Académique Documents
Professionnel Documents
Culture Documents
Foreword | xiii
Preface I xv
Part OneDiagnosis
1 Normal Binocular Vision I 3
Valu of Normal Binocular Vision |
Anatomy of the Extraocular Muscles
Neurology of Eye Movements | 6
Sensory Aspects of Binocular Vision
10
Vergences | 49
Sensory Fusin | 57
Recommendations on the Basis of Test Results
65
132
Contents
135
Suppression | 135
Amblyopia | 143
Anomalous Correspondence ) 166
Part TwoTreatment
9 Philosophies and Principies of Binocular Vision
Therapy I 263
Philosophies | 263
Principies | 268
Contents
Exotropia and Anomalous Retinal Correspondence | 340
Surgical Results n Cases of Anomalous Retinal
Correspondence | 341
Case Management 342
Case Examples | 343
Pa rt Th reeTec h n q u es
17 Vision Training for Eso Deviations I 489
MirrorStereoscope(T13.2,T14.4) | 490
ix
Contents
Contents
Appendixes | 547
A. Special Commentary: Vision, Learning, and DyslexiaA Joint
Organizational Policy Statement of the American Academy of
Optometry and the American Optometric Association | 549
B. Developmental History | 551
C. Strabismus Examination Record | 554
D. Stereoacuity Calculations | 556
E. Conversin of Prism Diopters and Degrees | 557
F. Visual Acuity and Visual Efficiency | 557
G. Visual Skills Efficiency Evaluation (Testing Outline)
558 H.
Visual Skills Efficiency Pass-Fail Gritera (Summary from
Previous Chapters) | 559
I. Visual Symptoms Survey
561
J. Suppliers and Equipment
562
Glossary | 589
Index I 593
XI
Foreword
XIII
Preface
This fourth edition of Binocular Anomalies: Diagnosis andVision Therapy follows the format and philosophy of the third edition. When the exact diagnosis
of a binocular anomaly is known, exact visin therapy can be prescribed. Part One covers diagnosis,
and Part Two is on treatment We have updated
many of the topics, because there have been important advances in diagnostic procedures and training
techniques. Deleting some of the od material has
been necessary to allow room for discussion of new
methods for diagnosis and treatment.
We take the accepted view that visin therapy
encompasses all modes of treatment of binocular
visin problems. Besides visin training, we
include the use of lenses and prisms, occlusion,
pharmaceutical treatment, motivational methods,
and extraocular muscle surgery when necessary.
Vision therapy of binocular anomalies is for treatment of strabismus, heterophoria, amblyopia, and
dysfunctions affecting educational, vocational, and
avocational performance. As n the previous edition, each visin training technique (active visin
therapy) s identified by a "T" number for easy
identificaron and referencing. Diagnostic methods
are referred to as procedures so that confusin can
be avoided between methods of testing (procedures) and training (techniques). Although these
techniques are discussed thoroughly in general
terms, we thought t would be helpful to include
specific, detailed discussions n a "how-to" format,
similar to the teaching method of a preclinical laboratory for students and practitioners (especially
primary-care clinicians) and other professionals
and therapists wishing to review and learn new
techniques. Part Three presents such detailed
instructions, including illustrations, on the most
frequently used vision-training techniques. These
instructions are applicable to clinicians as well as
to parents and patients for home training. Also
ncluded n Part Three are recommended sequencng of techniques for specific binocular anomalies
and practice management principies.
A self-assessment test of 100 multiple-choice
questions and explanatory answers s ncluded. This
addition s by popular request of students and practitioners. All questions follow the exact chapter-bychapter sequence of topics presented n the text.
Particularly updated topics include diseases
affecting binocular visin, binocular anomalies
and reading dysfunction, advantages of good binocular visin, and pharmacologic treatment. Additional case examples are included to Ilstrate the
mplementation of visin therapy and to help the
clinician connect theoretical principies with specific visin therapies.
A CD-ROM is included n which popular training techniques are discussed; these techniques can
be downloaded and modified according to the
wishes of each practitioner.
We have attempted to be semantically consistent with terminology so that the reader can sean
through various chapters without ambiguity and
always know what specified terms mean. For
example, we speak of viewing at far (e.g., 20 ft or
6 m) rather than using distance, which many clinicians use in their customary discourse. (One
could wonder if distance is referring to far distance, intermedate distance, or near distance.) In
addition, we have set eso and exo (and the like)
apart as single words when combined with fixation disparity and deviation. We have also
ncluded older terms n parentheses when a term
s ntroduced. For nstance, visuoscopy was once
spelled as visuscopy; we provide the reader with
both terms initially and retain the more accepted
term throughout the book. Our ntention s to
enhance the readability of the text.
We thank the following individuis for their help
in making this new edition possible: Karen Oberheim, Judy Higgins, Judy Badstuebner, Ronda Barton, L. Ernie Carrillo, Dr. James Saladin, Dr. James
Bailey, Dr. Walter Chase, Kirsten Griffin, R.N., Dr.
William Ridder, Dr. Lawrence Stark, Kim Vu, David
West, Donnajean Matthews, Denise Hess, Doreen
Keough, Pam Bickel, Lois Keup, and Holly Hoe.
J. David Grisham Berkeley
John R.
Griffin
Fullerton
xv
Binocular visin pertains to the motor coordination of the eyes and the sensory unification of their
respective views of the world. This is a unitary process but, for the sake of analysis, t can be broken
into sensory and motor components.
The sensory side starts with light emitted or
reflected from physical objects n the externa!
environment that is brought into focus on the retina by each eye's optics. This pattern of light
energy s transformed by retinal photoreceptors
into neuroelectrical impulses and is transmitted to
the visual perceptual reas of the cerebral cortex
and certain subcortical reas. The result of complex neural processing, which is only partially
understood, is the sensation of object attributes
(i.e., form, color, intensity, and position in space)
that, n turn, culminates n an immediate, vivid
perception of object identity and of the relations
of objects in the external environment.
The motor positioning and alignment of the
eyes completely subserve the primary sensory
function of image unification and allow visual
perception to proceed efficiently. The task of the
Retina! Correspondence 11
Panum's Fusiona! reas 11
Singleness Horopter 11
Physiologic Dipiopia 12
Pathologic Dipiopia 13 Types
of Sensory Fusin 13
Color Fusin 13
Form Fusin 13 Theories of
Sensory Fusin 15 Binocularly
Driven Cells and Ocular Dominance
16
VALU OF NORMAL
BINOCULAR VISION
One distinctive perceptual attribute of humans,
among all primates, s a high degree of stereoscopic binocular visin. Our skills in hunting,
food gathering, and tool making have helped to
direct our evolution. In the competition for food,
shelter, and safety, stereopsis is one of several
attributes that evidently provided mportant
advantages to those who possessed t. In the mod-
4 Chapter1
OD
FIGURE 1-1Extent of binocular visual field showing monocular temporal crescents. (OD = oculus dexter [right eye]; OS = oculus sinster [left
eye].) '
Chapter1
TABLE1-1. Superority of Task Performance under Binocular Conditons as Compared with Monocular Conditions
Task
30
20
9
4
4
2
-1
Q.01
0.05
NS
' NS -
NS = not signiflcant.
Source: Adapted from } Sheedy 1L Baitey, M Muri, E Bass. Binocular vs, monocular task performance. Am } Optom Physlol Qpt.
1986;63(10):839-846.
tigators concluded that stereopsis provides a performance advantage for many different Jobs, par-ticularly
those requiring nearpoint eye-hand coordi-nation. Persons in several occupations (e.g., pilots, microsurgeons,
cartographers) are aided by stereopsis in performing their tasks safely and efficiently.
Strabismus affects only a small percentage of the population (1.3-5.4%),5 but other deficiencies of
binocular visin, such as convergence insuffi-ciency and accommodative infacility, are much more
prevalent and may result in bothersome symptoms and inefficient performance. Except for those individuis
who have acquired strabismus and experience persistent double visin, most constant strabismics report few
extraordinary visual symptoms. On the other hand, many nonstrabismics with binocular visin
dysfunctions experience a variety of anomalies that are visual in origin, such as ntermittent blur at far or
near, tired eyes after reading or viewing a computer monitor, "eye-strain" at day's end, the appearance
of jumping or moving print, vision-related headaches, reduced depth perception, and mild photophobia.
Many of these symptomatic individuis experience "binocular efficiency dysfunction" (see Chapter 2).
Chapter1
Superior
Rectus
Levator Superior
Palpebrae^ obligue
LR
Oculomotor
Foramen
SR
Inferior
Rectus
Pulley
Inferior
Oblique
IR
-12mm
- 24mm
NEUROLOGY OF
EYE
MOVEMENTS
The neurology of the following systems are discussed briefly: accommodation, conjgate gaze
movements, and vergence.
Accommodation
Accommodation s one member of the oculomotor triad that also includes pupillary constriction
and accommodative convergence, all mediated
by the third nerve nucleus n the midbrain.
Accommodation is a reflex initiated by retinal
blur; t can, however, be consciously controlled.
The afferent pathway extends from the retina to
the visual cortex and projects from rea 19 to the
pretectum and superior colliculus before entering the Edinger-Westphal nucleus of the third
nerve complex. Projections from the frontal eye
fields (traditionally referred to as Brodmann's
rea 8) also enter the third nerve complex that, in
part, mediates conscious control of accommodation. The efferent component of the reflex are
from the third nerve complex synapses n the ciliary ganglion and again n the ciliary muscle
which, in turn, effectuates the change of lens
power
(Figure
1-5).
Chapter1
51 <
Medial
Wall
they are neurologically distinct, with different central pathways and dynamic properties.
Saccades
Saccadic eye movements refer to ballistic-type eye
movements that carry the eye quickly from one
target in space to another (i.e., a change in fixation). There are several types of saccades: (1)the
fast phases of either vestibular or optokinetic nystagmus; (2) spontaneous saccades occurring
approximately 20 times per minute and used to
sean the environment; (3) reflexive (nonvolitional)
saccades that occur in response to any new environmental stimulus; and (4) intentional saccades
that carry the eyes from one target to another predetermined target.9 The anatomy subserving voluntary saccades has been partly established by
monkey studies and clinical observation in
humans. For example, if there s an ntention for
dextroversion (eye movement to the right), stimulation occurs n Brodmann's rea 8 (frontal eye
field) in the frontal lobe of the left hemisphere.
Impulses then travel to the right pontine gaze center and are forwarded to the ipsilateral nucleus of
cranial nerve VI. Subsequently, the lateral rectus
muscle of the right eye contracts. Simultaneously,
impulses travel from the ipsilateral pontine gaze
center up through the medial longitudinal fasciculus that decussates to the left third nerve nucleus.
That results in contraction of the medial rectus of
the left eye (Figure 1-6). Because yoked muscles
have equal nnervation (Hering's law), 10 the two
eyes move n tndem. Versions are not restricted
because of the simultaneous relaxation of the
antagonistic yoked muscles (Sherrington's law of
reciproca! nnervation)10 (Figure 1-7).
Vestbulo-Ocular Eye Movements
The vestbulo-ocular system stabilizes the eyes on
a target during head movements and can be tested
with the "doll's-head" maneuver. The dynamics of
vestibular eye movements are relatively fast, having a latency of only 16 milliseconds as compared
with the 75-millisecond latency of the pursuit system.11 As the head turns, vestbulo-ocular reflexes
are initated by the movement of fluid wthin the
semicircular cais of the inner ear. For example,
stimulation of the left vestibular nucleus causes
impulses to travel to the right pontine gaze center.
From there, the pathway to the extraocular muscles
is the same as that described for saccadic eye
A F F E R E N T
LGN
Ciliary ganglion
reas 17-19
N III nucleus
E F F E R E N T
FIGURE 1-5Neural pathway for accommodation. (LGN = lateral geniculate nucleus; N III = cranial nerve III [oculomotor nerve].;
Chapter 1
Midbnn
Pona
Medidla
LMR
RLR
FIGURE 1 -6Neurologic pathways for saccades. a. Side view. Versional eye movements are initiated in rea 8 (supranuclear). A signal from rea 8
in the left hemisphere causes a versional movement of the eyes to the right. Axons travel down the left side of the midbrain and then decussate to
the right side at the level of the pons-midbrain. These axons then innervate the right pontine conjgate gaze center, which in turn innervates the
psilateral abducens (VI) and the contralateral oculomotor (111) nerve. b. Posterior view. (C = conjgate gaze center; IV = trochlear nerve; LMR = left
medial rectus; RLR = right lateral rectus.)
Vergences
Vergence refers to disjunctive eye movements, or
rotation of the eyes in opposite directions. The
two main types of vergence movements are
Chapter1
9
Occipital Lobes
/
fl
Left
U
LLR
LMR
J
RMR
Right
U
RLR
FIGURE 1-7Hering's law and Sherrington's law evident during levoversion. The right medial rectus (RMR) and the left lateral rectus (LLR)
ivoked muscles) contract, in accord with Hering's law. The left medial
rectus (LMR) is the antagonist of the left lateral rectus, and it relaxes,
as does the right lateral rectus (RLR) (antagonist of the right medial
rectus), in accord with Sherrington's law.
10
Chapter1
Blur
Retinas
Disparity
Visual and
Cerebral
Pathways
Midbrain
and
Pons
Extraocular
Muscles
NYI
MR
Nnr
LR
FIGURE 1-9Simplified illustration of neurology of vergences showing retinal blur stimulating accommodation, which in turn results in ac commo-dative
vergence, and retinal disparity resulting n disjunctive eye movements. Indirect stimuli (e.g., proximity and volition) are not depicted, or s cerebellar
integration. (IO = inferior oblique; IR = inferior rectus; LR = lateral rectus; MR = medial rectus; N III = oculomotor nerve [cranial nerve III]; N IV = trochiear
nerve [cranial nerve IV]; N VI = abducens nerve [cranial nerve VI]; SO = superior oblique; SR = superior rectus.)
Chapter 1
Monocular Considerations
For normal binocular visin, the best possible
visual acuity of each eye should be attained,
whether by means of spectacle lenses, contact
lenses, surgical ntervention (e.g., to correct for
cataract), or other possible treatments (e.g., visin
therapy for amblyopia). Poor acuity of either or
both eyes s a deterrent to sensory fusin. This s
particularly true when the visin of one eye s
much poorer than that of the other eye. The discrepancy may be due to such functional reasons
as anisometropic amblyopia and strabismic
amblyopia, or it may be due to organic causes,
such as macular degeneraron, cataract, and optic
nerve atrophy. Any organic disease must be ruled
out or managed correctly before functional testing s continued and visin training techniques
are begun.
Retinal Correspondence
Retinal correspondence refers to the subjective
visual direction and the spatial location of objects
n the binocular visual field. An individual s said
to have normal retinal correspondence when the
stimulation of both foveas (and other geometrically paired retinal points) give rise to a unitary
percept. (The correspondence actually occurs n
the cortex, but clinically it is easier to conceptale retinal points.) The existence of corresponding retinal elements with their common subjective
visual direction s fundamental to binocular visin.
Stimulation of corresponding retinal points results
n haplopia (singleness of visin), whether correspondence s normal or anomalous. (Anomalous
retinal correspondence s discussed in Chapter
5.) Conversely, double visin results when non-
11
12
Chapter 1
diplopia
singleness
diplopia
singleness
Fixatton
Spot
Physiologic Diplopia
The doubling of a nonfixated object is known as
physiologic diplopia, because there is nothing
abnormal about this phenomenon. With normal
binocular visin, all objects falling outside the singleness horopter can be seen as double if sufficient
attention is paid to the stimulus object. Homonymous physiologic diplopia (also called "uncrossed"
diplopia) occurs when objects are beyond the point
of bifixation. Conversely, heteronymous ("crossec/")
diplopia occurs when a farther object is bifixated
with a nearer object in view (Figures 1 -11 and 1 -12).
Because of physiologic suppression, these physiologic diplopic images usually are unnoticed under
ordinary viewing conditions.
Most patients consider seeing double to be
abnormal and seek help from an eye doctor. If the
examination does not reveal a paretic muscle or a
motor fusin problem and physiologic diplopia
seems the most likely explanation, then the doc-
Chapter1
13
Fixation
Spot
Pathologic Diplopia
Diplopia of a fixated target, or pathologic diplopia, s considered abnormal. It occurs n cases of
strabismus in which there is little or no suppression. Figure 1-10 shows one eye (left) fixating the
target of regard whe the esotropic (right) eye is
not fixating the target. In the right eye, the image,
rather than falling on the fovea, is nasal relative to
the fovea. This produces homonymous diplopia
("uncrossed"), in which the diplopic image s
seen on the same side as the strabismic eye. In
contrast, n cases of exotropia, pathologic diplopia s heteronymous ("crossed"); that s, the
diplopic image s seen on the opposite side of the
strabismic eye.
Cyclopean projection depicts the manner in
which the visual cortex mediates subjective
directionalization of ocular images. If the cyclopean eye is compared with a clock's face, the
principal visual direction would occur at the
fovea (assuming normal fixation and correspondence). In Figure 1-13, assume that the nasally
stimulated portion of the right eye is at the 7o'clock position. The directional projection is,
therefore, at the 7-o'clock position n the cyclopean eye. The difference of "1 hour" would normally cause noticeable diplopia (assuming one
image s not suppressed). When, however, the
difference is only a very small fraction of an
"hour," diplopia may not be obvious, as n fixation disparity. (Fixation disparity measurement is
discussed in Chapter 3.)
Binocular fusin of forms occurs within the singleness horopter, whereas diplopia occurs outside the
horopter. Fused binocular visin is precious, but it
is possible only in a relatively small band of visual
14
Chapter1
Fixation
Spot
-------------------- >
Whereas diplopia results from stimulation of noncorresponding retinal points, superimposition of two
ocular images (e.g., a bird in a cage) requires stimulation of retinal reas having common visual directions. Worth20 classified superimposition as "first
degree fusin." The importance of superimposition
testing is in measuring the subjective angle of directionalization (angle S) and also assessing the degree
of suppression, particularly in strabismic patients.
Worth20 classified fat fusin as "second-degree
fusin." This is true fusin but without stereopsis.
Fat fusin is defined as "sensory fusin in which
the resultant percept is two-dimensional, that is,
occupying a single plae, as may be induced by
viewing a stereogram in a stereoscope in which
the separation of all homologous points is identical."10 The most important reason to consider fat
fusin is for visin testing and training purposes, as
in phorometry measurements, fixation disparity
testing, and in amblyoscopic assessment and treatment (i.e., major amblyoscope instrumentation).
