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Why is it important to diagnose binocular Made Easy: A Practical vision problems? Approach to the Diagnosis and Management • Prevalence of Binocular Vision Disorders • Much more common than ocular disease conditions in children • 8.5 times more common than ocular disease in patients ages 6-18

Erin C Jenewein, OD, MS, FAAO Nova Southeastern University [email protected]

Scheiman et al. Journal of the AOA 1996, 67(4):193-202

Why is it important to diagnose binocular Chief Complaint vision problems? • Impact of binocular vision problems in children • Often BV problems have non-specific complaints • Blur at near • Asthenopia with near work • Impact of binocular vision problems in adolescents • • • Impact of binocular vision problems in adults • strain • Avoidance of near work

Chief Complaint Chief Complaint

• Sometimes the chief complaint is more specific, and can often help • Patient complaints you diagnose the condition….. • Parent complaints • Diplopia at near, with words “moving around on the page” • Blur at distance after reading/near work • Diplopia at distance

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Get the Details!!! Patient/Parent Symptom Questionnaires

• How long has it occurred for? • When do they notice symptoms? • How often? • Does anything relieve symptoms? • Occur on the weekend? • Do the symptoms subside as soon as near work stops?

Caution!! Neurological Signs and Symptoms…. Diagnosis: History

• Headache*** • Ocular History • Diplopia • Systemic History • ONH edema • Birth • Clumsiness, ataxia, gait imbalance • Development • • Family History • Nausea or vomiting • Personality or behavior change • Lethargy

Diagnosis: Academic History What tests do we use???

• Subject specific performance in school • Distance CT • Near CT • Learning problems • NPC • Tutoring or remediation • NRA/PRA/BCC • Repeated a grade? • AA/MEM • Behavioral problems • Ranges • ADHD • Smooth • Step • Facility • Accommodative (MAF/BAF) • Vergence

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Diagnosis: Accommodative Testing Diagnosis: Accommodative Testing

• Monocular versus Binocular Testing • Accommodative Amplitude Testing • Push Up/Pull Away • Advantages • Disadvantages • Minus to Blur • Advantages • Disadvantages

Diagnosis: Accommodative Testing Diagnosis: Accommodative Testing

• Calculating normative values • Case Example • Average • 18.5 – 1/3 age • Minimum • 15 - 1/4 age

Diagnosis: Accommodative Testing Diagnosis: Accommodative Testing

• Binocular Crossed Cylinder/Fused Crossed Cylinder • Negative Relative • Expected Value • Expected Value: +2.00 (+/- 0.50) • +0.50 (+/- 0.50) • Test of relaxation of accommodation • Disadvantages • Indirect test of positive fusional vergence • Difficult on young patients

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Diagnosis: Accommodative Testing Diagnosis: Accommodative Testing

• Positive Relative Accommodation • Monocular Estimation Method • Expected Values: -2.37 (+/-1.00) • Objective test • Test of stimulation of accommodation • Accuracy of accommodation • Indirect test of negative fusional vergence • Expected values: plano - +0.75

Diagnosis: Accommodative Testing Diagnosis: Vergence Testing

• Accommodative Facility Testing • Smooth Vergence Testing – Vergence Amplitude • Monocular • Blur • +/- 2.00 flippers • Fusional Vergence without Accommodation • 8 – 12 years old – 7 cpm • Break • Over 12 – 11 cpm • Fusional and Accommodative Vergence • Binocular • Recovery • +/- 2.00 flippers • Suppression check • 8-12 years old – 5cpm • Adults – 10cpm

Diagnosis: Vergence Testing Diagnosis: Vergence Testing

• Smooth Vergence Ranges • Smooth Vergence Ranges • Negative Fusional Vergence (BI) • Positive Fusional Vergence (BO) • Norms • Norms • Distance - x/7/4 • Distance – 9/19/10 • Near – 13/21/13 • Near – 17/21/11 • Indirectly testing positive relative accommodation • Indirectly testing negative relative accommodation

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Diagnosis: Vergence Testing Diagnosis: Vergence Testing

• Step Vergence Ranges • Vergence Facility • Advantages • Different from amplitude testing • Outside the phoropter • 3 BI / 12 BO • Objective test • Vertical row of letters • Norm • 15 cpm

Diagnosis: Vergence Testing Diagnosis: Vergence Testing

• Near Point of Convergence • Near Point of Convergence • Target Selection • Expected Values • Accommodative target • Accommodative Target • Penlight • • Penlight with R/G glasses 5cm/7cm • Repetition of test • Penlight and R/G glasses • 7cm/10cm

Scheiman et al. and Vision Science 2003 Mar;80(3):214-25

Treatment: Will Help? How do I know if plus will help???

