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Introduction

Anisometropia plays an important role in the aetiology of amblyopia and non-paralytic

Orthoptic measurement in anisometropia

strabismus Accurate correction of the anisometropia is an essential part of amblyopia and strabismus management

Introduction
Refraction should be assessed objectively Refraction should be assessed with and without cycloplegia in order to determine the accommodative component Subjective refraction is used to verify the findings of objective refraction and to find the best possible optical correction for distance and near vision in terms both of vision and comfort

Introduction
First assess the correction for each eye which gives the best visual acuity, then test the patient binocularly, noting: The presence of diplopia
Due to aniseikonia Due to manifest strabismus

The binocular visual acuity for near and distance The patients binocular functions

Introduction
Anisometropia should be fully corrected in young children in order to prevent or treat anisometropic amblyopia Older children and adults may be unable to tolerate a full correction binocularly and the optical correction of the more ametropic may need to be reduced, even if optimum visual acuity is not achieved

Introduction
Large anisometropia may need correction with contact lenses, which should be considered if: Insuperable aniseikonia is present Binocular vision can be restored Binocular visual acuity can be improved

Introduction
Patients with anisometropia may have microtropia with: Foveal suppression scotoma Amblyopia Eccentric fixation on the border of the scotoma Peripheral binocular single vision with

Anisometropia and binocular vision


Male 40 years Amblyopia LE, occlusion RE and glasses since age 12 VA RE: 1.0 sc VA LE: 0.4 sc 0.8 +2,50 (-2,50 x 90) RE: (-0,50 x 90) LE: +5,25 (-2,50 x 85) AS/PS: normal

Cycloplegic refraction

defective stereopsis

Anisometropia and binocular vision


10 PD left esotropia for near, 8 PD for distance 15 PD test: negative dominant LE Synoptophore: obj/subj: +7 peripheral fusion of 10 central suppression of 10 Suppression of the left eye in free space No stereopsis (Lang/Titmus)

Anisometropia and binocular vision


VA RE: 1.0 sc VA LE: 0.8 ccl

8 PD esophoria for near, 8 PD for distance 15 PD test: positive Peripheral fusion in free space of 15 Synoptophore: obj/subj: +4 peripheral fusion of 10 central fusion of 7 Stereopsis: Titmus 60, Lang pos !!!!! R/ Soft contact lens LE: +5,00 (-2,25 x 90)

Anisometropia and binocular vision


Conclusion
Compensation of convergent strabismus when aniso(hyper)metropia is corrected Recuperation of stereopsis when anisometropia is corrected Recuperation of fusion when anisometropia is corrected

Anisometropia and binocular vision


Male 44 years
Amblyopia RE, occlusion RE and glasses since age 10 Blurred vision RE, reading problems and problems during close work (dentist), RE bothers VA RE: 0.2 sc VA LE: 1.2 sc Near VA RE: 0.12 sc VA LE: 1.0 sc Cycloplegic refraction RE: +5,75 (-1,75 x 155) LE: +1,00 (-0,25 x 175) 0.6 1.2 +5,00 (-1,50 x 155) +0,50

VA BE: diplopia/confusion of both images

Anisometropia and binocular vision


15 PD test: fusion 4 PD test: suppression RE 8 PD intermittent right esotropia for near Synoptophore: obj/subj: +3 peripheral fusion of 6 central suppression of 5 Fusion: 16^BT till 18^BN Stereopsis: Titmus: only fly positive R/ Soft contact lens RE: +5,50 (-1,75 x 160)

Anisometropia and binocular vision


VA RE: 1.0 ccl VA BE: 1.0 no problems VA LE: 1.0 sc Near VA RE: 0.75 ccl VA LE: 1.0 sc

4 PD test: positive 6 PD esophoria for near Synoptophore: obj/subj: -2 peripheral/central fusion of 10 Fusion: 30cm: 18^BT till 14^BN 6m: 10^BT till 8^BN Stereopsis: Titmus 120, Lang pos !!!!!

Anisometropia and binocular vision


Conclusion
No diplopia and improvement of binocular vision aniso(hyper)metropia is corrected Correction of intermittent convergent strabismus when anisometropia is corrected Recuperation of stereopsis when anisometropia is corrected Recuperation of fusion when anisometropia is corrected

Anisometropia and binocular vision


Female 42 years Myopia RE, no occlusion, no strabismus, no glasses VA RE: 0.5 VA LE: 1.0 -9,00 (-2,50 x 160) (-0,75 x 0) RE: -8,75 (-2,50 x 155) LE: +0,50 (-1,00 x 0) Axial length: RE 25.95 No aniseikonia LE 22.27

Cycloplegic refraction:

Anisometropia and binocular vision


8 PD right intermittend exotropia and 6 PD hypertropia Synoptophore: obj: -5 R/L 9 subj: +6 R/L 7 incyclotorsion RE 7 suppression -5 till +12 R/L 14 till R/L 6 Total suppression of the right eye in free space No stereopsis (Lang/Titmus) Ocular motility: A pattern, underaction left inferior oblique

Anisometropia and binocular vision


VA RE: 0.6 ccl VA LE: 0.8 sc 4 PD exophoria and 6 PD right hyperphoria Synoptophore: obj: -2 R/L 2 subj: -1 R/L 5 incyclotorsion 5 fusion: -9 till +9 Fusion of 15 Lang: positive Ocular motility 0 till R/L 12

R/ Soft toric contact lens RE 8,00 (-2.25 x 160)

Anisometropia and binocular vision


Conclusion
Correction of intermittent exotropia and hypertropia when aniso-myopia is corrected Recuperation of fusion when aniso-myopia is corrected

Anisometropia and diplopia


Female 15 years Amblyopia RE, occlusion LE and under corrected glasses VA RE: <0.05 cc = -1,50 VA LE: 1.0 cc -1,50 (-1,00 x 0) Cycloplegic refraction: 0.2 -17,00

Recuperation of stereopsis when aniso-myopia is corrected


Axial length: RE 26.83 AS: normal PS: RE tilted disk

RE: -17,00 LE: -1,00 (-1,50 x 170) LE 22.66

LE normal No aniseikonia

Anisometropia and diplopia


Diplopia with correction of BE, not when LE corrected 6 PD right exotropia and 8 PD hypotropia Synoptophore: obj/subj: -3.5 L/R 3 total suppression Total suppression of the right eye in free space No stereopsis (Lang/Titmus)

Anisometropia and diplopia


Permanent vertical diplopia VA RE: 0.3 ccl -12,00 VA LE: 1.0 ccl -1,50 (-1,00 x 0) Suppression: L/R 3 PD till L/R 5 PD for near L/R 6 PD for distance, no amplitude 6 PD right exotropia and 20 PD hypotropia Synoptophore: obj/subj: -6 L/R 8 suppression: -9 till -3 L/R 7 till L/R 12

R/ Soft contact lenses BE


No stereopsis (Lang/Titmus)

Anisometropia and diplopia


Conclusion
Diplopia when the anisometropia is corrected with glasses or with contact lenses Suppression of the high myopic eye when undercorrected

Anisometropia and accommodation


Female 5 years Intermittent left esotropia VA RE: 0.8 sc VA LE: 0.4 sc Refraction without cycloplegia: RE: +2,25 LE: +4,50 Refraction under cycloplegia: RE: +5,50 LE: +5,50

Anisometropia and accommodation


25 PD left esotropia for near and distance Synoptophore: obj/subj: +8 Suppression of the left eye in free space No stereopsis (Lang/Titmus)

Anisometropia and accommodation


Conclusion
Anisometropia without cycloplegia No anisometropia in cycloplegia Hypoaccommodation of the strabismic eye

R/ Glasses: +4,50 BE

Anisometropia and accommodation


Female 7 years Intermittent right exotropia, 2 times strabismus operation for esotropia and exotropia, partial occlusion (1-2 h) left eye with glasses (since age 4) VA RE: 0.1 sc VA LE: 0.4 sc 0.1 cc (+5,00) 0.4 cc (+0,50)

Anisometropia and accommodation


Intermittent 14 PD right exotropia Small limitation of adduction RE, V pattern Synoptophore: obj/subj: -7 suppression 10 till +14 Suppression of the right eye in free space No stereopsis (Lang/Titmus) R/ Total occlusion LE + atropine LE

Refraction without cycloplegia: RE: +8,00 LE: +3,00 Refraction under cycloplegia: RE: +8,50 LE: +6,00

Optimal correction

Anisometropia and accommodation


Conclusion
Anisometropia without and with cycloplegia Hypoaccommodation of the strabismic eye Deep amblyopia of the strabismic eye

Anisometropia and amblyopia


Female 11 years VA RE: < 0.05 sc VA LE: 0.8 sc Cycloplegic refraction:

PS: RE: myopic aspect CT: no strabismus Stereopsis: negative R/ Glasses: -10,00 (2,75 x 10) plano Full time occlusion LE

RE: -10,00 (-2,75 x 10) LE: +0,50 (-0,25 x 45) LE: normal

Anisometropia and amblyopia


VA RE: 0.6 11.25 -2.25 x 15 VA LE: 1.0 -1 x 0 CT: 20 PD right esotropia, horizontal diplopia Syn: obj: +15 L/R 0.5 subj: +15 L/R 2 fusion: +10 till + 18 stereo: neg Prism bar: no fusion Axial length RE: 27.16 mm LE: 22.60 mm