Worth20 classified stereopsis as third-degree
fusin. Stereopsis may be defined as "binocular
visual perception of three-dimensional space based
on retinal disparity."10
Figure 1-14 illustrates central stereopsis: The
fused, small vertical une is perceived as being
closer than the star. Although there is lateral displacement of the vertical line, as seen by each eye,
there will be fusin of the two lines into one vertical line which appears centered (but closer) with
respect to the star. Lateral displacement of such
types of stimuli to produce stereoscopic depth is a
feature of many visin therapy targets, such as vectographs (Vectograms), anaglyphs, and stereograms (as in this example).
When the laterally displaced stimuli are located
more than 5 degrees from the center of the fovea,
peripheral stereopsis is being evaluated. In Figure
1 -15, the "Y" appears to be closer to the patient and
the "X" farther away in relation to the star. Clinicians
also describe stereopsis as "gross" or "fine." Peripheral stereopsis is necessarily classified as being
"gross," whereas central stereopsis is considered
"fine" if it measures 200 seconds of are or better.
Stereoscopically fused images appear to be
nearer to a bifixated reference point if Panum's
reas are stimulated temporally from the center of
the foveas. Conversely, if Panum's reas are stimulated nasal ly from the center of the foveas, an
image seems farther from the bifixated reference
point. If we think of the temporal retina as having
Chapter1
Line in
Temporal
Panum's
rea
15
Generally speaking, the finer the degree of stereoscopic discrimination, the higher the quality of
binocular visin. Conversely, suppression and
excessive fixation disparity tend to decrease stereoacuity; these anomalies often predispose a patient
to asthenopic symptoms and reduced visual performance. The main valu of stereopsis is as a clue to
depth at cise viewing distances; its valu to the
individual is barely significant at far distances.21 For
instance, a surgeon is more likely to need stereoscopic depth perception than is an airline pilot.
Monocular clues to depth (e.g., size, linear perspective, texture gradient, and overlap) tend to predomnate at far distances. Nevertheless, most passenger
airlines require their pilots to have superior stereopsis, because safety and prudence demand that every
possible perceptual clue to making accurate depth
judgments be available. This stringent criterion s
probably imposed because stereopsis is the "barometer of binocular visin."
Chapter1
Chapter1
REFERENCES
1. Brny E. A theory of binocular visual acuity and an analysis of the variability of visual acuity. Acta Ophthalmol.
1946-24:63.
2. Horowtz MW. An analysis of the superiority of binocular
over monocular visual acuity. J Exp Psychol. 1949;39:581.
3. Campbell FW, Creen DG. Monocular vs. binocular visual
acuity. Nature. 1965;200:191-192.
4. Sheedy JE, Bailey IL, Muri M, Bass E. Binocular vs. monoc
ular task performance. Am J Optom Physiol Opt. 1986;63
(10):839-846.
5. Michaels DD. Visual Optics and Refraction. St. Louis:
Mosby; 1980:677.
6. Derner JL, Miller JM, Poukens V, et al. Evidence for fibromuscular pulleys of the recti extraocular muscles. Invest
Ophthalmol Vis Sci. 1 995;36:1125-1136.
7. Clark RA, Miller JM, Demer JL. Location and stability of
rectus muscle pulleys. Invest Ophthalmol Vis Sci. 1997;
38:227-240.
8. Clark R, Miller J, Demer J. Three-dimensional location of
human rectus pulleys by path inflections in secondary
gaze positions. Invest Ophthalmol Vis Sci. 2000;41:37873797.
9. Glaser JS. Neuro-ophthalmology. Philadelphia: Lippincott; 1990:300.
10. Hofstetter H, Griffin J, Berman M, Everson R. Dictionary
of Visual Science and Related Clinical Terms, 5th ed. Bos
ton: Butterworth-Heinemann; 2000:284.
11. Maas EF, HuebnerWP, Seidman SH, Leigh RJ. Behavior of
human horizontal vestbulo-ocular reflex in response to
high-acceleration stimuli. Brain Res. 1989;499:153-156.
12. Bajandas FJ, Kline LB. Neum-Ophthalmology Review
Manual, 2nd ed. Thorofare, N.J.: Slack Inc.; 1987:51-54.
13. Hoffman FB, Bielshowsky A. ber die der Wilkur entzogenen Fusionsbewegungen der Augen. Arch Ges Physiol.
1900;80:1.
17
20
Chapter 2
For any patient being treated for binocular anomalies, the ultmate goal is the achievement of clear,
single, comfortable, and effcient binocular visin'.
Visual ski lis efficiency (VSE) s the term applied to
the ways n which various ocular systems oprate
over time and under various viewing conditions.
Clinical evaluation of visin efficiency necessitates
the assessment of sufficiency (amplitude), facility
\WQ\\\tj\ acawaq, wb stamm oi each ocular
function.
Practitioners in the nineteenth century were
concerned almost exclusively with clearness of
eyesight and with lenses that would optimally
reduce or elimnate blurred visin. Clearness and
singleness of binocular visin became the issue
with the advent of orthoptics. Effective therapeutic
regimens for strabismus were introduced by Javal1
and were expanded later by others.
Astute clinicians in the first half of the twentieth century became aware of the relationship
between accommodation and vergence. Knowledge of the zone of clear, single, comfortable
binocular visin was gained through various
models of visin, such as the graphical analysis
approach, and through an understanding of fixation disparity (see Chapter 3).
In the latter half of the twentieth century, more
and more emphasis was placed on efficiency of
visin, implying that effcient visual skills are
related to good scholastic abilities (school) and
occupational production (work) and to achievement in sports and hobbies (play). As a result,
lenses or functional training techniques frequently
are applied in clinical practice to help patients
attain efficient binocular visin in these activities.
(Surgery is not a mode of therapy commonly associated with visin efficiency therapy.)
Fundamental to having good VSE is the optimum correction of any significant refractive error.
Clinicians have found that correcting even small
errors of refraction can result in large changes in
visual comfort, stamina, and performance. If a
patient presents with a significant refractive error,
a visin efficiency evaluation ideally should be
performed with the new lens correction in place,
if necessary using a trial frame spectacle correction. Normative data presented in this chapter
assume that refractive error has been corrected.
Dysfunctions of visual skills also result from a
mismatch between a patient's oculomotor and
binocular physiology and the environmental
demands placed on the individuaos visual system.
Chapter 2
PATIENT HISTORY
The most mportant and revealing component of
the history is the chief symptom. Intense eye pain
and prolonged double visin are not symptoms
commonly associated with visin efficiency dysfunctions and usually indcate more severe and
acuite disorders. Vision efficiency dysfunctions,
particularly in adults, often are associated with
symptoms related to visually demanding activities
at near distances, such as reading, writing, sewing,
and computer use. The symptoms usually increase
in ntensity with ncreased time devoted to the task
and abate with sleep or rest.
Asthenopia applies to symptoms of ocular
fatigue or discomfort. The common symptoms of
tired eye with sustained visual activity should be
distinguished from reports of general fatigue. Tired
eyes do occur as part of chronic fatigue, systemic
diseases (e.g., hypothyroidism and other endocrine
mbalances), allergy attacks, and general stress
reactions. Clinicians are often challenged to make
the distinction between ocular fatigue and general
fatigue, because each can contribute to manifestations of the other. A carefully obtained, detailed
patient history may be necessary but sometimes
still is nsufficient.
Headaches can be causes of or exacerbated by
dysfunctions of accommodation or vergence or
both. However, headaches are attributable to
many different medical and psychological etiologies, and so differential diagnosis is necessary.
Ocular headaches usually are described as a dull
to modrate ache at the brow line, around the
eyes, or emanating from the orbits. Other locations
may be mplicated, particularly the back of the
head and neck, which are also associated with
general stress. Vision efficiency dysfunctions have
also been known to initiate a migraine headache
in sensitive individuis.
Reports of intermittent blur, doubling, or "wobbling" of print are also common and are highly associated with disorders of accommodation and
vergence. Except for symptoms associated with tracking dysfunctions, pinpointing specific conditions
associated with specific symptoms is difficult. The
symptoms associated with accommodative and vergence dysfunctions often overlap. Saccadic tracking
dysfunctions, however, often result n definitive signs
and symptoms. In such cases, patients report (1) skipping over words, parts of words, or sentences;
(2) inadvertent rereading of a line of print; (3) losing
21
MALADAPTIVE BEHAVIORS
Preschool and elementary school children rarely
report visual symptoms, even in cases of frank
visual dysfunction. On careful examination, some
are found to have significant dysfunctions by standardized clinical criteria but, when asked, they
seldom admit to any visin problem. As observed
n cases of early-onset myopia, n which reports of
blurred visin are also rare, young children do not
have a standard for comparison. They believe that
what they are experiencing visually, for better or
worse, is normal and expected. Children also rapidly modify their behavior when they do encounter
difficulties. With careful questioning of a child,
parents, and teacher, the clinician often finds that
the child compensates or maladapts by demonstrating avoidance behavior, a short attention span,
and distractibility, and develops a dislike for the
activity causing discomfort. To compnsate for a
binocular visin problem, a child might hold reading material very cise to enlarge the print, shut or
cover an eye with a hand, or lay his or her head on
the upper arm to disrupt binocular fusin. Some
children learn to hold the head up and turned to
one side so that the nose can act as an effective
occluder. Using one's hand to shade the eyes from
overhead lights provides some relief when oversensitivity is present (e.g., from a mild nflammation of the eyes). Rather than conducting a
problem-based examination of a child, the clinician must take a proactive approach to history taking for behavioral maladaptations and then
undertake a thorough examination, including measures of visin efficiency.
READING DYSFUNCTION
Do visual skill deficiencies adversely affect reading
performance? Does visin therapy for visual skill
dysfunctions result n mproved comfort, reading
efficiency, and reading performance on standardized tests? These are mportant and somewhat controversial questions. The American Academy of
Ophthalmology and the American Academy of
Pediatrics drafted a position statement denying any
22
Chapter 2
relationship between visual conditions (save uncorrected refractiva error) and reading disabilities. The
mplication is that visin therapy s ineffective and
a waste of remedial time.2 This statement s ambiguous in that the term "reading disability" can be
interpreted to mean dyslexia, a neurologically
based disorder in word decoding, or t can be interpreted to mean any significant reading problem
from other causes. The American Optometric Association, n collaboration with other optometric
organizations, have issued their own position statement arguing that several visual conditions aside
from refractive error are associated with poor reading performance and not necessarily dyslexia.3 (See
Appendix A for text of statement.) Furthermore,
visin therapy s a recognized and effective therapeutic intervention for improving or curing visin
efficiency dysfunctions. In cases n which such
therapy s applied, improved reading performance
often occurs. However, visin therapy techniques
for visual skill deficiencies are not intended to cure
dyseidetic or dysphonetic types of dyslexia.4 Both
visin specialists and the public at large need
authoritative information on these issues, due to the
obvious important mplications for school visin
screening and because of the serious social concern regarding improving students' reading performance across the nation.
Many studies have sought an association between
visual conditions and reading performance. As one
might expect, these studies vary considerably in
their subject groups, tests of reading and visin,
and quality of research design and analysis. One
statistical approach used to evalate a large number of studies with varying design features s called
meta-analysis. Simons and Gassler5 used this technique in evaluating the results of 32 controlled
studies that used valid tests for visin conditions
and reading performance. Good reading performance was found to be associated with uncorrected myopia. The tested students, as a group,
read better than did emmetropic students requiring
no spectacle correction. In uncorrected myopia,
the farpoint of accommodation (the punctum
remotum) resides at a near distance, so less accommodative effort is required for reading. Distant
visin s mpaired, but the eyes are optically in
focus at some near distance f the amount of nearsightedness is approximately equal in each eye
and is not severe. In contrast, poor reading was
found to be strongly associated with uncorrected
hyperopia (i.e., farsightedness). In these cases,
Chapter 2
23
What are the symptoms of either organic softsign or functional saccadic dysfunctioning? Several
performance problems may be evident f saccadic
eye movements are poor, even though the patient
s otherwise considered neurologically normal.
Inefficiency in reading is a major problem and s
frequently reported n such cases. Words may be
omitted, lines may be skipped, or loss of place may
occur often during reading. "Finger reading" may
indcate the need for hand support due to poor eye
movements. Head movement when reading is
another common sign of poor saccades. The
patient may present with a history of "having trouble hitting the ball" or "doing poorly in many athletic events." Job performance may be affected
adversely if eye-hand coordinaron is exceptionally
poor due to saccadic eye movement problems.
Saccadic Suppression
Javal may have been among the first to note that
visin turns off as a saccadic eye movement is
occurring. This makes sense; otherwise, the world
would appear to be a swimming, blurry mess as we
sean our environment. This perceptual inhibition,
which has been called saccadic "blindness," is
more aptly named saccadic suppression. According
to Solomons,9 each saccadic eye movement is preceded by a latent period of approximately 120-180
milliseconds before the eye movement actually
begins, and saccadic suppression begins to occur
approximately 40 milliseconds before the movement commences. The inhibition ncreases until
visual perception is almost zero during the first part
of the movement. Probably not until after the saccadic movement has ended does the saccadic suppression completely cease.
The first differential diagnostic issue for consideration s whether a pathologic etiology s present
when deficient saccadic eye movements are found.
If voluntary versions are severely restricted, the clinician should suspect neurologic problems affecting the saccadic pathway, such as myasthenia,
vascular disease, or tumors that may affect supranuclear control. Other signs of neurologic dysfunctioning would likely be evident n such cases.
Many times, however, only subclinical "soft" signs
are present, with the patient appearing to be normal n all other respects. Many patients have functional saccadic problems, such as those from poor
attention, hyperkinesis, or poor visual acuity due to
uncorrected refractive errors, and possibly because
saccadic skills were never learned adequately.
Objective Testing
Clinicians should evalate saccadic eye movements using both gross and fine tasks. Fine saccades are those nvolved in reading (approximately
7 degrees or less). Larger saccades than these are
considered gross. A patient's saccadic eye movement skills can be evaluated either on an objective
or a subjective basis.
Any target, such as small letters on two pencils,
can be used to test for gross saccadic ability. The
patient s asked to look voluntarily from one target
to the other. This usually is done n right- and leftgaze orientations, but vertical as well as oblique
orientations can be tested. If one of the patient's
eyes is occluded, testing s for saccadic ductions. If
both eyes are open, testing s for saccadic versions.
It should be noted that even behind an occluder,
the covered eye moves conjugately with the uncovered, fixating eye. A difference may be noted, however, in the performance of one eye as compared
with the other during duction testing. This possibility s an important consideration n therapy, as the
patient should, f possible, have equal saccadic
skills in both eyes.
Gross saccades are used in general environmental scanning to direct fixation to a point of interest.
They can be initiated by reflex stimuli or by volition, so both stimulus modes are employed n
screening. Because reading requires finer control of
saccades than s sampled by such screening tests,
these procedures are more appropriate for evaluating saccadic skill n general scanning and in sports
performance. The patient is asked to stand free of
24
Chapter 2
Chapter 2
25
'
D
Stable saccades for 20 secs (2)
Stable saccades for 10 secs (1)
E
Adequate stamjna (1)
Source: A, Heinsen, R, Schrock, personal communication, 1981.
"
A normal saccadic pattern in five-dot testing is
shown on the Eye-Trac recording strip in Figure 2-4a.
Note that five fixations were made for each row of
dots, and they were spaced fairly equally, but a very
slight undershooting occurred on the return sweeps
(gross saccades to the left). Figure 2-4b shows many
inaccuracies and regressions on this test. This type
of analysis is also possible with the Visagraph.
The Visagraph is comparable to the Eye-Trac.
The principal difference between these two systems
is that the patient being assessed by the Visagraph
wears special spectacles containing photosensitive
cells. The presumed advantage of the Visagraph is
that head movements will not interfere with
recordings of eye movements, in contrast to the
Eye-Trac.
The Visagraph II is an infrared eye movementrecording system used in conjunction with a personal computer for analysis of the eye movement
record. Taylor Associates (see Appendix J) designed
this instrument for clinicians and educators to evalate an individual's eye movement characteristics
during the act of reading standardized selections of
print and for analysis of saccadic control independent of information processing. For the purpose of
oculomotor evaluation, patients are asked to stare
at a dot target for 10 seconds and then alternately
to fixate two separated points for 10 cycles. The
record then is evaluated for stability of fixation and
saccadic accuracy (i.e., the number of fixations
actually made during the test). No normative data
are currently available, but gross disorders of fixation (e.g., nystagmus, saccadic intrusions, and
lapses of visual attention) can be identified by the
computer analysis of the fixation record or by
direct inspection of the original graph.
For evaluating sequential saccades (as used n
reading) independent of information processing, severa! lines of targets can be presented on a test card
(see Figures 2-3 and 2-5). The patient (or student) is
instructed as follows: "Look at each and every target
as rapidly as possible as if you were reading a book.
Don't say anything, however, even to yourself. Don't
miss any number and move from one to the next as
quickly as you can." After the test is given, the computer eye movement profile and the original graph
can be inspected relative to several detailed oculo-
Chapter 2
27
Subjective Testing
Saccades may also be evaluated indirectly by subjective means rather than directly by objective
observations. The following tests are examples of
subjective methods.
Chapter 2
Pierce Test
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Chapter 2
29
Right 164
164 36
38
Fixations/100 numbers
Regressions/100 numbers
0.28
0.28
130
Directional Attack
23%
Rate adj. for Rereading (numbers/min) 281
Class:
School:
Comment:
0.990
Test Numbers
Sex: M
Grade:
Lines found
Text:
Title:
t-0-0.txt
Numbers
10
1/1/0
30
Chapter 2
FIGURE 2-8Eye-Trac recordings (a) before and (b) after visin therapy showing improved performance for reading a paragraph.
Note the approximate 3-to-1 mprovement in saccadic efficiency between ages 6 and 13, whereas
beyond age 13, improvement is minimal.
that subtests II and III were too difficult for many 6year-old children, and so only subtest I is recommended; it was found to have norms of 30.98 seconds
with 1.32 errors for 6-year-old children. The King-
King-Devick Test
Cheonofcgic Age
Corrected Time Scores Expected
(secs)
55
12
13
Chapter 2
Age (yrs)
6
7
8
9
10
11
12
13
14
Time in
Seconds (total
of 3 subtests)
119
101
77
79
68
57
54
52
50
Number of
Errors (total of 3
subtests)
17
12
3
3
2
1
1
1
0
Manual of the
Bernell Corp.; 1993.
