The Examination

  • Burton J. Kushner


I am aware that many colleagues do cycloplegic refractions on all children, but in adults they only perform dry (manifest) refractions. There are several reasons for this. In patients with early nuclear sclerosis, dilation may compromise visual acuity testing. Also, in hyperopic patients it can be hard to predict how much latent hyperopia is present, and how much of the plus they will tolerate. But I find that many adult patients with strabismus (usually esotropes but not exclusively so) do “funny” things with respect to accommodation; they may not relax it during a dry refraction in the same way as non-strabismic patients do. I recall one patient who was referred to me for strabismus surgery in her late 40s. She had a history of accommodative esotropia (ET) that had been controlled for many years, but over the prior 10 years her eye began to increasingly cross. She had undergone five refractions over the prior 10 years, having seen five different comprehensive ophthalmologists, all of whom performed dry refractions; they did dilate her for fundoscopy. Although my dry refraction was close to what she was currently wearing in her spectacles, my cycloplegic refraction revealed three additional diopters of hyperopia. She was incrementally given more hyperopic correction which eliminated her ET and brought great relief from the asthenopia she was experiencing with visual tasks.


Active force generation (AFG) Anomalous retinal correspondence Bagolini lens test Dissociated vertical divergence (DVD) Dynamic retinoscopy Examination Forced duction (FD) Overdepression in adduction Overelevation in adduction Prisms Sensory testing Stereopsis Strabismus, measuring: Hirschberg test, Krimsky test, Spectacle induced prism, Redress, Prism and alternate cover test, Prism under cover test, Marlowe occlusion, False hypertropia Visual acuity, testing: Fixation preference, Induced tropia test, Grating acuity tests, Visually evoked potential (VEP) Worth 4-dot test 


  1. 1.
    Kushner BJ. Grating acuity tests should not be used for social service purposes in preliterate children. Arch Ophthalmol. 1994;112:1030–1.CrossRefGoogle Scholar
  2. 2.
    Kushner B, Lucchese N, Morton G. Grating visual acuity with teller cards compared with Snellen visual acuity in literate patients. Arch Ophthalmol. 1995;113:485–93.CrossRefGoogle Scholar
  3. 3.
    Kushner BJ, Morton GV. Measurement of strabismus in shortened exam lanes versus the 20-foot lane. Ann Ophthalmol. 1982;14:86–9.PubMedGoogle Scholar
  4. 4.
    Stager D, Everett ME. Comparison of strabismus measurements in mirrored and twenty foot lanes. Am Orthopt J. 1987;37:74–6.CrossRefGoogle Scholar
  5. 5.
    Choi R, Kushner B. The accuracy of experienced strabismologists using the Hirschberg and Krimsky tests. Ophthalmology. 1998;116:108–12.Google Scholar
  6. 6.
    Cestari DM, Hunter DG, editors. Appendix 4. Addition of two prisms with one placed over each eye. In: Learning strabismus surgery: a case-based approach. Philadelphia: Lippincott Williams & Wilkins; 2013. p. 234.Google Scholar
  7. 7.
    Morton GV, Kushner BJ. The use of diagnostic occlusion in strabismus management. J Ocul Ther Surg. 1983;2:194–200.Google Scholar
  8. 8.
    Guyton DL, O’Connor GM. Dynamic retinoscopy. Curr Opin Ophthalmol. 1991;2:78–80.CrossRefGoogle Scholar
  9. 9.
    Hunter DG. Dynamic retinoscopy: the missing data. Surv Ophthalmol. 2001;46:269–74.CrossRefGoogle Scholar
  10. 10.
    Simons K, Arnoldi K, Brown MH. Color dissociation artifacts in double Maddox rod cyclodeviation testing. Ophthalmology. 1994;101:1897–901.CrossRefGoogle Scholar
  11. 11.
    Kushner BJ, Haraharan L. Observations about objective and subjective ocular torsion. Ophthalmology. 2009;116:2001–10.CrossRefGoogle Scholar
  12. 12.
    Kushner BJ, Morton GV. Postoperative binocularity in adults with longstanding strabismus. Ophthalmology. 1992;99:316–9.CrossRefGoogle Scholar
  13. 13.
    Kushner BJ. Unexpected cyclotropia simulating disruption of fusion. Arch Ophthalmol. 1992;110:1415–8.CrossRefGoogle Scholar
  14. 14.
    Benegas NM, Egbert J, Engel WK, Kushner BJ. Diplopia secondary to aniseikonia associated with macular disease. Arch Ophthalmol. 1999;117:896–9.CrossRefGoogle Scholar
  15. 15.
    Kushner BJ. Intractable diplopia after strabismus surgery in adults. Arch Ophthalmol. 2002;120:1498–504.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Burton J. Kushner
    • 1
  1. 1.Department of Ophthalmology and Visual SciencesUniversity of Wisconsin-MadisonMadisonUSA

Personalised recommendations