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Binocular Vision CET Continuing education Binocular vision Part 4 – Compensation assessment In the latest in our series looking at binocular vision assessment in practice, Priya Dabasia describes the assessment and management of compensation and decompensation. Module C15357, one general CET point for optometrists and dispensing opticians he first part in this binocular vision to present in daily between the eyes in which the fovea mini-series detailed the practice. ‘Compensation’ refers to the of one eye corresponds with a small detection and measurement control of a heterophoria: foveal area of the fellow eye in higher of heterophoria using the ● ‘Well compensated’ – fully controlled cortical processing. This horizontally cover test (CT). This article with no symptoms in the absence of oval group of retinal elements is aims to provide an overview suppression known as Panum’s area, and occurs for ofT the assessment of heterophoria ● ‘Decompensating’ – poor control every point of the retina, increasing in compensation and management of poorly with symptoms, or where a practitioner size with eccentricity from the fovea controlled deviations. Heterophoria deems that lack of treatment is where it measures 5-10 minutes of occurs when both visual axes are likely to result in a deterioration of arc (Figure 1). For fusion to take place directed toward the fixation point but binocularity between the eyes, images must either deviate on dissociation. In the absence ● ‘Full decompensation’ – complete fall exactly on the same points, or of a visual stimulus such as under the failure of the vergence system resulting slightly disparate elements provided closed lid at rest, our eyes have a natural in a breakdown of a heterophoria to a they are located within Panum’s area. tendency to revert to their resting states heterotropia. This is highly probable in This misalignment of one or both visual by deviating upwards and outwards. childhood as a result of the instability axes is called fixation disparity (FD) or During CT, this translates on average of binocular vision, with associated retinal slip, and is evaluated clinically as a small esophoria at distance and foveal suppression and gradual loss of to provide a measure for the degree exophoria at near fixation. A summary depth perception. of compensation in heterophoria. of the basic types of heterophoria is When the visual system is subjected to shown in Table 1. Panum’s fusional area such undue stress, the axes slip closer Decompensated heterophoria is one For normal binocular single vision, to the limit of Panum’s area – if the of the most common anomalies of there is a point to point correlation misalignment is large enough to fall TABLE 1 A summary of heterophoria types, features and causes Type Details Causes Esophoria Convergence excess Greater at near than distance • Anatomical (narrow PD) Eye moves nasally under • Refractive (high hypermetropia) Divergence weakness Greater at distance than near cover • High AC/A ratio Non-specific Similar angle at near and distance • Weak divergent (negative) fusional reserves Exophoria Convergence weakness Greater at near, often but • Anatomical (wide PD) Eye moves temporally under not always with convergence • Refractive (myopia, presbyopia) cover insufficiency • Weak convergent (positive) fusional reserves Divergence excess Greater at distance than near • Age Non-specific Similar angle at near and distance Vertical phoria Hyper/hypo One eye rotates upwards and the • Refractive (high myopia) Eye moves up or down other downwards under cover under cover Alternating hyper/hypo Either eye moves upwards/ • Weak vertical fusional reserves downwards under cover • Anatomical (abnormal extraocular muscles) • Incomitancy – extraocular muscle anomaly (see Part 2) Cyclophoria either eye Incyclophoria Upper end of vertical axis is nasal • Oblique astigmatism ‘wheel rotates’ under cover Excyclophoria Upper end of vertical axis is • Incomitancy temporal 26 | Optician | 17.12.10 opticianonline.net Continuing education CET from adapting to a decompensating Fixation point heterophoria through suppression, Diplopia making it increasingly likely that they present with symptoms of: ● Headaches – horizontal heterophoria is associated mostly with a bilateral frontal ache while hyperphoria results in occipital pain Fusion ● Asthenopia – eye ache, dull pain Horopter behind the eyes and/or general soreness ● Blurring of print and difficulty changing focus to distance following a period of near work – the focusing capability of the eye is affected by the accommodative-vergence induced to control a heterophoria Figure 1 Panum’s fusional area ● Intermittent diplopia usually following a period of intense work beyond, the patient will appreciate refractive error, arising