31
32
Chapter 2
3
7
4
5
3
2
75
9
7
4
5
4
9
2
3
2
7
2
3
3
4
8
6
3
2
1
4
65
37
52
93
17
9
2
7
57
75
3
46
a
FIGURE 2-10Developmental Eye MovementTest showing (a) vertical array of numbers and (b) horizontal array of numbers. Similar to the Pierce test,
the Developmental Eye MovementTest uses a formula to determine "adjusted" time: Adjusted time = test time x 80/(80 - O + A), where test time =
actual time for number calling on the horizontal array; O = omission errors; and A = addition errors (numbers either being repeated or added).
test. This added demand is designed to assess ability for sustained performance (stamina).
Visual stamina and attention in performing saccadic tests have been found to be important factors
in distinguishing those students who fail the DEM
test and those who pass.16 More errors were made
in the second half of the horizontal test by the failing students.
Similar to the Pierce test, the DEM test uses a
formula to determine "adjusted" time:
Chapter 2
TEST
3
TEST B
4
2
1
2
9
3
9
1
7
8
2
7
5
1
7
2
1
TESTC
5
4
9
7
3
6
9
O
2
5
3
1
4
7
8
6**^ S
-*
G7
TIMI
J_
-L.
_s
errors
_a
<y o errors
/ t errors
80
TIMEx
(80-o + a)
21 sec
TOTALTIME: 4/
sec
ADJ TIME
'^ s e c ^ O
/
ERRORS:
sec
errors
TIME
ADJ
=
<)
33
,*;
=_z_/>#;
/ *O S-.es \
** T^ (***)
' RATIO = -
Chapter 2
34
Rank Description
5432
1
visin therapy.
Description
Very strong
4
3
Strong
Adequate
2
1
Weak
Very weak
Results
Two or more years above
average
One year above average
Average performance for
age
One year below average
Two or more years below
average
Chapter 2
Characteristics
According to Michaels,22 pursuits are unlike saccades n that visin is present (without suppression,
as n saccades) throughout the eyes' excursions. The
speed of pursuits s limited to approximately 30
degrees per second. They may be considerably
slower but not much faster. If the target velocity is
too high, the pursuits break down into a jerky
motion. The attempt to keep tracking requires the
faster saccadic responses to come into play in order
for the patient to regain fixation of the target. In
infants, pursuit eye movements start to manifest at
approximately 6 weeks of age and increase n tndem with the development of sustained visual attention to moving targets.23
Pursuits are a form of duction eye movements
when only one eye s being tested (monocular
35
36
Chapter 2
Up gaze
TABLE 2-7. Heinsen-Schrock System for Testing
and Rating Pursuit Eye Movements, Modified for
5-Point Scale
Patient's
_ Left
gaze
Patient's
Right _
gaze
Ten-Pont
Scale
Five-Point
Scale
3
2
1
O
1.5
1.0
0.5
0.0
3
2
1.5
1.0
1
O
0.5
0.0
B
Down gaze
FIGURE 2-12British flag pattern from clinician's view (lines indicatng movements of penlight) for testing pursuits with the Southern California College of Optometry 4+ test.
3
2
1
O
1
1.5
1.0
0.5
0.0
0.5
0.0
Heinsen and Schrock(A. Heinsen, R. Schrock, personal communication, 1981) introduced a rating
system (the H-S Scale) for pursuits that is similar to
that for evaluating saccades (discussed previously).
This 10-point scale is shown in Table 2-7. Our 5point ordinal ranking system also is shown, to
allow comparison of the very strong to very weak
Chapter 2
37
categories for pursuit skills with rankings of functions for other visual skills, as discussed previously
for saccades. The advantage of the HeinsenSchrock system over the SCCO 4+ system is that
automation and stamina are taken into account
along with head movements, smoothness, and
accuracy. Either a Marsden bal I or a motorized
instrument such as the Bernell RotatorTrainer (Bernell Corporation; see Appendix J) (Figure 2-13) is
ideal for this type of testing, although a handheld penlight that is moved smoothly and evenly
will suffice. Whatever target s used, smoothness,
accuracy, head movement, automation, and stamina are to be evaluated. Using the same cognitive
demands as in saccadic testing (discussed previously) and continuing the pursuits for 1 minute will
allow for judgment of automation and stamina,
respectively.
Afterimages
38
Chapter 2
Summary and
Recommended Tests
Clinical assessment is important for identifying
neurologic problems and dysfunctional visual
tracking (particularly relevant to sports performance). The SCCO 4+ test is recommended for use
by primary eye care practitioners in routine cases.
Pursuit tests should usually include monocular
(duction) as well as binocular (versin) testing.
Functional and organic causes should be differentiated. Some patients may require "diagnostic therapy" to determine whether the identified problem
abates as a result of visin training. Practitioners
choose their favorites from among the available
testing procedures. For example, a recently introduced test for pursuits, devised by Dr. W. C.
Maples, is becoming popular (see the section Summary of Saccade Testing).
FIXATION
Fixation (known also as position maintenanc)
involves all four eye movement systemssaccades,
pursuits, nonoptic (e.g., VOR) system, and vergences. Fixation evaluation usually is accomplished
toward the beg'mning of an eye examination (e.g.,
during the unilateral test). Assessment s made as the
patient fixates on a target in primary gaze.
Figure 2-14 shows Eye-Trac recordings of good
versus poor position maintenanc. Reading difficulties and various symptoms may occur with poor
position maintenanc.
True position maintenanc is actually a misnomer, in that very small movements are occurring all
the time during so-called steady fixation: The eyes
are not motionless during fixation. Ocular micromovements consist of rapid flicks and slow drifts of
a vev\ sma\\ ampVvtude that are not observable
without special equipment.TViese sma\\ movements
are believed to be useful for the purpose of correcting fixational errors, to keep the fixated target precisely on the fovea, and possibly preventing retinal
adaptation (fatigue).
Position maintenanc can be assessed by asking
the patient to fixate (monocularly) on a target.
There should be no noticeable drifting or eye
movement from the target of regard. If the patient
cannot maintain steady fixation, he or she should
be instructed to hold a thumb at 40 cm to determine whether the proprioceptive input from the
"hand support" is helpful in maintaining steady
eye positioning. The problem may persist (e.g., due
to congenital nystagmus). If the problem is psychological (e.g., lack of attention) or from other known
causes (e.g., fatigue or drug effects), improvement
of position maintenanc often is possible through
appropriate environmental changes and the efforts
of functional training techniques.
The vast majority of patients show steady fixation ability with each eye. Unsteady fixation of
one eye can be seen in some cases of amblyopia
or decreased monocular visual acuity from other
causes. Saccadic intrusions are unconscious,
rapid, bidirectional flicks of fixation off a target
and back on. These intrusions may be a presenting sign of a neurologic disorder. They look like
square-wave, to-and-fro "darting" movements of
the eyes on attempted fixation. Small saccadic
intrusions, from 1 to 5 degrees, can be seen in the
elderly; in patients with dyslexia, strabismus, or
schizophrenia; and in patients who are extremely
fatigued. However, larger saccadic intrusions, 5
to 20 degrees, can be associated with degenerative conditions such as mltiple sclerosis.
Chapter 2
39
Vestbulo-Ocular Reflexes
The eyes maintain gaze on a target with rotation of
the head through the neurologic control of VOR.
Head position and acceleration are sensed by the
semicircular cais and otolith apparatus and are
communicated to the oculomotor centers n the
midbrain. The effect of this process s that a head
movement in any direction s accompanied by an
equal and opposite eye movement, thus stabilizing
the eyes relative to a target. Vestbulo-ocular, neck,
and body reflexes combine with optokinetic
reflexes to stabilize the retinal image as an individ-
Chapter 2
, Rank
Description
Very strong
Strong
Adequate
Weak
Very weak
Results
Steady fixation for more
than 10 secs
Steady fixation for at least
10 secs
Steady fixation for at least
5 secs
Steady fixation for less
than 5 secs or hand support needed
Unsteady fixation almost
continuously
ual moves through the environment. Developmental disorders of VOR tracking are relatively rare;
most deficiencies are acquired by trauma or neurologic disease.
A complete assessment of VSE should include a
screening of VOR tracking. The patient is directed
to hold gaze on a discreet fixation target at far or
near, while either he or she moves or the clinician
gently moves the patient's head up and down for
several cycles at the rate of 1 cycle per second.
This pr oc edure then is repeated m ovi ng the
patient's head from side to side the so-called
"doll's-head" maneuver. Smooth tracking is the
rule. The presence of either saccadic intrusions
("catch-up" saccades) or nystagmus indicates a
failure in VOR tracking and should be further
assessed. In children, intervening saccades may
indcate simply lapses of attention to the task,
which should be taken into consideration.
Further assessment can include challenging
V O R tr ac k i n g t hr o u g h h e a d s h a k i n g th at i s
gr eater than 1 c ycle per s ec ond. Im m ediately
after 10 to 15 seconds of head shaking by the
patient in the vertical or horizontal pla e, the
practitioner should look for nystagmus using a
magnifier or ophthalmoscope. Another technique
is to measure binocular visual acuity before and
during head shaking, both horizontal and verti cal. Snellen visual acuity should not decrease
more than one line (e.g., 20/20 to 20/25) during
head shaking if ther e is good VOR tracking.
Patients having signs or symptoms of a VOR disorder should be referred for further neurologic
testing.
ACCOMMODATION
Functional disorders of accommodation can be separated into four types of problems: (1) insufficiency,
(2) excess, (3) infacility, and (4) ill-sustained accommodation (poor stamina). Patients can present with
an accommodative dysfunction thatfalls into any one
or all of these categories, as the categories are not
mutually exclusive. In fact, many patients who can
be described as having an accommodative insufficiency also show signs of infacility and poor stamina.
Two additional categories of accommodative dysfunction are (5) unequal accommodation and (6)
paresis or paralysis of accommodation. The etiology
of these last two disorders is not functional. In cases
of accommodative insufficiency stemming from neurologic disease or trauma, patients are best served by
a prescription for reading glasses rather than visin
training. 27 The first four categories do not imply an
organic etiology, as they often arise from functional
causes (e.g., deficient physiology, overwork, or inattention). Besides describing the characteristics of an
accommodative dysfunction, the clinician must
determine, insofar as possible, the specific etiology
and must seriously consider the many nonfunctional
factors (Table 2-9) before the condition is assumed to
be functional in origin. A review of accommodative
conditions and appropriate testing follows.
Insufficiency of Accommodation
Insuffidency of accommodaton is defined as "insufficient amplitude of accommodation to afford clear
imagery of a stimulus object at a specified distance, usually the normal or desired reading distance." 21 This-, is sometimes a problem in
prepresbyopic patients and very often is problematic
in presbyopic patients but is not too frequent in
younger patients. However, pathologic conditions
affecting the third cranial nerve, the ciliary muscle, or
the crystalline lens itself can result in paresis or paralysis of accommodation for all age groups. The use of
sympathomimetic (adrenergic) or parasympatholytic
(anticholinergic) drugs also result in symptomproducing lowered amplitudes of accommodation.
Although isolated accommodative insufficiency in
young patients is relatively rare, we saw three young
men with isolated accommodative insufficiency
within a 1-month period. All had a history of tropical
illnesses of some kind. All had to wear bifocals to
read clearly, and we happened to see them after they
had been to other practitioners who insisted they did
not need to wear bifocals because of their youth. The
Chapter 2
TABLE2-9.
41
Functional etiology
Binocular: deficient accommodation due to biolgica! variation in th populaton, excessive nearpoint work, low Illumination, low oxygen level, ocular and general fatigue or stress, vergence problems,
Monocular: strong sighting-eye domtnance resulting in poor accommodation n the nondominant eye
Refractive etiology
Binocular: manifest and latent hyperopia, myopes who do not wear spectacles at near, pseudomyopra, premature
and normal presbyopia
Monocular: uncorrected anisometropia, poor refractive correction, unequal lens sclerosis
Ocular disease
Binocular: internal ophthalmoplegia, bilateral organic amblyopia, premature cataracts, bilateral glaucoma, iridocyclitis, ciliary body aplasia, partial subluxation of lens
Monocular: same as for binocular condition, but affecting one eye more than the other, anterior choroidal metstasis,
trauma, rupture of zonular f ibers
Systemic diseases or conditions affecting binocular accommodation
Hormonal or metabolic: pregnancy, menstruation, lactation, menopause, diabetes, thyroid conditions, anemia, vascular hypertension, myotonic dystrophy
Neurologic: myastheia gravis, mltiple sclerosis, pineal tumor, whiplash injury, trauma to the head and neck, cerebral
concussion, mesencephalic disease, including vascular lesions
Infectous: influenza, intestinal toxemia, tuberculosis, whooping cough, measles, syphilis, tonsillar and dental infec-tions,
encephalitis, viral hepatitis, polio, amebic dysentery, malaria, herpes zoster, many acute infections
Drugs, medications, and toxic conditions affecting binocular accommodations
Residual effects of cycloplegic drops, alcohol neuropathy, marijuana, heavy metal poisoning, carbn monoxide,
botulism, antihistamines, central nervous system stimulants, large doses of tranquilizing drugs (phenothiazine
derivatives), parkinsonism drugs, many other systemic medications
Emotional, usually binocular: stress reactions, malingering, hysteria
Absolute Accommodation
The amplitude of accommodation s measured
monocularly using the push-up method for one eye
and then the other. This is absolute accommodation. The print size should be equivalent to 20/20
(6/6) at 40 cm, or smaller or larger depending on
the patient's mximum visual acuty. The mximum
Chapter 2
TABLE2-10.
Donders'Table ofAmplitude of
TABLE 2-12. Ranking of Relative Accommodation
(in which Dioptrc Powers Represent the First
Sustained Blur)
Accommodation
Age (yrs)
Amplitude (D)
10
14.0
20
30
40
50
10.0
7.0
4.5
2.5
A = 15 - 0.25(x)
where x is the patient's age in years. For example, if a
patient is 10 years od, the expected amplitude is 15
- 0.25(10), or 12.5 D. An amplitude of only 8.5 D in
the right eye would be very weak, as this is 4 D
below average. Table 2-11 gives accommodative
ranking. The Hofstetter formula may not hold true for
TABLE 2-11. Ranking of Accommodative Amplitude
Rank
Description
5
Very strong
4
Strong 3
Adequate 2
Weak 1
Very
weak
Amplitude
1 .00 D or more above
average 0,50 D above
average Average for
age 2.00 D below
average 4.00 D or more
below average
Rank
5
4
3
Description
Very strong
Strong
Adequate
Weak Very
weak
2.25 D
1.7S-2.00D
1.50D
<1.50D
very young children because their clinically measured amplitudes are often lower than would be predicted theoretically. Practitioners should consider
this when testing children younger than 6 years.
Semantic confusin often arises over the term
accommodative insufficiency. Some sources (inappropriately, in our opinin) refer to "accommodative deficiency" or "insufficiency" when talking
about accommodative nfaciUty. (Accommodative
infacility is discussed later in this chapter.)
Relative Accommodation
Chapter 2
43
Lag of Accommodation
Although t does not necessarily imply insufficient
amplitude of accommodation, lag of accommodation can be thought of as a clinical form of accommodative insufficiency for a particular nearpoint
target. Accommodative lag can also be thought of
as accommodative inaccuracy, just as fixation disparity can be considered to be an inaccuracy n
vergence. Lag of accommodation can be measured
in several ways, but two of the most reliable clini cal methods are described here.
Nott Method
The Nott dynamic retinoscopy method is based on
the linear difference between the fixation distance
(usually 40 cm) and the distance of the retinoscope
Chapter 2
m
Harmon distance (distance equal to that from the tip
of one's elbow to the middle knuckle of the clenched
fist measured on the outside of the arm).21 Distances,
however, may vary, as the patient's habitual reading
distance is recommended. The binocularly viewing
patient s instructed to read appropriate material (for
his or her age or cognitive level) mounted on the retinoscope. A trial lens s quickly interposed in the
spectacle plae of one eye to neutralize the retinoscopic reflex (Figure 2-16). The lens s removed from
the eye within a second, because latency of accommodation response is short. Tucker and Charman34
found a mean reaction (latency) time of 0.28 second
for one subject and 0.29 second for another. Therefore, the neutralizing lens must be quickly removed
once it is introduced before an eye. The stimulus to
accommodation might be changed if the lens is
before the eye for a longer duration. The possibility of
changing accommodative responses by changing
accommodative stimuli must always be kept in mind
when one is conducting the MEM test.
The lens power (addition of plus) necessary to
achieve retinoscopic neutralization is the estimated accommodative lag of the eye being tested
at the moment. If minus power should be required
for neutralzation, accommodative excess would
be indicated.
Using the Nott or MEM procedure, we believe
an accommodative lag of 1.00 D or greater is
cause for further investigaron. This concern was
shared by Bieber.35 A high lag of accommodation
suggests the possibility of anomalies of insufficiency of accommodation, infacility of accommodation, and ill-sustained accommodation, any of
which can be adverse factors in visin efficiency.
Ranking of either Nott or MEM results s shown n
Table 2-13. A rank of 2 or 1 s failing, and referral
for visin therapy may be recommended.
Excess of Accommodation
Another inaccuracy s accommodative excess,
sometimes called spasm of accommodaton, hyperaccommodation, hypertonic accommodation, or
pseudomyopia. Accommodation may be excessive n
focusing on a stimulus object and is considered to be
TABLE 2- 13. Ranking of Accommodative Lag
(Insufficiency, or Inaccuracy, of Accommodation)
Rank
5
Description
Very strong
4
3
2
1
Strong
Adequate
Weak
Very weak
MEM = monocular
stimate
OS = ocultis sinister.
Chapter 2
45
Rank
5
4
3
2
1
Description
Very strong
NA
Adequate
(borderline)
Weak
Very weak
Lerts Power
Indicating Lead of
Accommodation
+0.25 D
NA
0.00 D -0.50 0.25
D or Dgreater
NA = not applicable.
Facility of Accommodation
Another aspect of accommodation s facility. An
infacility of accommodation, also known as inertia
of accommodaton, is the inability to change focus
rapidly. Accommodative infacility can cause discomfort and reduced visin efficiency. For example,
such patients typically report slow clearing of
visin, most often noting blurring when looking
from the "book to the board." The standard testing
procedure s to use 2.00-D lenses. The recommended optotype s the equivalent of a 20/30 (6/9)
Une of Snellen letters at 40 cm while the lens power
is changed from plus to minus, and so on, for 1
minute. Lenses may be mounted in devices (Figure
2-17) that are similar to a Comparator (Bausch &
Lomb, Rochester, NY). Testing is done monocularly
(oculus dexter and oculus sinister) and then binocularly. Suppression can be monitored with vectographic targets (Figure 2-18). Although clinicians
may ask the patient to say "clear" with each stimulus change, a better technique s to nstruct the
patient to read each letter aloud as quickly as possible with the introduction of each lens flip. This
allows monitoring of correct or ncorrect responses.