• First step: good manifest prescription • Is your patient a plus acceptor?? • Dry • Lag on MEM/BCC • Cycloplegic retinoscopy • High NRA, Low PRA • Fails (-) on MAF/BAF • Eso at near • Low AA

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How to Determine Near Plus Rx? Treatment: Will Plus Lenses Help? • For Convergence Excess • Prescribing plus for near • Lenses that provide desired alignment (eso reduced or eliminated at near) • Taking myopic glasses off for near work • For AI or Pseudo CI • NVOs • Lenses that produce normal lag on MEM • Bifocals • Normal lag on MEM: +0.25 to +0.75D • PALs • Balance NRA/PRA??

Treatment: Will Minus Lenses Help? Treatment: Will Minus Lenses Help?

• When to consider added minus lenses for your patient • Prescribing overminus lenses • / • Methods of prescribing • Divergence Excess • Add at near? • High CA/C ratio • Young patients

Treatment: Will Minus Lenses Help? Treatment: Will Prism Help?

• Case example • Indications for prism • Vertical deviation • Intermittent • Large

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Treatment: Will Prism Help? Treatment: Will Prism Help?

• Prescribing Prism • Dissociated Prism Criteria • Dissociated Prism Criteria • Percentage Criteria • Associated Prism Criteria • Percentage of the total dissociated deviation given • May be 1/3 to as high as 2/3

Treatment: Will Prism Help? Treatment: Will Prism Help?

• Dissociated Prism Criteria • Associated Prism Criteria • Residual Vergence Demand • Fusion prism • Sheard’s Criteria • Amount of prism = 2/3 phoria – 1/3 compensating fusional vergence Type of Deviation Size of Deviation Residual Vergence Demand • Percival’s Criteria • Amount of prism = 1/3 Greater lateral limit – 2/3 Lesser lateral limit Esodeviation 6 – 20 prism diopters 4-6 prism diopters • Fixation Disparity

Exodeviation 20-30 prism diopters 10-15 prism diopters

Hyperdeviation 3-10 prism diopters 2-4 prism diopters

Caloroso and Rouse, Clinical Management of Strabismus, 1993

Accommodative Conditions Accommodative Conditions

• Accommodative Insufficiency • Accommodative Insufficiency • Common symptoms: Near blur/asthenopia • Management • Clinical signs • Lenses • Low PRA • • Large lag of accommodation • Low NFV • Difficulty with (-) on MAF/BAF • Low amplitude of accommodation

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Accommodative Conditions Accommodative Conditions

• Accommodative Excess • Accommodative Excess • Symptoms: Asthenopia/Blur at near • Treatment • Signs: • Vision therapy • Lead on MEM/BCC • Low NRA • Difficulty with plus on MAF/BAF • Low PFV

Accommodative Conditions Accommodative Conditions

• Accommodative Infacility • Accommodative Infacility • Symptoms: when looking from distance to near and • Management near to distance, near asthenopia • Vision therapy • Clinical signs: • Near lenses??? • Low NRA/PRA • Low MAF/BAF • May have low NFV/PFV

Vergence Conditions Vergence Conditions

• Convergence Insufficiency • Convergence Insufficiency Symptom Survey • Symptoms: Near asthenopia, diplopia, words moving on the page, poor attention or concentration • Clinical Signs: • Exo > near than distance • Receded NPC break • Inadequate PFV ranges at near • Lead on MEM/BCC • Low NRA ranges • Fails (+) on BAF

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Vergence Conditions Vergence Conditions

• Convergence Insufficiency • Pseudo Convergence Insufficiency • Management • Truly an AI • Office based vision therapy • (+) Acceptor • AI with a near XP • Lag on MEM/BCC • Low AA • (+) for near will improve NPC

Vergence Conditions Vergence Conditions

• Convergence Excess • Convergence Excess • Symptoms: Blurry vision, diplopia, asthenopia at near • Management • Clinical Findings • Plus at near • Eso at near > Eso at distance • VT • Low NFV at near • Low PRA • Fail BAF with (-) • High lag on MEM or BCC

Vergence Conditions Vergence Conditions

• Divergence Insufficiency • Divergence Insufficiency • Symptoms: Diplopia at distance • Management • Clinical Signs: • Prism • Eso D > N • Vision Therapy • Decreased NFV at distance

