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Managing Accommodative and Vergence Dysfunction Plus, Minus, Prism, and Therapy: Managing Accommodative and Vergence Dysfunction American Academy of Optometry Meeting, Boston 2011 Kristine B. Hopkins, OD, MSPH, FAAO University of Alabama at Birmingham School of Optometry [email protected] Case History Onset: Sudden vs. gradual; Longstanding vs. recent Frequency: every day, only school/work days, mornings, afternoons Duration: minutes vs. hours Eliciting factors: associated with near work, computer work, lighting, etc. Pertinent medical history/medications: accommodative side effects? Symptom Checklist or patient/parent survey Functional Vs. Organic Lesion Functional Organic Etiology Reduced function not related to Neurological lesion or other organic defect organic lesion source of decreased function Symptoms Typically longstanding without precise Typically sudden onset, often severe onset. May be unilateral or bilateral Typically bilateral Signs Not associated with neurological loss, Typically associated with other neurological systemic illness, or medications signs, systemic illness, or medication use. EOM palsy, pupil abnormality, visual field defect, ptosis. Initial exam should rule out significant refractive error and ocular pathology. If significant refractive error present, Rx and return to re-test BV and accommodation with new Rx (4-6 weeks later). Significant Refractive Error (patients 6 years and older): Myopia -1.00D or greater Hyperopia +2.50D or greater* Astigmatism -1.00D or greater Aniosmetropia 1.00D difference or greater *May prescribe for lower amounts of hyperopia in presence of BV/accomm dysfunction AAO Meeting 2011: Hopkins Page 1 of 8 Binocular, Accommodative, and Ocular Motor Testing Battery and Norms BV Alignment and Vergences Test Age Condition Expected Value Cover Test Any Near 3 XP (±3) Distance 1 XP (±1) AC/A Any 3/1 to 5/1 CA/C Any 0.5D per 6Δ Smooth Vergences Any Near BO 17/21/11 Near BI 13/21/13 BI/BO ranges in Distance BO 9/19/10 phoropter with Risley Distance BI X/7/4 Prisms Step Vergences Child 7 to 12 Near BO 23/16 Near BI 12/7 BI/BO ranges with Adult 12 Near BO 19/14 prism bar Near BI 13/10 Distance BO 11/7 Distance BI 7/4 Vergence Facility Any 3BI/12BO 15 cpm Fused prism NPC Children With accomm tgt 6 cm (minimum 10cm) Adults With accomm tgt 5/7 cm (minimum 10cm) Adults With R/G tgt 7/10 cm Accommodation Test Age Condition Expected Value Amplitude Any Any Minimum=[15-(age/4)]-2 Monoc. Facility 8-12 yo ±2.00 flipper 7 cpm (±2.5): at least 4 cpm 13-30 yo ±2.00 flipper 11 cpm (±5): at least 6 cpm Binoc Facility 8-12 yo ±2.00 flipper 5 cpm (±2.5): at least 2 cpm 13-30 yo Scaled flipper 10 cpm 13-30 yo ±2.00 flipper Approx 8 cpm NRA Any +2.00 to +2.50 PRA Any -2.37 to –3.37 Accom Response Any MEM +0.25 to +0.50 AAO Meeting 2011: Hopkins Page 2 of 8 Accommodative Insufficiency Symptoms Associated with near work: blur (text “comes in and out of focus”), headaches, tired or sore eyes, poor reading comprehension, fatigue, blinking or squinting to read. Signs Reduced amplitude of accommodation [15-(age/4)]-2 May or may not show higher lag on MEM Critical Tests Accommodative Amplitude Push-up (highest value and lowest repeatability) Pull-away Minus lens amps (lowest value but best repeatability) Objective amps with retinoscope (over estimates amps) Treatment Options Additional plus at near Plus build up—subjective MEM method—for patients with high lag on MEM, add plus until MEM normalizes NRA/PRA midpoint—accounts for vergence ranges but doesn’t always indicate need for additional plus BCC—subjective For young patients: Rx FT at lower pupil margin, PAL 2-3cm high, or NVO specs (multifocal CL’s?) Vision therapy Often best choice if AI is also associated with BV dysfunction Accommodative Infacility Symptoms Blur (may be distance or near), difficulty copying from the board, headaches, fatigue, eye strain Signs Reduced monocular and binocular accommodative facility Difficult with + and – sides of flipper May also show decreased NRA/PRA Critical Tests Monocular Accommodative Facility Reduced binocular facility not specific to accommodative infacility (may also indicate poor vergences) Treatment Options Additional plus at near if NRA is high enough (see AI) Vision therapy AAO Meeting 2011: Hopkins Page 3 of 8 Accommodative Excess/Spasm Symptoms Blur (may be distance or near) worse after prolonged near work, headaches, eye strain, fatigue, diplopia (if associated with ET) Signs Neutral or lead with MEM Difficulty clearing plus with monocular facility testing Reduced NRA Dry ret/auto may show more minus than wet Critical Tests MEM Monocular accommodative facility Wet retinoscopy Treatment Options Vision Therapy Cycloplegic agents for extreme spasm Spasm of the near reflex: lead on MEM, ET, and