The number of accurate calis is recorded and converted into cycles per minute by dividing that number by 2. For example, f the number of correct calis
for an eye is 8, there are 4 cycles per minute.
46
Chapter 2
FIGURE 2-17Bernell flipper devices for accommodative facility testing. (Courtesy of Bernell Corp.)
Chapter 2
47
Results
Study
Burge39
37
Grffn et al.
38
Griffin et al.
36
Lu et al.
40
41
Grisham et al. and Pope et al,
Age Group
Children and young
adults
Young adults
Young adufts
dulls
Children
SO = standard deviation.
Chapter 2
48
Ill-Sustained Accommodation
Rank
Description
5
Very strong 4
Strong 3
Adequate 2
Weak
1
Very weak
OD or OS
>18
14-18
10-13
6-9
Binocular*
>10
8-10
6-7
4-5
<6
<4
Chapter 2
as it s for saccades, pursuits, and position maintenance (discussed previously).
If a patient meets the recommended criteria for
accommodative facility testing with a consistently
good rate of responses throughout the test, there is
no need for stamina testing.
TABLE 2-17.
5
4
Summary of
Accommodation Testing
Accommodative nsufficiency s tested n several
ways. The amplitude of absoluta accommodation
s found by monocular push-ups and, possibly, by
bracketing between push-ups and push-aways
when necessary. PRA and NRA are binocular tests
of relativa accommodation. Dynamic retinoscopy
under binocular viewing conditions, conducted
with either the Nott or MEM method, determines
an accommodative naccuracy.
Testing for infacility introduces the element of
time, which relates to the efficiency of accommodative responsiveness. The standard testing procedure is to use 2.00-D lenses, first monocularly
and then binocularly. At least 10 cycles per minute
are necessary for monocular adequacy and 6
cycles per minute binocularly (with suppression
monitoring). Testing for ll-sustained accommodation also involves the element of time. The difference between this and testing for infacility is that
the quality of accurate responses as to stability and
endurance is assessed, rather than the mere quantity of accurate calis.
VERGENCES
Vergences are disjunctive eye movements (rather
than conjgate movements, as n the three other
movement systems). The occipitomesencephalic
neural pathway for vergences, at least for convergence, extends from rea 19 to the third nerve
nuclei. Vergence movements are slow (as compared with saccades) and mainly involuntary.
According to the traditionally used Maddox classification, there are four components of convergence: tonic, accommodative, fusional (disparity),
and proximal (psychic). Although authorities may
disagree about whether this classification s the
only true classification, the consensus s that the
Maddox concept is useful for clinical purposes.
Nevertheless, factors other than those considered
in the Maddox classification (e.g., prism adapta-
Monocular (secs)
Rartk
49
Description
Very strong
Strong
Adequate
Weak Very
weak
Binocular
(secs)*
2:108
>60
84-108
48-59
60-S3
36-47
3S-59 24-35
<36 <24
Note:
2 Testing s at the rate of 6 secs/cycle (i.e., 3
secs per each corred responso) with 2.00-D tenses. The cutoff
point s desig-nated as a response time exceeding 3 secs on any
lens
1 flip or whenever there is an incorrect response. *Suppression
should be monitored using either anaglyphie or vectographic
targets when binocular testing is done.
Absolute Convergente
The total amount of convergence of the visual
axes (Unes of sight) from paral le sm at far to a
bifixated target at near is called absoluta convergence, often also called "gross" convergence.
Absolute convergence may involve all four components of Maddox.
Testing Techniques
The clinical test for absolute convergence is performed with a small target, traditionally a pencil
tip, for measuring the nearpoint of convergence
(NPC). The patient views a target in the midline as
it s moved closer to the spectacle plae. Any
object for fixation can be used, but a target requiring accurate accommodation s recommended. A
small isolated letter // E// ofapproximately 20/30
(6/9) size at 40 cm (1.5 minutes of are) has become
a clinicai standard. The examiner moves the target
steadily at a rate of approximately 3-5 cm per second toward the bridge of the patient's nose. The
patient s asked to look at the letter and report
when t first becomes blurred and then when it
appears doubled. Despite blurring, some patients
may be able to maintain bifixation on the target all
the way to the bridge of the nose (i.e., approximating the spectacle plae). Most patients, however,
Chapter 2
50
Rank Descripton
5
Verystrong 4
Strong 3
Adequate 2
Weak
1
Very weak
Breakpoint
(cm)
<5 56 7-8*
9-15
>15
Recovery to
Singteness
(crn)
<8 8-9
10-11
12-18
>18
be expressed in prism diopter (A) units. If, for example, the breakpoint is 7 cm from the spectacle plae,
the magnitude in prism diopters of absolute convergence can be calculated trigonometrically. The following formula, however, isconvenient for clinical purposes:
100
X + 2.7
A = 6 100 7 +
2.7
A = 62
7cm
2.7 cm
FIGURE 2-19Example of nearpointof-convergence conversin from centimeters to prism diopters. (E = fixation
target; IPD = interpupillary distance.)
Chapter 2
Sufficiency of absolute convergence is determined by the usual testing method of pencil pushups, as described earlier, although a small detailed
target s recommended rather than a pencil tip. The
blurpoint is so variable among the normal population that norms have not been established. Ideal ly,
however, blurring should not occur until the target
approaches a distance n the range of 10-15 cm. In
contrast, the breakpoint should be much less
remote, normally 7-8 cm or closer. Either diplopia
of the target (as reported by the patient) or loss of
bifixation (as observed by the examiner) at a distance exceeding 8 cm is considered "failing,"
which can be used as a cutoff point for referral
considerations (seeTable 2-18). Certainly a remote
NPC greater than 10 cm is a failing test result.
The reporting of diplopia s a subjective test.
Subjective NPC results should be corroborated
with objective test results (observation of examiner). Ordinarily, direct observation of the patient's
eyes will suffice, but greater accuracy s possible
by observing the corneal reflexes from an auxiliary
penlight source held a few centimeters above the
letter f fixation target, a modified Hirschberg test.
(See Chapter 4 for discussion of Hirschberg testing.) Suppression may be indicated if there is no
report of diplopia and the clinician observes a lack
of bifixation.
Facility of absolute convergence can be assessed
indirectly by the patient's ability to recover bifixation. Only singleness, not necessarily clearness of
the target, s demanded for normative evaluation
purposes. The patient should be expected to recover
singleness (and recurrence of bifixation should be
objectively observed by the examiner) at a distance
of 10-11 cm or closer as the target is withdrawn.
Poor vergence recovery is indicated if the distance is
more remote. In other words, a recovery beyond 11
cm s considered "failing," and referral for visin
therapy should be considered (seeTable 2-18).
Stamina of absolute convergence is assessed by
repeating the break and recovery testing four
times, for a total of five routines. Poor stamina is
ndicated f the endpoints are more remote on repetition. Any decrement in performance over this
period s considered failing or, at least, s suggestive of a dysfunction of gross convergence. Note
that the training effect of repeated NPC testing may
result in prism (vergence) adaptation, which theoretically should help the patient to converge more
sufficiently. If, however, sufficiency s reduced on
repetition because of lack of stamina, the patient
51
52
Chapter 2
Relative Convergence
Testing and Norms
Convergence is the term traditionally applied to
both convergence and divergence. However, in
discussions of relative vergences, the general term
vergence probably is preferable to inclusin of
the semantically restrictive prefix con-. Use of vergence would avoid the need for awkward or
superfluous denotations such as negativa fusional
convergence and positiva fusional convergence.
The terms relative vergence, fusional vergence,
and disparity vergence may be used interchangeably for most clinical purposes. (Refer to Chapter
3 for further discussion on relative vergences.)
The stimulus for fusional vergence eye movements is ret'mal disparity, with other intervening
variables excluded: This means that a constant
testing distance is maintained during increasing
prismatic stimuli. Relative vergence is conveniently measured from the orthophoric demand
point, which simplifies clinical recording. For
example, a patient views a target at 40 cm while
base-out (BO) demand is increasingly introduced
with Risley prisms.The blurpoint, breakpoint, and
recovery point are recorded directly from the
scale on the instrument as though the patient (and
every patient) is orthophoric. The actual magnitude of the disparity vergence response, however,
must take into account the fusion-free position of
rest, which involves the effects of tonic, accommodative, and proximal vergence. If, for example,
a patient has exophoria of 6A at 40 cm and the
blurpoint with BO demand is 10 A , the total
fusional (disparity) vergence response would be
16A. Suppose another patient has an esophoria at
40 cm of 4A: The total fusional (disparity) vergence
response would be only 6 A for the 10 A BO
demand. This method of measurement complicates establishment of norms for clinical usefulness. Conveniently, however, relative vergences
measured from the common-denominator orthophoric position allow for standardizaron of
norms. Henee, re/af/ve vergence is the preferred
term and testing procedure for clinical purposes.
Fusional divergence at far is also. known as negative fusional vergence, negativa fusional convergence, and negativa disparity divergence, among
other designations for this function. For the sake
of consistency and historical precedent in this
text, we adhere to negative relative convergence
(NRC} at 6 m as the clinical nomenclature of
choice. The stimulus to fusional divergence is ret'mal image disparity (which is Bl demand). The
responses of tonic, accommodative, and proximal
vergences must be minimized, to the extent possible, so that only fusional vergence is measured.
Fusional divergence can be measured by several
clinical methods. The most common method for
measuring NRC is by the use of Risley prisms in a
phoropter. From a distance of 6 m, the patient is
instructed to view a vertical column of letters, normally of 20/20 (6/6) acuity demand, but the letter
size may vary depending on the best attainable
acuity of the patient. If, for example, the patient's
best corrected visual acuity is 20/40 (6/12), that
particular mnimum angle of resolution for letters
should be used for testing. For reliability of all
visual skills testing, CAMP lenses for mximum
Chapter 2
53
5.
TABLE 2-19. Ranking of Results of Negatve Relatve
Convergence Testing ai 6 m (Base-ln)
Rank
5
4
3
2
1
DescriptionBreakpoint ( )
Very strong
8
Strong
Adequate
Weak
Very weak
7
6
5
4
Recoveryto
Singleness ()
6
5
4
3
2
The nearpoint testing procedure for fusional divergence is similar to that at farpoint, except a blurpoint is expected. It is known simply as NRC, the
40-cm testing distance being implied. Ranking
standards are shown n Table 2-21. All nearpoint
testing of fusional divergence is conducted at 40
Chapter 2
54
Rank
5 -~
A .'
. 3: - - .
Bturpoint (A)
>14
Description
Very strong
Strong
Adequate
Weak
Veryweak
11-14
8-10
7
<7
Vergence Facility
Vergence facility depends on both amplitude
and speed of vergence movements. The quantity
and quality of disparity vergences should be
evaluated. (Discussion will be limited to horiTABLE 2-21. Ranking of Resulte of Negative Relative
Convergence Testing at 40 cm (Base-ln)
Rank
Description
5
Very strong
Strong
Adequate
Weak
Very weak
3
2
1
>26
>18
14-18
12-13
11
<1 1
22-26
20-21
19
<19
14-18
11-13
10
<10
Breakpoint (&)
>24
21-24
16-20
15
<15
Recovery to
Singleness (4)
>15
12-15
9-11
8
<8
Reflex Fusin
Clinically, we recommend evaluating vergence
facility by direct observation. A small-power prism,
the vergence stimulus, is inserted in front of one
eye as the patient fixates a detailed target. The
latency, velocity, accuracy, and stamina of vergence
responses can be directly observed and assessed.
Without eye movement-recording equ-ipment,
these dynamic components cannot be quantified
but, with practice, the clinician can make accurate
and valid judgments regarding the quality of reflex
vergence function by closely noting the eye movements stimulated by the prism. A virtue of this tech-
Chapter 2
TABLE2-22.
55
Rnk
Description
Very strong
4
3
2
1
Strong
Adequate
Weak
Very weak
Blurpotnt (A)
,
Breakpoint {A)
>23
>28
>18
18-23
15-17
22-28
19-21
18
<18
13-18
8-11
14
<14
7
<?
56
Chapter 2
Study
Kenyon et al.48
None in strabismks
Pierce49
Jacobsow et al.54
Comments
Also none in some amblyopc subjects without strabsmus
Median for chtldren; 7.5 c/min recommended as cutoff for "normal" versus "learningdisabled" childrert
Mean for sixth gradees
Mean for third gradees
Mean for sixth graders
Mean for third graders {cutoff crteron of 3 c/min recorrmended)
Young adults
At farpoint
At nearpoint
At farpoSnt
At nearpoint
Young adulto wth no visin problems; jump vergences wth two
seto of vectographtc targets
Approximately same results (adult
subjects)
SI = base-in; BO = base-out
useful in evaluating the quality of a patient's binocular status and, possibly, the patient's developmental-perceptual status. Pierce 49 reported a
difference in vergence facility between normal
and learning-disabled children. Other studies50'51
reported developmental differences between
schoolchildren in the third and sixth grades, the
results being approximately 5 and 7 cycles per
minute, respectively, using 8 A Bl and 8A BO flippers (Table 2-23). Moser and Atkinson52 found an
average of 8.14 cycles per minute in young adults
using 8A Bl and 8A BO flippers in vergence facility
testing. Rosner 53 proposed the following criteria
for screening (for referral): 6 A Bl and 12A BO
demands at farpoint and 12 A Bl and 14A BO
demands at nearpoint. For ultmate goal, Rosner53
suggested at least 18 cycles in 90 seconds at farpoint and nearpoint using free-space orthopic and
chiastopic fusin without instrumentation or filters. (These types of fusin are discussed in Chapters 13 and 14.)
Chapter 2
Rank
5
4
3-4
fll - base-in; BO = base-out.
Note: Suppression should be
<3
3
monitored with anagJyphic or vectographic targets with targets equivalent to 20/30 being clear and
single 2
with each prisrn flip. The Vectographic SBde is recomrnended for 6 m, and Vectograms, as used for accommodative
faclity, are recommended for testing at 40 cm.
1
57
Oescription
Very strong
4
3
2
1
Strong
Adequate
Weak
Very weak
Bl = base-n; BO = base-out.
Note; Suppression should be m onftored as n vergence faelity
testing.
Vergence Stamina
rather low recommended number for screening and
referral purposes. If absolute Bl and BO powers of 5A
and 15A, respectively, are used, we believe a screening criterion of 5 cycles per minute is useful as a cutoff valu, particularly for children. A training goal,
however, would be much higher.
Delgadillo and Griffin 55 found that 5 A Bl and
A
15 BO gave approximately the same results as 8A
Bl and 8A BO; therefore, either test can be used at
nearpoint, at least n adults with normal binocular
visin.
Considering the aforementioned reports and on
the basis of our clinical experience, we recommend evaluating vergence facility as shown n
Table 2-24. For children of ages 7-11 years, a
lenient cutoff criterion for failing s 4 or fewer
cycles per minute; 5 cycles per minute or more
would be passing and would obvate the need for
referral for visin therapy. These criteria apply at
40 cm with 8 A Bl and 8 A BO prism demands as
well as at 6 m with 4 A Bl and 8 A BO prism
demands. Although these criteria appear to be
lenient, some of the earlier reports recommending
greater vales for cycles per minute did not
include suppression monitoring. We have found
that patients general ly are much slower when vectographic targets and viewing filters are used,
reduced perhaps by as many as 3-5 cycles per
minute, whether n children or adults. We believe,
therefore, that the criteria in Table 2-24 can apply
to both children and adults for evaluation of vergence facility.
SENSORY FUSIN
From a clinical perspective, the systems of saccades,
pursuits, fixation, accommodation, and vergences
are principally motoric. However, there must be
sensory (and usual ly perceptual and often cognitive)
input so that visual functioning can occur. Clinical
testing of sensory fusin also nvolves a motoric
Chapter 2
iponent. Nevertheless, for instructional pur-s, it
is convenient to deal with motor fusin and sensory
fusin as though they were seprate, keep-ing in
mind that this distinction is artificial and that they
are really indissoluble.
On a clinical basis, motor fusin can be considered basically to involve the amplitude and speed
of various ranges of vergences. In contrast, the
basic clinical concern in sensory fusin is suppression. Sensory fusin is classified according to the
Worth taxonomy into three categories: first-, second-, and third-degree fusin. (Refer to Chapter 1
for theoretic discussions of these degrees of sensory fusin.)
In clinical diagnosis, sensory fusin of form can
be classified into four levis, a modification of the
categories of fusin recommended by Worth (as
cited by Revell56):
Simultaneous perception (diplopia)
Superimposition (first-degree fusin)
Fat fusin (second-degree fusin)
Stereopsis (third-degree fusin)
These categories of binocular sensory status can be
conveniently tested by using vectographic techniques, colored filters, and the numerous stereoscopic methods employing septum arrangements.
Many methods and instruments are presented in
this book, particularly in case examples.
Simultaneous Perception
Although Simultaneous perception is classified as
one of the levis of sensory fusin, there is actually
no real fusin with this particular binocular
demand. Simultaneous perception is determined
to be present merely by the patient's awareness of
binocular images at the same time. In clinical
usage, Simultaneous perception refers to the stimulation of noncorresponding retinal points that give
rise to diplopia. An example is shown in Figure 110, in which the fixated light is seen diplopically
because the dioptric image is on a noncorresponding point of the deviated right eye.
The usual test applied in determining whether a
patient can appreciate Simultaneous perception is
to elicit a diplopic response when one object (e.g.,
a penlight) is fixated. When deep suppression interferes with diplopia testing, stimulating a noncorresponding point somewhere outside the suppression
zone may be desirable. This is conveniently accomplished by placing a vertically oriented lose prism
Superimposition
The Superimposition of two dissimilar targets is
known as first-degree fusin. However, when this
occurs, confusin rather than true sensory fusin
exists, because similar targets are not being integrated; they merely have common oculocentric
directions. Because two dissimilar objects stimulate corresponding retinal points and are perceived
as superimposed, the definition of Superimposition
is satisfied.
With the exception of the Maddox rod test,
Superimposition testing usually requires more
instrumentation than a penlight in free space. Stereoscopes containing a different target for each eye
(e.g., a fish seen only by the left eye and a tank
seen by the right eye) are usually necessary (see
Figure 5-6).
Fat Fusin
Fat fusin is true sensory fusin and is the integration of two similar ocular images into a single percept. There may be one target in free space, such
as a page of print, or there may be two identical
targets in a stereoscope. In any event, to be classified as a flat-fusion stimulus, this type of target
must be two-dimensional and identical in form for
each eye.