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Vergence Conditions Vergence Conditions

• Divergence Excess • Real versus Simulated DE • Symptoms: • Occlusion test • May have diplopia at distance • • Closes one eye in bright light +3.00 test • Clinical Signs: • Exo D > N • May have normal PFV ranges • Normal NPC

Vergence Conditions Vergence Conditions

• Divergence Excess • Basic • Management • Symptoms • Vision therapy • May present at both distance and near • • Added minus lenses Clinical Signs • Esophoria D = N • Low NFV D & N • Low PRA • High lag on MEM • Difficulty with (-) lenses on BAF

Vergence Conditions Vergence Conditions

• Basic Esophoria • Basic Exophoria • Treatment • Symptoms • Correct any hyperopia • May occur at distance and near • • Near addition lenses if indicated Clinical Signs • Exophoria D = N • Prism • Low PFV • Vision Therapy • Low NRA • Receded NPC • MEM – lower lag or lead

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Vergence Conditions Vergence Conditions • Fusional Vergence Dysfunction • • Symptoms Fusional Vergence Dysfunction • • Near asthenopia, , headache, blurry vision Management • • Clinical findings Vision Therapy • D and N phoria normal -Vergence amplitudes • Low NRA/PRA -Vergence facility • Low PFV/NFV • Fails BAF • Low vergence facility (BI and BO)

Amblyopia What is Significant ?

Unilateral or bilateral condition Isoametropic Anisometropic -BCVA is poorer than 20/20 -No structural or pathologic anomalies ≥2.50D ≥1.50D -One or more of the following conditions occurring before 6-8 years of age: ≥6.0D ≥3.0D • Significant refractive error • Constant, unilateral strabismus Hyperopia ≥4.0D ≥1.0D • Form vision deprivation

**Tarczy-Hornoch et al. (2013) . 120:1220-1226.

Strabismus Form Deprivation • 0.1% of the general population* • Early onset • Severe • Constant • Obstruction of the line of sight • Unilateral –Prolonged blepharospasm/ • More commonly ET – – – –Vitreous opacity

*Friedman, D.S.,et al. (2009). Ophthalmology. 66 (11) 2128-2134

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Is It Really Amblyopia??? Normal Findings in Patients with Amblyopia • Amblyogenic factor must be present • Must rule-out any underlying ocular or neurological • pathology that may explain a decrease in VA • Amsler Grid • Ocular pathology may co-exist with amblyopia • Visual Field • Color Vision

• If any of these are abnormal, carefully consider your diagnosis!!!!!

Amblyopia Amblyopia

• Management • Spectacle Correction • Spectacle Correction • Resolves strabismic and strabismic/aniso amblyopia in 25% of children 3 - <7* • Important first line of treatment for amblyopia • Most bilateral amblyopia resolves within 1 year of correction** • Resolves aniso amblyopia in 1/3 of children 3 - <7*** • Cycloplegic retinoscopy/refraction • In older children (7-17 yrs) amblyopia improves in 25% of patients with • Should I cut the Rx? correction alone****

*Cotter, S. et al. Ophthalmology2012 Jan;119(1):150-8 **Wallace, D. et al. Am J Ophthalmol 2007 Oct;144(4):487-96 ***Cotter, S. et al. Ophthalmology 2006 Jun;113(6):895-903 ****Scheiman, et al. Arch Ophthalmology 2005 Apr; 123(4): 437-47

Amblyopia Vision Therapy Basics

• Management • Improve accommodative amplitude and stimulation of accommodation • Patching regimens • Lens sorting • Near/Far Hart Chart • Monocular Loose Lens Accommodative Rock • Improve Smooth Positive and Negative Fusional Vergence Amplitudes • Vectograms • Brock String • Tranaglyphs • Computer RDS therapy

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Vision Therapy Basics Vision Therapy Basics

• Improve Ability to Stimulate and Relax Accommodation Efficiently • Integrate accommodative changes in vergence therapy • Monocular Accommodative Rock • Lenses to change accommodative demand with vergence therapy • Red Red Rock • Improve Vergence facility (Change from convergence to divergence) • Binocular Accommodative Rock • Aperture Rule(s) • Improve Positive and Negative Fusional Vergence Facility • BI/BO Vectograms • Aperture Rule • Eccentric circles • Vectograms • Vergence integrated with versions and • Tranaglyphs • Eccentric circles • Brock string • Lifesaver Cards

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