pupil miosis Consider 1% Atropine OU twice/week with near add (wean over time) Bifocal lenses not indicated (low NRA—patient will not accept plus) Binocular Vision Dysfunction: Making the Diagnosis Begin with measurement of ocular alignment at distance and near to make Duanne’s classification and generalization about AC/A. Look at tests that belong to compensating testing group for depressed findings to support diagnosis o For an exo deviation, the tests that measure Positive Fusional Vergence (PFV) findings would need to be normal or high to prevent symptoms. Depressed PFV findings along with symptoms support the diagnosis and need for treatment. o For an eso deviation, the tests that measure Negative Fusional Vergence (NFV) findings would need to be normal or high to prevent symptoms. Depressed NFV findings along with symptoms support the diagnosis and need for treatment. If symptoms and signs are present, recommend treatment Deviation Compensating Group Tests Exo Deviation Positive Fusional Vergence Group BO (PFV) ranges (smooth or step) BO ability with vergence facility NPC NRA Binocular Plus with accommodative facilty MEM (may show lead?) Eso Deviation Negative Fusional Vergence Group BI (NFV) ranges (smooth or step) BI ability with vergence facility PRA Binocular minus with accommodative facility MEM (may show lag?) AAO Meeting 2011: Hopkins Page 4 of 8 Expanded Duanne’s Classifications Cover Test Duanne’s Classification AC/A Supporting Signs Greater eso at near Convergence Excess (CE) High Reduced NFV findings at near than distance Greater exo at Divergence Excess (DE) High May show reduced PFV findings at distance than near distance (but often normal) Greater eso at Divergence Insufficiency (DI) Low Reduced NFV findings at distance distance than near Greater exo at near Convergence Insufficiency (CI) Low Reduced PFV findings at near than distance Similar eso at Basic Eso Normal Reduced NFV findings at distance distance and near and/or near Similar exo at Basic Exo Normal Reduced PFV findings at distance distance and near and/or near Nearly ortho at Fusional Vergence Dysfunction Normal Reduced PFV and NFV at distance distance and near and/or near Convergence Excess Symptoms Headaches and eye strain with near work, blur, diplopia at near, fatigue with reading, slow reading, poor reading comprehension, words moving on page, avoidance of reading Signs Greater eso at near than distance High AC/A Low NFV group findings May show high lag with MEM Critical Tests Cover Test NFV group tests MEM Treatment Options Additional Plus at near High AC/A responds well to low amounts of plus Rx amount of plus that reduces near phoria to near ortho (maximum plus to correspond with working distance) Base Out Prism May be needed if small eso present at distance and near add still leaves residual eso with symptoms Vision Therapy Not generally first line of treatment. May be necessary of optical management alone does not resolve symptoms or if patient unable/unwilling to wear optical correction AAO Meeting 2011: Hopkins Page 5 of 8 Divergence Excess Symptoms Cosmetic concerns about outward eye turn (often IXT), rarely diplopia, rarely near point symptoms Signs Parent/patient report of IXT (may not manifest with CT) Greater exo at distance than near PFV and NFV ranges may be normal at distance and near May show suppression or ARC at distance when the eye is XT High AC/A by calculation but may not be truly high with gradient Critical Tests Cover Test PFV data (although may be normal) May do prolonged CT to rule out Pseudo-DE Treatment Options Over minus lenses Recommended for young patients (under 6) with true high AC/A Trial over minus in office Rx for FTW generally up to -2.50 over minus Vision Therapy DE IXT’s generally respond well to VT and often first line of tx Emphasize diplopia awareness and vergence ranges Prism Horizontal prism not generally beneficial Occlusion FT occlusion for as long as 2 months may decrease suppression and improve fusion More popular with ophthalmology Surgery Considered for very large (>35-40), frequent deviations that fail to respond to more conservative treatment Divergence Insufficiency Symptoms Longstanding intermittent diplopia at distance, headaches, ocular fatigue, difficulty focusing from far to near Signs Greater eso at distance than near (phoria or tropia) Reduced NFV group findings at distance Critical Tests Cover Test NFV group tests (at distance) EOM’s (rule out 6th Nerve Palsy) Treatment Options Prism BO prism often treatment of choice for low magnitude deviation Vision Therapy Improving NFV ranges and vergence facility often helpful Surgery Last resort if deviation cannot be managed with prism and VT AAO Meeting 2011: Hopkins Page 6 of 8 Convergence Insufficiency Symptoms
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