Such targets are the most frequently employed
in testing and evaluating motor fusin (fusiona!
divergence and convergence). Usually Snellen letters or printed words are used as targets, to be
fused with the incorporation of unfused suppression clues in the test design. (An example of a fat-
Chapter 2
fusin target with a test design for extrafoveal suppression s shown in Figure 5-7.) If the angular separation from the center of the target to a
suppression clue is greater than 5 degrees, testing
for peripheral suppression is being accomplished.
Testing for foveal suppression requires that a suppression clue be located in or near the center of
the target. Therefore, the location of the clues that
are suppressed determines the size of the suppression. These specifications regarding targets for
determination of suppression size are Usted in
Table 5-1.
In cases of heterophoria, however, foveal suppression, rather than larger suppression zones
occurring in strabismus, is usually the concern.
Similarly, depth of suppression is necessarily evaluated n cases of strabismus but rarely s evaluated
in heterophoria. (Testing for depth of suppression s
discussed in Chapter 5.)
Stereopsis
Stereopsis is the perception of three-dimensional
visual space due to binocular disparity clues. Test
targets for Stereopsis are similar to those for fat
fusin with one exception; n the former, there s
lateral displacement n certain portions of the target. The displacement of a set of paired points
(referred to as homologous points) s relative to the
position of other pairs of homologous points on the
stereogram. For example, n Figure 1-14, consider
the star as the figure that s fixated and fused. The
small vertical lines are displaced inwardly (BO, or
crossed disparity effect) relative to the fused star.
Assume that the patient is concentrating on the
fused star. The vertical lines are maged on each
retina temporally in relation to the star, which
causes the fused image of the lines to appear
closer than the star. The opposite would be true if
the lines were disparately nasalward on each retina. The rule to remember is that f the retinal disparity is temporalward ("templeward") from the
center of each fovea, the stereoscopic image will
appear closer, whereas if the retinal disparity is
nasalward, the image will appear farther.
If the disparities become too far separated, the
lines can no longer be fused (by remaining within
Panum's reas) and are seen diplopically. Because
they fall on points too disparate, they cause diplopia in the same manner as n simultaneous perception testing. However, if the disparities are not very
great, the targets are fusible even though they do
59
60
Chapter 2
test, which s designed for farpoint measurements. The test consists of two black, movable
vertical rods viewed through an aperture against
a white background. The patient is seated at a dis-
Chapter 2
61
FIGURE 2-26Lang test. Images for the eyes are separated by the fine
parallel cylindrical strips to crate perception of stereopsis by way of
lateral displacement of images seen by each eye. Note that this is Lang
test 1; another versin, Lang test 2, is also available.
Stereoacutty
(seconds of are)
10
20
2
3
7
10
13
16
20
60
80 100 200 300 400 500 26
33
NatetAn taterpuptHary distance of 60 mm is
66
assumed, Stereoacuities were determined by
99
the foHowing formula: T\ = IPD (x)/ef2 x
206,000, where i\ (eta) is the symbol for
132
stereoacuity in seconds of are; P0 is the
interpupillary distance n rnillime-ters; x is 165
30
40
50
Chapter 2
Stereoacuity
(seconds of are)
3,090
772
60
80 100 110
150 200 300
130
343
124
86
48
31
26
Note: Response to all eight trgets must
be correct. The stereo-threshold vales
18
in this tafole are calculated for an
14
interpupillary distance of 60 mm, The f\
8
valu (stereoacuty) is calculated using
an x valu of 2,5 mm, which s the
3
displacement of one strip from the
plae of the other two strips. Verhoeff stereoacuites are
calculated according to the same formula used for the HowardDolman test (see footnotes to Table 2-27).
distance of 1 m. The better the Stereoacuity, the farther away the test apparatus can be held for the
eight correct responses (Tabie 2-28).
Percentage of Stereopsis
Occasionally, practitioners are asked to report percentage vales of stereopsis rather than vales
recorded in seconds of are. Percentage scales were
empirically determined by Dr. Cari F. Shepard for
such purposes, and calculations and Information
pertaining to this method were presented by Fry. 57
Table 2-29 gives percentage vales corresponding
to Stereoacuity n seconds of are.
Screening for Binocular
Problems wth Stereopsis
The level of stereopsis determines the level of binocular status in most cases: Stereopsis s the
"barometer" of binocularity, If stereopsis is good,
the binocular status is good, but the opposite cannot always be said with certainty. That s, a patient
may be found to have no stereopsis but have normal sensory and motor fusin n all other respects.
Some individuis may lack cortical binocular dis-
63
Stereoacuity in Seconds of
Are
20
72
15
10
78
95followlng
Note: Shepard percentages are calculated using the
100
formula of Fry57:
Percentage stereopsis = '^r106
-5
ti+ 81
where f[ is trie symbol for Stereoacuity.
64
Chapter 2
SEMICONTOURED TARGETS
NONCONTOURED TARGETS
NUMBER OF SUBJECTS 16
NUMBER OF SUBJECTS
16
I
c
o
o
Q
Ltl
(O
(f)
+1.00
+2.00
+3.00
LEVEL OF INDUCED ANISOMETROPIA
+1.00
+2.00
+3.00
LEVEL OF INDUCED ANISOMETROPIA
al
o
NUMBER OF SUBJECTS 16
+1.00
+2.00
+3.00
LEVEL OF INDUCED ANISOMETROPIA
NUMBER OF SUBJECTS 16
NUMBER OF SUBJECTS 16
i
e
n
o
o
LU
co
05
+1.00
+2.00
+3.00
LEVEL OF INDUCED ANISOMETROPIA
+1.00
+ZOO
+3.00
LEVEL OF INDUCED ANISOMETROPIA
+1.00
+ZOO
+3.00
LEVEL OF INDUCED ANISOMETROPIA
70" OR BETTER
140" OR SETTER
400" OR BETTE
Chapter 2
65
Rank
Deserlption
Very strong
Strong
Adequate
Weak
Very weak
3
2
1
Summary of
Sensory Fusin Testing
In cases of heterophoria, flat-fusion testing s performed for purposes of measuring binocular
accommodative facility, relative vergence ranges,
and testing for fixation disparity. Stereopsis general ly s an ndex to binocular status, although some
patients are stereoblind even though other visual
skills may be normal. Ranking of stereoacuity may
be done in a manner similar to ranking of other
visual skills.
RECOMMENDATIONS ON THE
BASIS OF TEST RESULTS
Referral for visin therapy is appropriate if there
are symptoms of discomfort and performance
problems related to poor visual skills, including
saccades, pursuits, fixation, vergences, and sensory fusin. Referrals should take into account
these considerations and should not be made
merely because a finding (or even several) s below
average. Professional judgment is necessary whenever referral decisions are being made. Isolated
abnormal findings may be spurious. A general pattern of binocular dysfunction provides the strongest basis for making a diagnostic statement.
Contouret
>20
20-30
3t-60
61-100
<100
Noncontoured
>30
31-50
51-100
OI-iOO,
<00
REFERENCES
1.
2.
3.
4.
Most clinical systems used n the analysis of vergence disorders are conceptually based on the
interaction of the four Maddox components of
vergence: tonic, accommodative, fusional, and
proximal. Graphical analysis, with roots extending from Donders 1 and Maddox 2 in the nineteenth century, uses a cartesian coordnate
system to Ilstrate relations between accommodation and vergence. To this day, clinicians may
find t helpful to draw a graph of phorometry
measurements (i.e., heterophoria, relative vergence, and relative accommodation) to visualize
better the interactions. A graph can readily
reveal various clinical syndromes and alert the
clinician to inconsistencies n the data. The
analysis implies relation between accommodative response and vergence eye position, n
which changes in accommodation affect vergence and, conversely, changes in vergence
affect accommodation.
Measurement 79
Prescribing Prism 85 Validity of
Diagnostic Criteria 87 Recommendations
for Prism Prescription 90 Vergence
Anomalies 92
Convergence Insufficiency 93
Basic Exophoria 93
Divergence Excess 94
Divergence Insufficiency 94
Basic Esophoria 95
Convergence Excess 95
Basic Orthophoria with Restricted Zone 96
Normal Zone with Symptoms 96
Bioengineering Model 97
Chapter 3
70
BASE IN
5 0 5
15
15
25
65
75
ASE OUI 35
tS
25
i
j}
q-i
JO
IEAK
A-J
to
MO
tn.
ECOVEIW
x n
-7.50
<OR1A
9
3
87 o
65 o
43
^o
21
.6
v>
/>
10
-.
-1.50
OJO
4-0.50
4-1.50
/
20
IN
4JO
JO
s
^
10
20
30
40
Priun tcoU ot 6 m.
50
60
70
0
90
100 BASE
SASE OUT
Farm 1.1 .49
Chapter 3
71
TABLE 3- 7. Calculated Accommodative- Convergence/Accommodaton Ratio Depending on Far and Near Magnitudes of the Angle ofDeviaton foran Interpupillary Distance of60 mm
Angle H at Far
Exo
35
30
25
20
1S
z
105
e
01
g
**
5
10
15
20
25
30
35
35
30
34
32
Eso
25
20
15
10
32
30
28
30
28
26
30
28
28
26
24
22
20
18
16
14
12
10
8
6
26
24
22
20
18
16
14
12
10
8
6
4
26
24
26
24
22
24
22
20
24
22
22
20
20
18
18
16
16
13
14
12
22
20
18
20
18
14
12
10 8
18
16
16
14
16
14
12
12
10
10
8
8
6
16
14
14
12
12
10
10
8
8
6
6
4
2
0
12
10
10
8
8
6
6
4
4
2
2
0
10
15
20
25
30
35
20
18
18
16
16
14
12
10
14
12
10
8
6
4
2
12
10
8
6
4
2
0
10
8
6
4
2
8
6
4
2
00
6
4
2
0
2
0
Eso = either esophoria or esotropa; ixo = either exophoria or exotropa; H - the objective horizontal angle of deviation of the visual axes.
72
Chapter 3
Gradient AccommodativeConvergence/Accommodation
Ratio
The magnitude of the AC/A ratio may also be determined by measuring the effect of spherical lenses
on vergence. At far, minus lenses are used for this
purpose; at near, either plus or minus lenses will
give the valu. Regardless of the testing distance,
the AC/A ratio should be determined with the
patient wearing CAMP lenses.
The following is an example of how the gradient
method may be used. Assume that a patient has
exophoria of 15A at far, as determined by objective
means such as the cover test or, possibly, by subjective diplopia testing (e.g., Maddox rod). A
spherical lens of -2.00 D s placed before each
eye. The patient is nstructed to focus and clear the
fixation target while looking through the lenses.
When the patient reports that the target is clear,
another measurement of the angle of deviation is
made. If the lenses cause the angle to changefor
example, from 15A exo deviation to 5A exo deviation, the gradient AC/A ratio is 5/1. This s determined by dividing the change in the deviation by
the change of accommodative stimulus (i.e., the
power of the added lenses). Thus, 10 divided by
2.00equals5A/1 D.
Clinically, the gradient AC/A ratio is most often
determined at near by using a phoropter. The nearpoint heterophoria s measured subjectively by
either the von Craefe method or Maddox rod.
Spheres of +1.00 D are added, and the heterophoria is remeasured. The magnitude change of the
angle bf deviation indicates the gradient. Greater
precisin is gained by using +1.00-D, then -1.00D added lenses to evalate the amount of deviation change. If there is a large depth of focus,
either +1.00 D or -1.00 D may be an insufficient
stimulus to elicit a sufficient accommodative
response. In such cases, larger increments of lens
power might be required.
The gradient method will usually give a lower
AC/A ratio than will the near-far calculation
method. A gradient valu of more than 5/1 is considered high. The depth of focus causes the reduced
Chapter 3
BASE IN 35
50
25
15
Prm col* o 40 o.
15
25
35
45
55
1 i
1211
TW
54
/
/
//
/
20
IN
10 "
O BA D
!
1
--AM
^Ifl B
10
20
30
40
Pri,KaUol6m.
50
70
BO
BASE OVT
75
BASE OUT 35
BS
25
9.50
8JO
7JO
FHOKIA
i
/
76
7
34
32
1
!
i
z
9
I
%
/
(i
v/
T
/
20
IN
"10 "
/
/
/
y
0
r/
/
10
^,
FIGURE
3-3Zone of clear, single binocular
visin. Vision is blurred outside the
enclosure.
/
/
/
/
y
\^,
/! /
/\
SM
4JO
8 3M
11
-"8 - 2 J O
30
40
Pmm KaU o> 6 m.
S s^
-UO
OJO
4.ACA
s*
s*
\s /
20
4.1 ca
50
M
MO BASE
Fwm M*4*
KEOOVEKY X
9t
2J
-u
MEAK A
1110
A.
Sft
/!
A/
_/*
3
1
t
9
y
/
32
15
m
n VF
76
BASE IN
5 0 5
D BUEAIC
A tEOOVEXY
x PHOSIA
15
SfOUt
O w*
109
73
70
BO
BASE OUT
0
100 BASE
Farm |.|*-4
Chapter 3
74
BASE IN
S O S
15
12 11
45
75
BASE OUT 35
5
35
15
MO
u*.
10 9
Q-l
tEAJC
A-W
:covEX
-JO
x n Y
87
fOUA
43
43 o
1
\
I
I
1
/l"t~
i
1
1
vi
~t
0 *"" 0
-^^
//
/ J"
I
10 "
/
V /
*^/
21
20
IN
25
r^
B
J
s^\
-&50
SJO
4.50
3JO
c
o
......... _ 2 JO
t
o
OJO
+OJO
20
30
40
Prim cok ot < m.
?
s
+1.SO
SO
70
W
0
100 ASE
ASE OUT
Form 1-19-49
Chapter 3
BASE IN
5
15
25
25
15
BASE ota
I
75
65
75
140
O BLUK D
1HEAK
A RECOVEty
10
-7 JO
X mOKIA
8
.S
7
|
s
43
21
a
E
/
/A
/
,
yr
"10 -
10
/"
/ /
S
V
Ai^ / ^ ^
f
/
i
,y>*
$
:
20
IN
S
FIGURE 3-5Zone of clear, single
binocular visin showing charting of
the negative relative accommodation
(lower circle) and the positive relative
accommodation (upper circle).
/*
1
20
30
40
Pmmttob tm.
50
Si
^
C
Ti
-4JO
0
7IW
9
-USO
AJO
3
_i_n<ft
+130
70
0
0
100 BASE
tASE OUT
Foon I-19-49
sented
bylimit
the amplitude
between the phoria line
6. Normally, there s no blurpoint for fusional divergence at far.
That
is
and
the
Bl
to
blur
line
(divergence
blur limit).
ndicated by a breakpoint (diplopia). If a blurpoint s found, then the most likely
4
Sheard
emphasized
the relation between the
explanation is that the refractive error s not fully corrected with most
plus
for
direction
hyperopia or is overcorrected with minus in a case of myopia. Suchphoria
blurring
usually and the compensating fusional
(disparity) vergence range. When discussing
indicates a spasm of accommodation.
Sheard's concept, the term reserve vergence
The horizontal limits are the same as were drawn previously n this example, but the
s used. For example, if there is an exophoria as
limits of relative accommodation are added (Figure 3-5). (Refer to Chapter 2 for
rep-resented n Figure 3-3, then positive
discussion of NRA and PRA.)
fusional reserve convergence s the distance
The clinically relevant features of the ZCSBV are the relations between its constituent
between the phoria and the opposing blurpoint.
parts (i.e., demand Une, phoria une, range of fusional vergence, and amplitude of relative
Similarly n an esophoric case, the negative
accommodation). Custom dictates specific ames for each of these features. PRC and
fusional reserve convergence s the distance
NRC are the ranges of fusional (disparity) vergence to the blurpoint that are measured
from the phoria line to the Bl to blur line. It is the
relative to the demand une (see Figure 3-3). These are the vales directly measured using the
relation between the phoria position and the
Risley prism vergence technique in both convergence and divergence direc-tions. Another
compensating vergence range that has clinical
way to describe the horizontal extent of the ZCSBV s to refer to the vergence ranges relarelevance according to Sheard.4 The
tive to the phoria line. Positive fusional convergence s the amount of convergence
significance and utility of these relations will be
measured between the phoria at any particular viewing distance to the BO blurpoint (or
discussed later.
breakpoint, if no blurpoint is found). Similarly, negative fusional convergence is repreGross
convergence
(nearpoint
of
convergence, or NPC) is not usually charted but
may be calcu-lated. A conversin formula
(centimeters to A) for clinical use is
Gross convergence (A) = IPD
100
Note that 2.7 is a correction factor for the
distance from the spectacle plae to the center
of rotation of the eyes.
For example: If the IPD = 60 mm and the
push-up NPC = 5 cm from the spectacle plae
(bridge of the nose), then A = 6 x (100/5 + 2.7) =
78A.
76
Acceptable Range
Test
Phora, far
Mean
1Aexo
iO blur, far
Q&
TO brk, far
BQ rec> far
1QA
11 brk, far
Bl rec, far
10**
7A
4*
A
3
Phoria, near
17*
BO btur, near
214
iO brk, near
11a
IO rc, near
Bl blur, near
13a
Sitarte, near
21A
Bl rec, near
13A
PRA
-2.37 D
NRA
+2.00 D
.MORGAN'S
0.5 SO
Furvctions
Ortho 2* exo
2
4
2
2
1
' 3
3
3
4
2
?Ho11 A
154to23A
84 tOl2A
5H09*
3a to 5a
Ortho to 6 exo
W tdZO*
18a to 24A
7Ato15A
1Pto15 A
19a to 23A
Wtolo^
-1.75Dto-3.00 D
+1.75Dto+2.25 D
2
3
0,62
0.25
-0.80
+0.80
+0.70
+0.50
+0.50
+0,50
NRA = negative relative accommodation; NRC
-0.50
NORMATIVE ANALYSIS
Morgan, a principal founder of binocular visin case analysis, accumulated and analyzed clinical
phorometry data on 800 nonpresbyopic adults, ages 20-40 years.5 He established clinical norms for his
patient group, suggested expected vales for clinical evaluation (Table 3-2), and recommended using
one-half of a standard deviation from the mean to represent clinically suspicious findings. (These
expected vales are factors in the vergence clinical ranking system recommended in Chapter 2.) Morgan
also evaluated the pattern of clinical findings by determining correlation coefficients for various zone
components.6 His results are presented n Table 3-3. His important contribution demonstrated the
quantitative strength of these relations. Other findings also deserve interpretaron. For example, the
correlation between PRC and NRA was +0.5, a modrate correlation. A direct association exists between
these two features of the zone; the larger the PRC, the larger is the NRA. In many cases, accommodation
can limit vergence; conversely, vergence can limit accommodation. This relation
suggests the possibility of clinical syndromes, as Morgan astutely pointed out.
