze, 
    • Lift one eyelid other starts to drop
    • Cogans lid twitch..look down 15 seconds, and rapidly look up
    • Can simulate nerve palsies
    • Weakness of facial expressions when tired, speech, chewing, breathing 
    • Diagnostic tests..sleep improves ptosis etc
    • Ice..cooling lids improves ptosis 90% Eye 18
      Ice cube in finger or rubber glove  2 minutes on lid, some false positives
    • Tensilon test 
    • Acetylcholine receptor antibodies
    • Anti musk antibodies..worse prognosis
    • Thyroid antibodies
    • Pyridistigmine 30 mg qid and increase, to 90  ,   propantheline, steroids
    • Variable diplopia 
    • Cas if symptoms worse 
  • 6th n palsy versus decompensating distance esophoria
    • 6n palsy
      • more likely to have constant diplopia in distance
      • inability to fuse
      • head posture ...more likey lateral rectus restriction
      • large base out with prism in laevoversion (left 6th)
      • much larger deviation when fixing with affected eye
      • Hess chart
  • 4th Eye20
    • 60% vascular
    • 20% trauma
    • 5% brain lesion
    • 5% late decompensation


  • Eye 15    111 and VI n palsies need imaging, acute palsies in children, There are many causes.
  • ?Lyme disease ("Two children presented with acquired nystagmus, one with combined nystagmus and partial sixth nerve palsy, one with partial sixth nerve palsy, one with ptosis and one with Adie’s pupil. Five of the patients presented with severe fatigue, malaise, nausea, headache and fever. Four had recognised a tick bite recently, and two developed erythema migrans. Intrathecal synthesis of IgM and/or IgG antibodies specific for Bb was positive in all children, and five showed CSF pleocytosis. Cerebral MRI or CT of the brain were normal. Treatment with intravenous or oral antibiotics produced rapid clinical improvement in five of the six children")
  • Acute esotropia
    • Diagnosis including retinoscopy, Even clumsy, treat with Botox
    • investigate: 5% tumour
    • Exclude 6 th
    • Child acute. ..other symptoms, lack of hypermetropia, scan
  • Nystagmus in infants Eye 19
    • Infantile nystagmus, or latent: infantile may be sensory
    • Aquired nystagmus...scan
    • Infantile nystagmus= congenital but may not be present at birth, horitzontal, null zones, reduced with convergence, worse with attention and stress Eye 19
    • Fusion maldevelopment nystagmus syndrome (FMNS, previously MLN) Eye 19
      FMNS is characterised by horizontal nystagmus which beats in the direction of the viewing eye, worsening in abduction and improving in adduction of the viewing eye. It is commonly seen with strabismus without neuropathology and is thought to be due to maldevelopment of fusion.
    • Periodic alternating nystagmus (PAN) Eye 19
      PAN may be congenital (isolated or commonly seen in albinism) or related to identifiable lesions of the cerebellar nodulus/uvula. It alternates less regularly in congenital forms when it tends to be more asymmetrical and less predictable (asymmetrical periodic alternating nystagmus (APAN)).
    • Vertical  Eye 19
    • Photophobia
      • night blind, familial, refractive error prsent, iris trans illumination
      • Half albinism, electophysiology, many cone dysfunction 
      • Portable oct helpful
      • Reduction pit and outer nuclear layer
    • with optic nerve hypoplaia
      • optic atrophy, spasmus mutands, see saw
      • Spasmus mutans, dysconjugant
    • Monoculer neurological
    • Latent nystagmus, dirction changes with gaze
    • Upbeating nystagmus... retinal
  • complex conditon communication JAMAP18