primarily as ● Intermittent ‘confusion’ or distorted physiological double vision (diplopia) a consequence of the relationship vision – instability in binocular in the absence of suppression. between accommodation and alignment results in the perception of accommodative-convergence. A young letters or words moving, flickering or Causes of decompensation hyperopic patient without spectacle jumping so that words/ lines of text The size of a heterophoria does not correction must accommodate to are missed or patients may even report relate directly with the likelihood of overcome refractive blur; the resulting shapes or patterns on the page a patient becoming symptomatic – a accommodative-convergence effort ● Less commonly patients describe 2 dioptre hyperphoria can give rise induces an esophoric deviation that difficulties in depth perception, to a multitude of symptoms while is greater at near. Similarly, a myopic particularly during sport a patient can be oblivious to an 8 patient reading unaided lacks the ● Adaptation to binocular discomfort dioptre exophoria. The causes of accommodative-convergence to by closing one eye to read, or adopting decompensation can be attributed to control a near exophoria. The other an abnormal head posture to prevent one or more of the following: contributory factor that cannot be double vision by using the nose to block ● Reduction in fusional reserves – the corrected is age – as the amplitude of the image of one eye. convergence, divergence and vertical accommodation reduces over time, the Typically, these symptoms will be range between the eyes that maintains average heterophoria at near has been absent on waking, arising later in binocular single vision found to increase up to 6Δ at the age the day with increased visual activity. ● Disruption in fusion of monocular of 65 years. Patients may report that symptoms images of each eye alleviate with breaks from work. ● Exceptionally large amplitude Symptoms of decompensation heterophoria The difficulty in making a diagnosis Tests for assessing From a clinical perspective, the based on symptoms alone is that they can compensation practical manifestations of these factors be non-specific ranging from general Compensation is evaluated using are listed in Table 2. irritation to vertigo/ nausea. Unlike in tests conducted during the course of The main optical cause of childhood, the increasing stability of the a routine eye examination, with the decompensation is uncorrected binocular system prevents young adults addition of a few readily available Season’s Greetings from the team at Nikon Optical www.nikonlenswear.co.uk opticianonline.net 17.12.10 | Optician | 27 CET Continuing education TABLE 2 A summary of the causes of decompensation of heterophoria Optical Medical Environmental Uncorrected refractive error Poor health, fatigue, worry and anxiety Increase in ocular activity • Esophoria decompensated by uncorrected • Reduces fusional reserves • Change in occupation hyperopia • Reduces amplitudes of accommoda- • Extended period of work at a particular • Exophoria decompensated by uncorrected tion and subsequent accommodative- distance (eg prolonged VDU viewing) myopia convergence Over/under corrected refractive error Traumatic injuries Poor working environment • Reduces the acuity and dissociates the eyes • Head trauma can result in temporary or • Reading at too close a distance for long periods • More pronounced where one eye is affected permanent reduction in fusion • Poor illumination or contrast of visual task more than the other Poorly fitted spectacles Adverse effects of drugs Playing games • Particularly with high refractive errors that • Certain antihypertensive and antidepres- • Video games that involve rapid, repeated can induce unwanted prismatic effects sant agents can reduce accommodation pursuit fixation movements • Alcohol has been found to reduce • ‘Magic Eye’ 3D autostereograms that dissociate horizontal fusional reserves and disrupt accommodation and convergence Anisometropia Short period of occlusion Night driving • Difference in image size between the eyes • Patch worn over one eye following a • Reduced visual information prevents binocular (aniseikonia) makes fusion difficult corneal injury functioning between the eyes • Patch worn in childhood for the treat- ment of amblyopia Extensive visual field loss Extensive monocular viewing • Glaucoma reduces binocular matching • Jewellers between the eyes • Watch makers • Advanced AMD in one eye supplementary assessments. ● Frequency of deviation – whether it is constant or intermittent, presenting 1) History and symptoms – it is with fatigue or at a particular fixation essential for the practitioner to acquire distance full details of the presenting symptoms ● Speed of recovery to
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