Morgan demonstrated that certain features of the ZCSBV tend to be congregated. Morgan's group A
findings are amplitude of accommodation, PRA, and NRC. Group B findings are NRA and PRC.
(Morgan also proposed another classification, group C, which includes the far and near phorias, the gradient AC/A ratio, and the calculated AC/A ratio.) When group A findings are low, group B findings tend
to be high; Morgan refers to this case type as accommodative fatigue. The treatments of choice are
often a plus add for reading or visin training that would better balance A and B findings. When group
B data are found to be low and group A high, then the case type is referred to as convergence fatigue.
The recommended treatment would be either Bl prism to balance the two groups or fusional
convergence (BO) visin training.
77
Sheard's Criterion
One of the oldest and most widely used clinical
78
near.
Chapter 3
Chapter 3
Percival's Criterion
Percival's criterion differs from the other criteria in
that it ignores the phoria position. Percival proposed that the clinically important relationship in
the ZCSBV is the position of the demand Une with
respect to the limits of convergence and divergence blur unes.8 He delineated a zone of comfort
resting within the middle third of the ZCSBV, limited horizontally by the blur lines on either side
and extending vertically from O to 3 D of accommodative stimulus. Percival believed that the
demand line should ideally fall within or at a limit
of this comfort zone. If it did not, then prism,
added lens correction, or visin training was indicated. The clinician can assess whether Percival's
criterion is satisfied by direct inspection of the
plotted ZCSBV and by adding the NRC and PRC
findings and dividing by three. This trisects the
total range of fusional vergence and defines the
zone of comfort, the inner third. Does the demand
line fall within the zone of comfort for all viewing
distances? If not, the amount of prism necessary to
shift the demand line to the nearest limit of the
comfort zone can be easily determined from the
Chapter 3
79
ANQLE f
O.S.
!. ----- -SEEN BY O.S. ONLY
POLARIZED TARGET
POLARIZED FILTERS
C.
O.D. fovea
O.S. lovra
PATIENTS PERCEPTION
(CYCLOPEAN PROJECTION)
toms.11 Both abnormal and normal aspects of fixation disparity can, therefore, occur n the same
individual. Forexample, a heterophoric patient with
deficient vergence compensation can have a large
fixation disparity, indicating vergence stress but,
after visin therapy, there may be only a small residual fixation disparity that indicates a normal set
point for that individual.
An example of an exo fixation disparity s llustrated in Figure 3-6, which depicts a posterior view
of the eyes. If the error of vergence for the fixated X
target is very small and fusin of X is possible
because of Panum's reas, the X will appear to be
single and not diplopic. The vertical lines (which are
seen independently by each eye), however, will not
be perceived by the patient as being n vernier
alignment. This manifest deviation from exact alignment is too small to be detected by the cover test
(i.e., unilateral cover test). For this practica! reason,
fixation disparity is not considered to be a smallangle strabismus, despite a manifest misalignment
of the visual axes. Morgan12 summed up the quantification of fixation disparity by stating, "Normally,
fixation disparity rarely exceeds 10 minutes of are,
although it may be somewhat greater when a substantial degree of heterophoria exists, and probably
any deviation approaching 30 minutes should be
considered abnormal." Because 30 minutes of are s
regarded as being a limiting valu, and t is approximately the magnitude (0.9) of a prism diopter, it is
practica! to consider any manifest deviation of 1 A or
greater as being a strabismus. If the deviation s less
than 1A and there is foveal fusin, the condition s
POINT ZERO
Clinical evidence suggests that excessive fixation disparity tends to reduce stereopsis. Col and
Boisvert 13 conducted a study and reported that
the nduction of fixation disparity on otherwise
normal binocular subjects caused an increase n
stereothreshold (decrease in stereoacuity). In
another study, Levin and Sultn 14 neutralized
existing fixation disparities in 12 subjects by
means of prisms to determine the effect on stereoacuity and found that stereoacuity improved n
10 of the subjects.
Measurement
Fixation disparity testing can be done at both far
and near. Instruments for such testing have in common the same general principies. The patient fuses
a flat-fusion target under natural lighting condi tions. Such tests incorprate vernier fiducials,
clued to each eye by means of crossed polarizing
filters, so that the patient can report any noticeable
misalignment. These vernier markings also serve as
suppression clues. Central suppression is indicated
f one line s not seen. Generally, two types of
nstruments are usedthose that give a direct measure of fixation disparity (e.g., Saladin Card [Figure
3-7]) and the Wesson Card (Figure 3-8). The Saladin Near Point Balance Card allows for both dissociated and associated phoria measurements. The
numbers 20 exophoria to 20 esophoria are for horizontal phoria testing with the modified Thorington
method using a Maddox rod; the 10-10 scale s for
vertical measurements. The associated phoria, horizontal or vertical, can be measured using the two
80
Chapter 3
RJU.
iva
ADTS
Mons
ATd
NOdTI
anos
A '" M
SnHn Eq.
"~"
X ~"~ A
~~ Z
LogMAR
e7
HZDiV
RtHyper
vcoi
Hypo
HI
80
RKCOS
O-6
63
ZSDNG
O.S
50
0EKVR
YEMA
40
*4
'2
SLOW
0.4
CDNKH
0.3
ZH v ns
32
25
0.2
.....
0.1
0.0
0.1
20
18
S A C
1B 1R
1d
19
1O
>
/i
A lo
4A
-IB
1O
UTO
THEN
UPON
K
18X
J
14X
I
10X
H
8X
S8t
Z
SH
A
SOI-
ss
AA
G
6X
F
4X
9
A
S*
2
i
C
18
XV
B
2S
A
4S
X*
4
FD
A4
B2
ClRtHyper
DO
Horizontal Analvsis 1. Assume
t'of are Fixation Disparity (F0)
measurement error 1. PD sbcrnW
bebetween 4' so ande' mss
3. FD and phoria should be in the sane direction
given 2' of FD measurement error
4. Noticeable variability for either FD or phoria is
abnonnal
Aialsts
. Assume O tneaswement error 2.
VeoicaFDshouWbeiessthan l'of
gfe and in the same direction as the
vertieal phoria
E1
64
Chapter 3
81
Red
Orange
Green
, Green
Orange
DISTANCE: 40 CM (1 6 INCHES)
25 CM (1 0 INCHES)
t
F.D.(MIN.ARC)
F.D. (MIN. ARC)
RED
0
0
0
1/2
4.3'
6.9'
GREEN
1
8.6'
13.7'
1-1/2
ORANGE
BLACK
BLACK
2
3
4
12.9'
17.2'
25.8'
34.4'
ESO F.D.:
ESO F.D.:
20.6'
27.5'
41.2'
55'
ARROW TOLEFT
ARROW TORIGHT
FIGURE 3-8Representation of the Wesson Card for fixation disparity (F.D.) testing.
phoria are the Bernell test (Figure 3-9) and the Vectographic Slide (Figure 3-10) or similarly designed
targets. Vertical associated phoria can be measured
with either test; the Bernell test can be rotated 90
degrees to test for vertical fixation disparity (see
Figure 3-9b).
DISPARITY
82
Chapter 3
a. O
KSEEN BY O.S.
e. --Oy
SEEN BY O.D.
b. u
c. o
9-
ame
ui
a u E
n
E
d.O h. O
-e
oo
oo
oo
oo
o
o
o
o
o
o
o
o
o
o
o
o
oo
oo
oo
oo
oo
oo
oo
oo
o
o
o
o
FIGURE 3-10Results of fixation disparity testing with the Vectographic Slide. a. No fixation disparity. b. Eso fixation disparity (oculus dexter
[OD] dominant eye). c. Eso fixation disparity (mixed dominance). d. Exo fixation disparity (OD dominan t). e. No vertical fixation disparity.
f. Hyper fixation disparity (OD dominant). g. Incyclo fixation disparity (OD dominant). h. Foveal suppression of oculus sinister (OS), i. Adult versin of the Vectographic Slide. (Courtesy of Stereo Optical Co.) j. Children's versin of the Vectographic Slide. (Courtesy Stereo Optical Co.)
Chapter 3
83
DIPLOPIA
BASE-OUT
DEMAND(A)
BASE-IN
DEMAND
24
DISSOCIATED PHORIA
OF 8A EXO
BLUR
o
15
15
*!
^~ ^-
10
DISSOCIATED PHORIA O F
8A EX O ^ ^^ ^
BASE-IN
.
.
DEMAND
24
18
ance Card.
'
12
'
/6
V
"/"N.
\
12
18
24
BASE-OUT
DEMAND(A)
AT ZEROA (ORTHO)DEMAND
THE EXO FIXATION DISPARITY
IS 5 MINUTES OF ARC.
ASSOCIATED PHORIA OF6A EXO
(FIXATION DISPARITY
NEUTRALIZED WITH 6A BASE-IN)
10'
15"
the vertical or horizontal Unes. If there is no misalignment, the clinician can conclude that there is
foveal fusin with no fixation disparity. If there s
misalignment, compensating prisms are used to
crate vernier alignment. The power of the neutralizing prism is not the magnitude of the fixation disparity (YIN) but, rather, the measurement of the
associated phoria (XIN).
A good example of target design for nearpoint fixation disparity testing s the Mallett fixation disparity
84
Chapter 3
Chapter 3
85
Prescribing Prism
Two principal criteria have been recommended for
the prescription of prism on the basis of fixation disparity: Sheedy's cterion22 and the associated pho-
86
Chapter 3
FD at near
Demand Line
FD at far
FAIR
POOR
Chapter 3
87
c.
Demand
Line
FD at f ar GOOD
FD at near
FIGURE 3-13Three-dimensional models of binocular visin showing the relations of accommodation, vergence, and fixation disparity (FD).
a. Indication of fairly good fusional vergences for clear, single, comfortable binocular visin, b. Poor fusional vergences indicating lack of good,
clear, single, comfortable binocular visin, c. Good fusional vergences ndicating excellent binocular status as to clarity and comfort.
88
Chapter 3
most of the diagnostic criteria used in the prescription of prism and lens additions n cases of vergence dysfunction have not been subjected to
rigorous tests of concurrent validity; their use has
evolved slowly by experience n clinical practice.
A measure of face validity accrues to the criteria of
Sheard, Percival, Sheedy, and associated phoria,
because they are al I based on notions that have
physiologic credibility, but much of the evidence
supporting their clinical use is anecdotal.
Craphical case analysis can be criticized on the
basis of the subjective methods used in clinical
testing of accommodation and vergence through a
phoropter. Phorias, relative accommodation, and
vergence endpoints can be influenced by a number of nonphysiologic factors, including a patient's
(1) understanding of the instructions, (2) attention
level, (3) cooperation level, and (4) conscious
effort expended. In addition, (5) rate and smoothness of prism or lens power induction by the examiner, (6) elapsed time between tests, and (7) the
amount of central and peripheral contour n the
fixation target affect these parameters. The way that
instructions are phrased also can make a significant difference in the measurement of vergences:
For example, "Report when the image splits into
two" may elicit a quite different response than
might "Try to keep the image single, but report
when it doubles."23 With several nherent sources
of nonphysiologic variation and error, how can the
examiner trust the validity and reliability of these
clinical methods? More important, can any criterion for distinguishing a disorder from normal
functioning, based on these endpoint measurements, be considered valid and reliable? Fortunately, these questions can be answered, at least
for clinical purpose.
Morgan23 found that tests for the farpoint phoria
showed high reliability even when the interval
between tests was many years. Most standard clinical tests of far and near heterophoria have acceptable reliability and concurrent validity, with the
exception of the Maddox rod test at nearpoint. 24
The reliability may be mproved, as Saladin suggested,24 by having the patient hold or touch the
penlight to stabilize accommodation at the 40-cm
test distance. However, little has been reported on
the test-retest reliability of Risley prism vergence
ranges.
There is evidence to support the overall validity
of graphical analysis and other clinical criteria of
vergence assessment. Three different approaches to
Chapter 3
in preference to no prism in esophoric subjects (particularly for farpoint viewing) and in presbyopic,
exophoric subjects. However, nonpresbyopic adults
with exophoria did not prefer the prism beyond a
chance level. Fortunately, visin training techniques
for ncreasing fusional convergence are very effective in such cases.
Payne et al.28 provided two sets of lenses to 10
patients with asthenopia and fixation disparity at
near. The prism amount was determined by measuring the associated phoria using a nearpoint Mallett
Unit, and a double-blind (masked) procedure was
employed. By this criterion, all patients (eight nonpresbyopic exophores and two esophores) chose to
keep the prism prescription. Grisham 29 reported
prism acceptance in a group of symptomatic presbyopic exophores using associated phoria as the
prism criterion. Of the 12 patients, 10 chose to keep
the prism that neutralized their fixation disparity at
near. On the basis of theoretical considerations,
some clinicians do not believe in the use of associated phoria alone for prism prescription. However,
the preceding evidence suggests that this method
has clinical utility, at least when determined by a
test that has a central fusin stimulus (i.e., "lock")
for example, the Mallett unit, Bernell fixation disparity slide, or the Saladin Card.
The three approaches just described for evaluating
the validity of graphical case analysis have all, in general, supported its clinical utility. However, any clinical analysis system based solely on subjective
response indicators suffers from inherent limitations.
In coming to a particular diagnosis of a binocular
dysfunction, the clinician s advised to base judgment
on a pattern of findings rather than on any specific
attribute of the ZCSBV. Several clinical Gritera should
be applied in case analysis when looking for a pattern of responses indicative of a functional binocular
visin dysfunction. Fixation disparity analysis is an
alternative system of evaluation that often s used in
addition to graphical analysis to establish the diagnosis and management of vergence disorders.
An evaluation of fixation disparity and the
attributes of the FDC has become a popular mode
of vergence case analysis. Ogle et al. 9 initially
reported good reliability of fixation disparity measurements, and subsequent studies of the FDC n
individuis having normal binocular visin indicated only a small amount of measurement drift
over days and weeks.18'30 Although increases in
convergence or divergence fusional demand
(prism demand) may result in some variability of
89
12
3
4
Exophores Esophores
Sheard's criterion Y Phoria amount Fixation
ntercept
disparity
curve slope Recovery
X ntercept
range Break range
Vergence
opposing phoria Vergence opposing phoria
Vergence recovery
90
Chapter 3
XIN from being excessive, but t allows the clinically significan! fixation disparity component due
to fusional vergence stress to be revealed. Fortunately, the Saladin Card provides a target with a
foveal fusin lock for measuring the associated
phoria (XIN). In other words, the foveal fusin lock
might elimnate the appearance of the physiologic
fixation disparity, but t allows the clinically significant fixation disparity component due to fusional
vergence stress to be revealed.
RECOMMENDATIONS FOR
PRISM PRESCRIPTION
Other than the studies by Sheedy and Saladin,26 little research has been conducted to compare the
relative effectiveness of the various criteria for prescribing prisms and adds to alleviate vergence dysfunctions. In the absence of abundant research
data, clinicians adopt treatment preferences based
on their own clinical experiences. From our experiences, we make the following recommendations
regarding the relative effectiveness of prism prescription criteria (Table 3-5). Our initial bias in
most cases of significant heterophoria, or ntermittent strabismus, is to recommend visin training for
improvement of fusional vergences. Prism compensation may also be necessary as a supplement
to training. When visin training is an unacceptable alternative or training results are unsuccessful,
prism therapy becomes the treatment of choice.
The clinical wisdom criterion for prism prescription works well for exophores, esophores, and
hyperphores at both far and near. Generally speak-
Exophoria
Esophoria
Hyperphoria
Clinical vwisdom
Sheard's crterton
Perdyal's criterion
Associated phoria
Ftatportion @f fixation disparity curve
{iheed^'s eriterion)
Pfismconfirmtri pro eedur
Prlsmsptation test
3
1
3
2
2
3
2
NA
NA
3
NA
3
1
3
1
3
1
Chapter 3
91
92
Chapter 3
power that neutralizes a fixation disparity will usually make print appear closer. 41 A valid prism prescription is ndicated when there is a strong
acceptance response by the patient. To check for a
placebo effect, however, the prism direction is
reversed surreptitiously and again tried. Validity is
confirmed if there is strong rejection of the
reversed prism. If, however, the patient accepts the
reversed prism, further triis with different prisms
are necessary. If no prism is accepted by this confirmation procedure, the prescription of prism is
often unwarranted. Other approaches to resolving
the patient's problem might be recommended
(e.g., visin training, lens power additions, changing viewing conditions, or referral for a general
health examination).
If, after applying these prism-prescribing methods, a question still remains regarding whether a
prism is appropriate, a prism adaptation test may be
helpful in resolving the issue. Heterophoric patients
having normal binocular visin with no ocular
symptoms typically show strong prism adaptation.
After wearing a prism for approximately 10 minutes,
they often will have the same, or nearly the same,
phoria as originally measured. For example, if a 6A
exophoric patient with normal binocular visin
wears a 6A Bl prism (which initially neutralizes the
angle of deviation) for a short period, the examiner
typically finds the phoria to be increasing, resulting
in another 4A to 6A of exo deviation. The prism
would be ineffective, because that patient reverts to
the habitual phoria through the spectacles. Conversely, symptomatic patients with vergence problems usually benefit from prism compensation and
do not typically show significant prism adaptation.
If a prism, worn for 10 minutes, contines to neutralize the angle of deviation, then that prism establishes an acceptable physiologic relation between
the heterophoria and the compensating vergence,
relieving the oculomotor stress. Complete prism
adaptation, when it occurs, usually is complete
within 24 hours, but most of the adaptation occurs
within the first 10 minutes. This test is, therefore, a
relatively quick clinical procedure. The results of
this test are not always clear-cut, and interpretation
often is difficult. At times, this can be a good backup
test of prism acceptance, but professional judgment
remains necessary.
Applying Fresnel prisms to spectacle lenses can
also be used for prism adaptation testing and,
occasionally, for permanent wear. The smooth side
of the membrane is placed on the ocular side of a
VERGENCE ANOMALIES
The predominant classification system for vergence disorders is based on the tonic deviation of
the eyes and the AC/A ratio. It is used to describe
both strabismic and heterophoric cases and is
widely accepted in optometry and ophthalmology
and by interested third-parties (e.g., insurance
companies). Duane42 first proposed this model of
classification, which clinically is called the DuaneWhite classification. Schapero43 also used this
model as a basis for his 10 case types. Duane proposed that a difference of at least 10A between the
far and near deviations was necessary before a
patient should be classified into one of his four
original categories. Other writers have suggested a
15A difference between far and near, and many clinicians use 5A. We prefer to use a 5A difference or
greater between the deviations at far (6 m) and
near (40 cm) to indcate the presence of an abnormally high or low AC/A ratio.