Anisometropia and amblyopia


5mm recession medial rectus BE
CT: small esotropia RE APCT: 30 cm/6m: 4^ ET, L/R 4^ Syn: obj=subj: +5 L/R 4 fusion: +8 till 0 Fusion: 4^ BT, 4^ B RE VA RE: 0.7 (cl-10,00) +(-2,00 x 20) VA LE: 1.0 cc

R/ RE: Cl 10,00

C-2 x 20

5^ b 135

Anisometropia and amblyopia


CT: sc: small esotropia RE (diplopia) cc: 0 APCT: 30 cm/6m: 3^ ET, L/R 3^ Syn: obj=subj: +3 L/R 2 fusion: +12 till -1 R/L 1 till L/R 5 Fusion: 30cm: 18^ BT till 6^BN 3^ B till 6^B (LE) 6m: 10^BT till 2^BT 3^ B till 8^B (LE) Stereo: cc: Titmus: 300

Anisometropia and amblyopia


Conclusion
Anisometropia with deep amblyopia Decompensation after prolonged fulltime occlusion Correction of diplopia after strabismus surgery, contact lens and prism glass Recovering binocular vision with moderate fusion and stereopsis

Anisometropia and amblyopia


Male 7 years
Abused child, mentally retarded, full time occlusion and glasses since age 5 VA RE: 0.6 VA LE: 0.05 +4,00 +6,50 PS: normal PS: normal RE: +4,50 (-0,25 x 2) LE: +5,25 (-0,50 x 179) Cycloplegic refraction: RE: +5,25 (-0,25 x 0) LE: +7,75 (-0,25 x 175) Fixation: RE: central LE: paramacular

Anisometropia and amblyopia


CT: 10 esotropia LE, no central fixation APCT: 30 cm: sc: 40^ ET 6m: sc: 40^ET Syn: obj= sc: +14 cc: + 20 Ocular motility: V pattern with overaction left inferior oblique muscle cc: 25^ET cc: 18^ET

Automatic refraction:

Anisometropia and amblyopia


Conclusion
Anisometropia with deep amblyopia No decompensation after prolonged full time occlusion Eccentric fixation of most ametropic and strabismic eye No improvement in vision due to eccentric fixation Too old to start inverse occlusion

Anisometropia and microtropia


Female 5 years Myopia RE, astigmatism BE, two pairs of glasses, patient refuses to wear second glasses VA RE: 0.1 VA LE: 0.5 VA RE: 0.2 VA LE: 0.1 -5,00 (-3,00 x 5) (-3,50 x 170) -9,00 (-3,00 x 5) -7.00
glasses 1

glasses 2

Cycloplegic refraction: Axial length: RE 25.19

RE: -8,50 (-3,25 x 0) LE: +1,25 (-3,00 x 175) LE 22.08

Anisometropia and microtropia


LR: straight eyes 15D PT: fusion 4D PT: suppression RE CT: micro-esotropia RE Synoptophore: obj/subj: +4 peripheral fusion: -7 till +16 central suppression: +3 till +6 No stereopsis (Lang/Titmus)

Anisometropia and microtropia


VA RE: 0.5 VA LE: 0.6 -8,50 (-3,00 x 5) (-3,50 x 170) RE: -7,25 (-3,25 x 0) LE: +1,25 (-3,00 x 175) LE 22.30

Cycloplegic refraction: Axial length: RE 25.01 No aniseikonia

R/ Glasses:

R/ Glasses:

-8,50 (-3,00 x 0) (-3,00 x 175) Occlusion LE

-7,25 (-3,00 x 0) (-3,00 x 175)

Anisometropia and microtropia


Conclusion
Anisometropia with large astigmatism Straight eyes with microtropia Slight improvement of myopia in most myopic eye

Anisometropia and reading


Male 13 years Headaches after reading, reading problems, no glasses VA RE: 0.9 sc VA LE: 0.3 sc Automatic refraction 0.9 0.9 +1,25 (-1,00 x 95) -1,50 RE: (-1,00 x90) LE: -1,75 (-0,50 x 85) Cycloplegic refraction RE: +2,75 (-1,00 x 90) LE: +0,75

Anisometropia and reading


14 PD intermittent right esotropia for near Synoptophore: obj/subj: +6 Stereopsis: 120

Anisometropia and reading


Conclusion
Hyperaccommodation with headaches Relaxation of accommodation with glasses No more reading problems and headaches after correction of the anisometropia Better compensation of esodeviation and stereopsis

R/ Glasses:

+2,00 (-1,00 x 90) plano

No more headaches, reads better VA RE: 1.0 cc VA LE: 1.0 sc 8 PD esophoria for near Stereopsis: 60

Conclusion
Check refraction with and without cycloplegia
Accommodation difference

Conclusion
Check peripheral and central fusion
Suppression scotoma present?

Check visual acuity monocularly and binocularly


Diplopia present?
Aniseikonia Strabismus

Check stereopsis Amblyopia risk from 1D difference in hypermetropia Check microtropia (4^prism test/Gracis biprism)

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