The larger vales typically are used by ophthalmic surgeons, as the desired level of accuracy
in surgical procedures is approximately 10 A. Compensation of the angles of deviation with prisms
and added lenses, however, is more refined and
often the therapy of choice. For example, if a
symptomatic patient with an IPD of 60 mm manifests orthophoria at far and 10 A esophoria at near,
the calculated AC/A ratio is 10 A/1 D. This convergence excess often is treated with a bifocal add,
using the effect of the high AC/A ratio to reduce the
near deviation. However, if the same symptomatic
patient measured ortho at far and 5A esophoria at
near, the calculated AC/A ratio would be 8 A/1 D,
which is considered to be high by Morgan's normative data. Added lenses at near remain an ideal
management approach. We believe a 5A difference
between near and far deviations is consistent with
optical treatment approaches, and so we prefer
this amount for the sake of clinical categories of
vergence anomalies. This assumes that there are
symptoms and visin inefficiencies resulting from
the vergence anomalies. Implicit in any of the
Duane-White categories is poor compensatory
fusional vergences.
Chapter 3
-2O
-1O
10
20
30
40
93
50
CONVERGENCE (A)
Convergence Insufficiency
Convergence insufficiency (Cl), or convergence
insufficiency exophoria as it is sometimes called, is
characterized by a low AC/A ratio resulting in an
increased exophoria at near viewing distances
(Figure 3-14). A symptomatic patient showing
orthophoria at far and 5 A exophoria at 40 cm
would be an example. Other clinical findings associated with Cl include a reduced PRC, a reduced
NPC (poor gross convergence), and deficient
accommodative responses.44 Vision training is the
treatment of choice for most Cl cases. There s
abundant evidence in the literature that this s
effective.44 Because the AC/A ratio is low, added
lenses (e.g., minus power) are of little valu. Prism
prescriptions have the disadvantage in these Cl
cases by inducing an esophoria at far. Sometimes t
is advisable for patients presenting with accommodative insufficiency and Cl to have a reading add
together with Bl prism for nearpoint use only.
However, these patients also respond well to
visin training. Some Cl cases sometimes present
with a large exo deviation (low tonic convergence)
at far, combined with a low AC/A ratio. These are
the cases that most likely benefit from a Bl prism
prescription (relieving the exo deviation at far) in
conjunction with visin training to improve
fusional convergence at near.
Another similar Cl case type, usually ignored in
most classification systems, is presbyopic exophoria. Most aging presbyopes show increases in their
exophoria at near. Often there is reduced PRC, and
these patients develop classic symptoms of Cl (e.g.,
tired eyes, sleepiness when reading, and avoidance
of near work). Unfortunately, most clinicians and
the patients nterpret these symptoms as part of the
normal aging process. If a young person presented
with typical Cl symptoms, visin training would
likely be recommended. We believe that many
Basic Exophoria
Basic exophoria refers to cases n which the tonic
position is exophoric at far and the AC/A ratio is
normal. The far and near exo deviations are
approximately equal in magnitude. An example
would be a symptomatic patient who presents with
8A exophoria at 6 m and 8A exophoria at 40 cm
(Figure 3-15). The basic exophoria patient may
experience visual symptoms at both far and near.
Much clinical literature indicates that significant
exophoria is more prevalent in people experiencing reading difficulties.47 Because fusional conver-
Chapter 3
S
S 7
Z
BLUR
RECOVCRY
PHORIA
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Divergence Insufficiency
Divergence insufficiency esophoria is the least
prevalent of the esophoria cases. It is defined as a
significant esophoria (high tonic convergence) at
far, combined with a low AC/A ratio. An example
would be 12A esophoria at far and 3A esophoria at
near (Figure 3-17). These patients can lapse into an
occasional esotropa at far if fusiona! divergence is
poor. For them, driving a vehicle, particularly at
night, can be a serious problem.
Successful management of some cases of divergence insufficiency is difficult. One approach that
seems moderately effective is to prescribe BO prism
correction in single-vision lenses for general wear.
For example, this may be 8A BO if the far esophoria
is 12A. If there is no prism adaptation, the resulting
farpoint esophoria would be 4A, which considerably
reduces the fusiona! divergence demand. However,
with these spectacles in place, the near eso deviation would measure 5A exophoria instead of 3A eso-
Chapter 3
95
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CONVERGENCE (A)
ts
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30
4O
50
Basic Esophoria
Bas/c esophor/a is characterized by a significant eso
deviation at far and a modrate AC/A ratio, so that
the far and near angles of deviation are approximately equal. An example would be esophoria of
1P at all viewing distances (Figure 3-18). Other
associated findings often include reduced NRC, a
low PRA, and high NRA. BO prism s an obvious
and safe treatment approach in basic esophoria and
usually is effective, because most symptomatic esophores do not adapt to prisms. Vision training s also
useful in combination with prism prescription.
Without the prism, completion of divergence training often takes several months, and there can be frequent regression of fusional divergence skills. If the
basic esophoria patient is symptomatic only at near
due to work requirements (e.g., computer or desk
work), a reading add (either single-vision lenses or
bifocals) may also be considered.
Convergence Excess
Convergence excess esophoria is the case that typcally presents with little or no esophoria at far but
with a high AC/A ratio. An example would be
orthophoria at far and 7 A esophoria at near (Figure
3-19). Patients with convergence excess often
BLUR
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SO
If the condition proves to be caused by accommodative and vergence dysfunctions, visin training is recommended. This mode of visin therapy
is usually successful within a matter of a few
weeks. The visin training goal would be to
expand the range of the entire ZCSBV and
improve the facility of all oculomotor functions.
43
Sst
Chapter 3
96
Chapter 3
BIOENGINEERING MODEL
Maddox48 believed that the vergence system could
be categorized by four additive components tonic,
accommodative, proximal (psychic), and fusional
(disparity) vergence. Graphical analysis based on
this concept was developed gradual ly by several
notable individuis such as Percival, Sheard, Morgan, Fry, and Hofstetter and became the scientific
bundation for binocular case analysis. We have
emphasized the graphical analysis perspective in
this chapter and adapted the Duane-White classification scheme to heterophoric disorders. We also
applied Morgan's normative analysis, which s consistent with classic graphical analysis. In Chapter 2,
the emphasis was on evaluating various oculomotor
systems over time, testing the dynamic components
of each system. Accuracy, speed, and stamina were
distinctive clinical features n that analysis. These
two perspectives, graphical analysis and visin effi-
97
One of the most useful research tools of bioengineers is to build mathematic control models of biological systems and then to compare them with
empiric physiologic evidence. The model s modified until ts features accurately simlate physiologic responses and are consistent with what s
known aboutthe anatomy of the biological system.
Several mportant insights have evolved from the
relation between control systems modeling and
physiologic evidence.
The accommodative system of the eyes and the
vergence system are cross-linked and dynamically
influence each another. Accommodation drives
convergence (AC/A) and convergence drives
accommodation (CA/C). When both systems are
stimulated simultaneously, the cross-links interact
and respond differently from when either system is
stimulated n isolation.49 Classic graphical analysis
has not taken into account this dynamic relationship and has largely gnored the influence of the
CA/C. Nevertheless, clinicians have long been
aware that disorders of accommodation and vergence often are associated.
Stimulation of some adaptive mechanisms for
the AC/A, CA/C, and fusional vergence result in
tonic changes n both accommodation and vergence. Therefore, there are both momentary and
more lasting adaptations to prism and lens stimuli;
a particular patient's physiologic responses to
skteA toes os ^'ms cm^te 3m\u\aty \K&each delinales visual functions, and disorders
thereof, that the other may neglect. For example,
disorders of accommodation, other trian accommodative insufficiency, are ignored by classic graphical
analysis. Vision efficiency analysis of accommodation, however, includes evaluation of lag of accommodation (accuracy), facility (speed), and stamina
(sustainability).
Originating in the 1950s, fixation disparity analysis tended to reinforce and supplement the vergence evaluation of graphical analysis. Graphical
analysis and fixation disparity analysis emphasized
different aspects of vergence and accommodative
dynamics, but the systems were intimately related,
as they both described the same underlying oculomotor physiology. What has become clear since
the time of Maddox s that vergence and accommodative physiology, and disorders thereof, are
substantially more complex than Maddox originally formulated. This realization has largely come
to light through a bioengineering systems control
approach used in basic research.
98
Chapter 3
Desired
Accommodative .
Level
Desired
Vergence
Level
Accommodative
Response
""
Vergence
^ Response
Blur
Detectors
Accommodative
Controller
Slow
Adaptation
Ciliary
Musce and
Leus
FIGURE 3-22Theoretical bioengineering model llustrating interaction between accommodation and vergence in a closed-loop system. (Mod-ified
from JJ Saladin. Horizontal Prism Prescription. In: Clinical Uses of Prism. SA Cotter, ed. St. Louis: Mosby; 1995:123.)
this optical compensation. Cood vergence adaptation relates to visin training n which increased
prism demand (rather than compensating prism) s
introduced for the purpose of increasing fusional
vergence ability and, ultimately, favorably affecting
tonic vergence.
The influence of proximal vergence on nearpoint vergence eye position has been largely
ignorad n classic case analysis, yet in some
patients the amount of proximal vergence can significantly influence the associated phoria status,
for better or worse.53 Wick and London54 proposed a
versin of the Hung-Semmelow model of nteractions between accommodation and vergence
that takes into account the influence of proximal
convergence. They emphasized that one difficulty
with the traditional system of binocular case analysis is that the vergence deviation that exists under
binocular (associated) conditions often s not the
same as that measured under dissociated viewing
conditions (e.g., Maddox rod test). They joined
Saladin55 in a strong appeal for evaluating binocularity under closed-loop (associated) conditions
Chapter 3
15.
16.
17.
18.
19.
20.
21.
22.
REFERENCES
1. Donders FC. On the Anomalies of Accommodation and
Refraction of the Eye, trans. Moore WD. London: The
New Sydenham Society; 1864.
2. Morgan MW. The Maddox classification of vergence eye
movements. Am J Optom Physiol Opt. 1980;57:537-539.
3. Flom MC. Treatment of Binocular Anomalies of Vision. In:
Vision of Children. Hirsch M, Wick R, eds. Philadelphia:
Chilln; 1963:216.
4. Sheard C. Ocular discomfort and its relief. EENT.
1931;7.
5. Morgan MW. Analysis of clinical data. Am J Optom Arch
Am Acad Optom. 1944;21:477-491.
6. Morgan MW. Accommodation and convergence. Am J
Optom Arch Am Acad Optom. 1968;45:41 7-491.
7. Sheedy JE, Saladin JJ. Phoria, vergence, and fixation dis
parity in oculomotor problems. Am J Optom Physiol Opt.
1977;54(7):474-478.
8. Percival AS. The Prescribing of Spectacles. Bristol, U.K.:
JohnWright; 1928.
9. Ogle KN, Martens TG, Dyer JA. Oculomotor Imbalance
in Binocular Vision and Fixation Disparity. Philadelphia:
Lea & Febiger, 1967:145-151, 328-331.
10. Schor CM, Ciuffreda KJ, eds. Vergence Eye Movements:
Basic and CHnical Aspects. London: Butterworths;
1983:467.
11. Mallett RFJ. The invstigation of heterophoria at near and a
new fixation disparity technique. Optician. 1964;148:547551.
12. Morgan MW. Anomalies of Binocular Vision. In: Vision of
Children. Hirsch MJ, Wick RE, eds. Philadelphia: Chilln;
1969:176.
13. Col RG, Boisvert RP. Effect of fixalion disparity on stereo-acuily. Am] Optom. 1974;51:206-213.
14. Levin M, Sullan B. Unpublished snior sludent research
study. On file in Ihe M.B. Kelchum Memorial Library,
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
99
History 101
Time of Onset 102
Modeof Onset 102
Duration of Strabismus 103
Previous Treatment 104
Developmental History 104
Summary of Clinical Questions 105
Measurement of Strabismus 105
Direct Observation 105
Angle Kappa 105
Hirschberg Test 106
KrimskyTest 107
Unilateral Cover Test 107
Altrnate Cover Test 108
Four Base-Out Prism Test 109
Brckner Test 110
Comitancy 110
Causes 110
Criteria and Terminology 111
Primary and Secondary Deviations 112
Ductions 113
Versions 115
Three-Step Method 115
Recording Noncomitant Deviations 118
Spatial Localizaron Testing 121
HISTORY
Resides giving tentative determinaron for each of
the aforementioned variables, a patient history s
needed to assess the time of onset of a manifest
deviation, its mode of onset, its duration, previous
treatment and results, and pertinent developmental
history that may have a bearing on the binocular
status of the patient.
102
Chapter 4
Time of Onset
A vital part of any strabismus diagnosis is to ascertain
whether the strabismus s congenital. More correctly,
congenital strabismus should be referred to as essential infantile strabismus because, in many such cases,
the manifest eye turn s not present at the time of
birth. In cases of essential infantile strabismus, clinical experience with visin therapy, including surgery,
has shown that the prognosis for normal binocular
visin s very poor unless treatment occurs very early.
We believe that the age of 4 months is the critical
cutoff between essential infantile and early acquired
strabismus, because by that time the accommodation
has developed to a large degree. The classification of
late acquired strabismus pertains to occurrence of
strabismus beyond the age of 2 years. For example,
an infant with intermittent esotropa at 6 months of
age may have an accommodative-convergence component that results n the strabismus. For children 2
years of age and younger, parents should be questioned to determine the specific month of onset. For
example, an essential infantile esotropa at birth
probably has a poorer prognosis for cure with early
treatment (e.g., surgery before age 2 years) than if the
onset were at 4 months of age. In the latter case, the
nfant has presumably experienced 4 months of cortical development for binocular visin.
To ascertain the time of onset, a complete report
of previous professional examinations should be
obtained. However, this is not always possible and
information from parents, relatives, and friends is
often erroneous. Pseudostrabismus can be confused
with true strabismus; the appearance of esotropa
can be simulated by epcanthal folds, negative-angle
kappa, narrow nterpupillary distance, and other
cosmetic factors. Any of these factors can cause parents to beleve that their baby has esotropa, when n
fact there s only pseudostrabsmus. Further confusin as to time of onset s introduced when a pseudostrabismus later becomes an acquired strabismus.
A patent history obtained from the parents s not
always reliable for accurate tming of the onset. Parents can also be msled by the poorly coordinated
eye movements usually present n the early postnatal
period, which can cause a report of congenital strabismus when, n fact, the infant's binocular status
was normal with respect to age.
We believe the prevalence of infantile esotropa is
approximately 25% of all cases of constant esotropa.
In the majority of esotropes (whether constant or
intermttent), onset is after the age of 4 months and
usual ly before 6 years but occasionally later. Because
time of onset is mportant in the prognosis for functonal cure, the clincian must differentiate infantile
from later-acquired esotropa. When the history fails
to pnpoint the onset of esotropa, certain testing may
indcate whether the esotropa was essential infantile
or acquired: Some possble characteristics of essential infantle esotropa can be compared with those of
acquired esotropa (Table 4-1). These findings are
useful when the patient history s insufficient. It also
may be helpful to have parents bring early childhood
photographs for nspection, partcularly those taken
before the child reached the ages of 1 and 2 years.
The prevalence of essental infantle exotropia s
lower than that of nfantile esotropa. Onset of
acquired exotropia, however, may be early, often
before the age of 2 years.
Mode of Onset
It is important to know whether the strabismus was
intermittent or constant when t became apparent. An
intermittent strabismus is relatively more notceable
than one of equal magnitude that s constant and
unchanging. Although an intermittent strabismus may
cause cosmetic concern, t has a less deieterious
effect on binocular function than does constant strabismus. Even f treatment were delayed, t can be
assumed that the child with an ntermittent manifest
deviation did not completely lose central binocular
fusin, as would happen n constant strabismus. This
is a particularly important point for consideraron n
cases of small-angle esotropa with a monofixation
pattern. Even though the eyes are apparently straight,
a small constant esotropa may be present. Only
when peripheral fusin breaks down and the larger
eso component is manifest will the esotropa be cosmetically notceable. This seemngly ntermittent
esotropa s, nevertheless, constant.
Exotropia, on the other hand, tends to be either
purely intermittent or constant; the deviating eye s
likely to be either all the way out or all the way
aligned for bifoveal fxation. Mode of onset reported
in the history s usually more relable n cases of
exotropia than n esotropa. Early acquired exo
deviations tend to be intermittent as compared with
eso deviatons, which tend to have a sudden constant mode of onset. Typcally, an ntermittent exo
devation that begins at approximately 2 years of
age contines to be ntermittent for many months.
Frequently, intermittent exotropia n young children
gradually becomes more frequent and may become
constant over time, unless visin therapy s insti-
Chapter 4
103
TABLE 4-1. General Guidelines for Characteristics That Might Differentiate between Essental Infantile
and Later-Acquired Esotropa
Aequired Esotropa
AC/A = accommodative-convergence/accommodation.
Duration of Strabismus
The duration of time elapsng between the onset of
a manifest deviation and therapy is a crucial factor
n the re-education and recovery or further development of normal binocular visin. This s particularly
so in the child younger than 6 years. We believe the
best surgical results n infantile esotropa, as indicated by long-term random-dot stereopsis, occur
104
Chapter 4
Both
Muscle(s) undergoing operation
Technique (e.g., recession, resecton)
Cosmetic appearance
Preoperatively
Immediately postoperatively
Later postoperatively Functional result (much
depending on professional
reports) Repeat precedng information for additional
surgeries
Previous Treatment
After questioning regarding time, mode, and duration of onset has been completed, another important
fact to determine from the patient history is the
extent and type of previous treatment that the patient
has actually received. However, treatment all too
often is recommended but not sufficiently undertaken. Treatment usually takes the form of patching
an eye, but in many cases it is found to have been
inadequate. The lack of proper occlusion therapy
impedes recovery; in addition, a history of a patient's
having been patched can lead to erroneous conclusions on the part of a subsequent examining clinician. The second doctor may mistakenly conclude
that everything possible was done for the patient and
that any existing amblyopia cannot be eliminated by
means of patching, as such therapy has been tried
without success. To avoid such incorrect assumptions, questions regarding previous treatment must
be pursued in depth. This rule applies not only to
occlusion therapy but to any of the other various
forms of treatment for binocular anomalies. Table
4-2 lists information that should be obtained when a
patient has undergone extraocular muscle surgery.
Developmental History
The purpose of obtaining a developmental history
is to determine the important milestones at different ages in a child's Ufe. Of interest are the physical, mental, and emotional development of the
individual mainly in the plstic years before age 6.
A developmental history may explain why a
patient has a particular binocular anomaly.
Fisher1 stated that gross neurologic dysfunction
has been found in almost 25% of patients with infantile esotropa. In contrast, the prevalence of such
Chapter 4
UREMENT OF STRABISMUS
il methods may be used for detection of strabis-Some
are more sensitive than others, meaning tdetection is
more likely using those methods. For ampie, the
unilateral cover test s more likely to strabismus
than s direct observation. Objec- methods are
Usted in Table 4-4, and the relative 9BBtvity for
detection of each is shown.
Observation
Horizontal manifest deviations greater than 20A can
be detected by observation alone, because
105
Oirect observation
Hirschberg test Krtmsky
test Four base-out prsm
test Unilateral cover test
Brckner test
Angle Kappa
Angle kappa s the angle between the visual axis and
the pupillary axis. It s practically the same as angle
alpha, which is the angle formed at the first nodal
point by the intersection of the optic axis and the
visual axis. Because angle alpha cannot be measured
by clinical means, angle kappa is the traditionally designated clinical term, although technically the clinician is measuring angle lambda (the angle subtended
at the center of the entrance pupii of the eye by the
intersection of the pupillary axis and the visual axis).
The magnitude of angle kappa (actually lambda)
customarily is referred to in terms of millimeters
rather than prism diopters (A) or degrees. Although
the normally expected magnitude s from 0.25 mm
positive (nasalward) to 0.5 mm positive, there s
nothing abnormal about a larger or smaller angle
kappa (even a negative, or temporalward, angle)
provided the magnitude is the same for each eye.
The distance in millimeters between the corneal
reflection of the fixated penlight and the center of
the pupil determines the magnitude (Figure 4-1).
Testing is performed monocularly under dim room
illumination. The patient fixates a penlight at a distance of approximately 50 cm. The examiner's sighting eye must be directly behind the light source. The
position of the corneal light reflection n relation to
106
Chapter 4
FIXATION
LIGHT
K!
PUPILLARY
AXIS
O.D.
b.
O.S.
OCCLUDED
FIGURE 4-1Illustrations of angle kappa (K). a. Top view of right eye,
illustrating a positive angle kappa. b. Front view of right eye, illustrating a
positive angle kappa. The light reflection is displaced nasally by approximately 1 mm. (f = fovea; O.D. = oculus dexter; O.S. = oculus sinister.)
Hirschberg Test
In the latter part of the nineteenth century, Julius
Hirschberg2 introduced a quick and practical test
for measuring the angle of strabismus. The procedure has remained the same over the years,
although interpretation has varied. The Hirschberg
test is performed by directing a small light source,
such as a penlight (Hirschberg used a candle
fame), onto the patient's eyes. From behind the
light, the examiner sights the eyes while the patient
is fixating the light. The examiner's dominant eye for
sighting is directly behind the light, preferably less
than 10 cm from the light source. Hirschberg recommended approximately a 30-cm distance
between the light and the patient, although this may
be increased to 1 m and still maintain accuracy. We
recommend a range between 0.5 and 1.0 m for
clinically measuring an angle of strabismus.
Chapter 4
O.D.
107
O.S.
a.
b.
c.
with results by the altrnate cover test. 8 Hirschberg
test accuracy and reliability can be mproved by
video enhancement of the mage of the eyes with a
millimeter scale in the field, so that direct measurements can be made. 9This method may be applicable in infants and small children in whom other
methods are not providing consistent results.
d.
Krimsky Test
e.
108
Chapter 4
of dissociation, making fusin impossible. The altrnate cover test cannot determine whether a deviation
s concealed by fusin.
The test is performed by alternately occluding one
eye and then the other while watching for any conjgate movement of the eyes, which would indcate a
deviation. The greater the conjgate movement, the
greater is the deviation (either strabismic or phoric).
An exo deviation will result n conjgate movement n
the same direction as the movement of the occluder
("with" motion), whereas an eso deviation causes an
"against" motion during the altrnate cover test.
The testing procedure is best explained by using
an example. Assume that the patient in this example has an esotropa of the right eye of 25A. The frst
step is to occlude the eyes alternately at a rate of
1-2 seconds per occlusion to determine whether
there is an eso, exo, or hyper deviation. The direction and magnitude of the conjgate movement of
the eyes indcate the drecton and magnitude of
the deviaton.
Assuming the unilateral cover test was done previously, certain information about the deviation of
the visual axes s already known (.e., whether the
deviation is strabismic or phoric, the dominant eye
preferred for fixation, the direction and estimated
magnitude of the deviation). Bearing in mind the
knowledge gained from the unilateral cover test, the
examiner's next step is to occlude the nondominant
deviating eye. In this example, the right eye s
occluded and no movement of either eye is
expected, because the left eye remains the fixating
eye and is motionless. When, however, the occluder
Chapter 4
s switched to the left eye, the right eye takes up fixation, which causes a conjgate eye movement to
the patient's right-hand side.
The next step is to switch the occiuder to the
right eye and place a prism between the eye and
the occiuder. Then the occiuder is switched to the
left eye, and any conjgate movement is noted; f
there s no movement, the prismatic power represents the magnitude of the deviation (Figure 4-6). If
there is an "against" motion, the BO neutralizing
prismatic power is nsufficient, with a residual eso
deviation. If there s a "with" motion, the prismatic
power s overcorrecting the eso deviation (as
though the patient has an exo deviation).
a
l
E
c
c
e
n
t
r
i
c
F
i
x
a
t
i
o
n
109
FIGURE 4-7Preparing for the four base-out prism test in the case of
a small esotropa of the right eye.
A pitfall of the cover test is that its validity s vitated f there s eccentric fixation. (Refer to the discussion on eccentric fixation n Chapter 5.) For
example, suppose the patient has nasal eccentric
fixation of 5A of the right eye and has an esotropa
of the right eye of 5A. The measured magnitude on
the cover test would be zero. If, in another case,
the true angle of esotropa s 8A, the cover test
would yield a magnitude of 3 A of eso deviation.
Eskridge7 proposed rules to differentiate between
the measured and true deviation. Nasal eccentric
fixation causes the measured angle Hto be smaller
than the true angle H in esotropa but larger than
the true angle H n exotropia. In contrast, temporal
eccentric fxation causes the measured angle H to
be larger n esotropa but smaller in exotropia
(Table 4-5).
Chapter 4
frequent exceptions to this rule. Pigmentary difference, unequal pupil size, and anisometropia invaldate the Brckner test: That is, the fixating eye may
appear brighter than the deviating eye in such cases.
Nevertheless, the Brckner test s a good adjunct
method for detecting microstrabismus.
small esotropic angles, less than 4 A, because the prism power is larger than the angle of deviation. This is
because peripheral (extramacular) fusin may allow a convergence response to the prism, although usually not
the full 4A of convergence.
If the deviation were esophoric rather than esotropic, the left eye, and later the right eye, would be expected to
adduct. Clinical results from this test and the unilateral cover test provide nformation on tropia versus phoria,
assessment of suppression n an objective manner, and information about which eye tends to be strabismic. In
both tests, analysis of the patient's eye movements requires keen observa-tion. These tests appear to be very
simple, but they probably require more clinical acumen than other tests for assessing binocular visin.
Brckner Test
10 11
An extremely sensitive, although not always reliable, method for detecting strabismus is the Brckner test. ' It is
performed by using an ordinary direct ophthalmoscope held at approximately 75 cm from the patient's eyes with
the beam of the ophthalmoscope directed to the bridge of the nose and equidis-tant from each eye. The examiner
observes the fundus (red) reflex and compares the brightness between the two eyes. The strabismic eye, as a
rule, will appear brighter (Figure 4-9), although there are
COMITANCY
All deviations are classified as being either comitant or noncomitant. (The correct etymological terms are
concomitant and nonconcomtant, but the short-ened words generally are preferred for ease n clinical usage.)
Comitancy (or comitanc) means that the angle of deviation of the visual axes remains the same throughout all
positions of gaze. This implies that there are neither abnormal underactions or overactions of any of the 12
extraocular muscles controlling eye movements. In contrast, noncomi-tancy (or noncomitanc) means that the
magnitude of the deviation changes when the eyes move from one position of gaze to another. Thus, there s
either abnormal restriction to movement or overaction of one or more of the extraocular muscles.
Causes
Underactions are the result of one of three basic malfunctions. First, the extraocular muscles them-selves may
be paretic, as in cases of direct traumatic injury. Second, and more frequently, mechanical reasons such as faulty
muscle nsertion and liga-ment abnormalities may restrict ocular motility. Third, and most frequently, the
extraocular muscle paresis responsible for underactions is caused by innervational deficiencies due to
impairment of the cranial nerves (III, IV, and VI) that innervate the muscles. Nerve impairment is commonly
attributable to
111
vascular
problems,
such
as
hemorrhages,
aneu-rysms,
and
embolisms in older patients. Infectious
diseases that affect the central nervous
system also are frequent causes and
should be suspected, par-ticularly in
young patients.
Overactions may be due to
mechanical anoma-lies, such as a faulty
muscle insertion giving mechanical
advantage to the particular muscle.
More often, however, the overaction
can be explained by Her-ing's law of
equal innervation to two yoked muscles.
This law states that the contralateral
synergists are equally innervated when
a movement s executed by both eyes.
If, for example, the right lateral rectus
muscle is paretic and requires an
abnormally high level of innervation to
abduct the right eye, the equally high
level of innervation is sentto the medial
rectus of the left eye (the yoke muscle
of the lateral rectus of the right eye)
(Table 4-6). This results in an overaction
of the left medial rectus, which further
increases an eso deviation due to the
paretic right lateral rectus. If this
overaction contines for several months,
a permanent state of contracture may
result, whereby the tissues of the left
medial rectus eventu-ally become
fibrotic and nonelastic. This worsens the
prognosis for cure of an eso deviation.
In this example of a paretic right lateral
rectus muscle, the right medial rectus
(homolateral antagonist) can also
become spastic and, eventually, fibrotic.
Precautions and appropriate therapy in
such cases are discussed in Chapter 15.
112
Chapter 4
Chapter 4
a. Dextrosupraverston (Tertiary)
c. Levosupraversion (Tertiary)
b. Supraversion (Secondary)
d. Dextroversion (Secondary)
e. Primary Position
g. Dextroinfraversion (Tertiary)
h. Intraversin (Secondary)
113
<JE>
f. Levoversion (Secondary)
O
i. Levoinfraversion (Tertiary)
FIGURE 4-12The nine diagnostic positions (a-i) of gaze for conjgate eye movements, with secondary and tertiary positions indicated.
Ductions
The words duction and vergence have caused confusin n clnica! usage. Technically, ductions are
monocular eye movements (Table 4-7). The common interchanging of the two terms probably arse
from clinicians' misuse of the word ductions when
vergences was meant.
Duction testing is useful when evaluating noncomitancy. It is not as sensitive, however, as versin
O.D.
O.S.
114
Chapter 4
Classifcation
Convergente
Ductions
Horizontal Adduction
(nasal)
P
a
r
etic
RLR
Excessive
Innervation
toLMR
FIGURE 4-17Esotropa of the left eye is llustrated in a case of paresis of the right lateral rectus muscle when the right eye is fixating. This
is the secondary angle of deviation, which is much larger than the primary angle. (f = fovea; LMR = left medial rectus muscle.)
Divergence
Positive
Abduction (temNegative
poral) Supraduction
Vertical* (elevation) Infraduction
Incyclovergence
(depression)
Torsional Incycloduction
Excyclovergence
(intorsion) Excycloduction
(extorsin)
Dextrosupraduction LevosupraducTertiary
postions tion Dextroinfraduction Levonfraduction
*Vertical vergence s also known as vertical divergence. It is positive f the right eye elvales and negativa if the left eye elevates.
Chapter 4
TABLE 4-8.
115
Gaze
Gaze
Right
Left
Left
Right and up
Right and down
Left and down
Left and up
Right :
Left and up
Left ard down
Right and down
Versions
Versions are conjgate movements of both eyes. Testing for noncomitancy is more sensitive with versions
than with ductions, because a change n the deviation of the visual axes from one position of gaze to
another can be measured fairly precisely in versin
testing, in contrast to duction testing, in which only
one eye s being examined and a restriction or overaction must be relatively large to be observed.
Detecting a change in deviation under binocular seeing conditions during versions is relatively easy. For
example, assume the patient has a mild paresis of the
right lateral rectus muscle. On duction testing, the
patient may be able to abduct the right eye with a
Right and up
large excursin, complicating the diagnosis of noncomitancy. Dextroversion testing, however, would
probably detect the restriction in the DAF of the right
lateral rectus in this case, because an eso deviation
would increase dramaticaliy on rightward gaze.
The three objective methods of versin testing,
ranging from least to most sensitive, are (1) direct
observation, (2) Hirschberg testing, and (3) the
altrnate cover test with prism. Each method may
be used n the nine DAFs liustrated in Figure 4-12.
For example, with dextroversion, the DAFs are for
the right lateral rectus and the left medial rectus. If
the right lateral rectus muscle s paretic, esotropa
is likely on rightward gaze, whereas f the left
medial rectus is paretic, exotropia is likely.
Three-Step Method
Ordinarily, analyzing the eight cyclovertical muscles
s more difficult than analyzing the four horizontally
acting recti. A useful paradigm for identifying an
isolated paretic cyclovertical muscle, taking into
account a vertical deviation, was introduced by
F*arks.12 The three basic steps of this method are
shown inTable 4-9 for each cyclovertical muscle.
The three-step method is best explained by using
as an example a known paretic muscle and then proceeding to the three differentially diagnostic steps.
Suppose the patient has a paretic right superior
oblique muscle. This muscle's main action s infraduction and, secondarily, intorsion. In the primary
position, the superior oblique has a slight action of
abduction, but this can be considered negligible for
purposes of our discussion. When the patient fixates
n the primary position of gaze, the right eye is likely.
to have a small degree of hyper deviation. This could
be either hypertropia or hyperphoria, depending on
the results of the unilateral cover test. The likelihood
that a right hyper deviation will be present s attribut-
116
Chapter 4
TABLE 4-9.
R
R
R
L
L
L
Paretic Muscle
Left inferior oblique
Right inferior rectus
Right superior oblique
Left superior rectus
Right superior rectus
Left superior oblique
Left inferior rectus
Right inferior oblique
L= left R=right
Chapter4
117
118
Chapter 4
Primarv Position: RE Hyper
(LIO
RSR
LSR }
RIO
LSR
RSR
RSO
RSO
LSO
LIR
RSR
LIR
LSO
LIO
LSO
JLSRj)
Ti
LIR
RSR
RIO
RIR
RSO)
LIO
LSO
LIO
LI
problems do not always provide a clear-cut diagnosis, as in cases of newly acquired paresis. Furthermore, if more than one cyclovertical muscle is
involved, the three-step method will not be valid.
LIR
Chapter4
119
c
RIO")
RSR
RIR RSO
LIO
LSR
LSO
RSR
RIR
RlOj)
LIO
RSO
LSO
LSR
LIR^)
RSR
RICM
RIR
RSO
LIO
LSR
LSO
LIR
RIO)
RIR
RSO
LIO
LSR
LSO
LIR
RIO)
120
Chapter 4
OD Fixating
2 eso
5 eso
OS Fixating
20 eso
2 eso
Seso
20 eso
2 eso
5 eso
20 eso
Seso
15 eso
35 eso
Seso
15 eso
35 eso
Seso
15 eso
35 eso
-1
-2
FIGURE 4-24Grading of
ocular motilityin this case,
restriction of the left lateral
rectus muscle (LLR)on a
ranking scale similar to that of
Jampol-sky, with -1 being the
most mild and -4 being the
most marked in severity.
Chapter 4
Overactions can present either unilaterally or bilaterally. Thorough diagnosis requires the grading of
overactions on a 4-point scale. The clinician moves
the fixation target, often a penlight, to direct the
patient's fixation into an extreme field of gaze. For
example, when checking for an overaction of the
right inferior oblique muscle, the clinician should
direct the patient to fixate with the left eye in extreme
left gaze (see Figure 4-25). Also, testing should be
performed with the patient's left eye in extreme upper
left gaze. (Likewise, to check for overaction of the
right superior oblique muscle, the fixating left eye
would be directed to the extreme lower left field.)
Then the vertical alignment of the two eyes should
be compared for differences. We recommend the
following convention: If the nonfixating eye is 1
mm higher than the fixating eye in up-gaze or 1
mm lower than the fixating eye n down-gaze, the
overaction is graded as +1; f the difference s 2
mm, then the grade s +2; f a 3-mm difference,
then +3; and f a 4-mm or greater difference, then
+4. Divergence often accompanies overactions of
the oblique muscles n grades +3 and +4, as s indicated in Figure 4-25. In the primary position of
gaze, the oblique muscles have the tertiary action
of adduction. On extreme abduction, the eye does
not move to 51 degrees, where there would be
purely vertical action, but falls short, allowing for
some abduction. In extreme overactions of the
oblique muscles, the abduction becomes apparent.
121
to be normal. Correctional judgments of localization are learned over time, which explains why sensitivity of this test diminishes in cases of paresis of
long duration.
If testing is conducted correctly n a newly
acquired case of a paretic right superior oblique muscle, the patient will likely miss the target by pointing
to the left of the target (.e., patient's left) and below t.
All 12 extraocular muscles can be tested in this manner, in the DAF of each. Clear-cut evidence of spatial
localization error implicates a newly acquired paresis
as the cause of noncomitancy.
Diplopia
Young children nfrequently report diplopia. We
have seen many children who, when examined
and asked, replied, "I thought everybody sees double." Their lack of life experience and difficulty in
articulating what is and what should be may
explain n part why reports of diplopia may not be
heard from many young children who are strabismic. Another reason is that young children can
usually suppress the aggravating image caused by
the deviating eye.
Suppression s more difficult to achieve with
maturity. Most adults have trouble coping with
diplopia that results from a manifest deviation of
sudden onset, such as from a newly acquired
paretic muscle. In such cases, diplopia is the main
reason for an office visit. If, however, a patient has
always had poor binocular visin with deep suppression, diplopia may not be noticed and would
not be a warning of a newly acquired paresis.
Abnormal Head Posture
An affected extraocular muscle can often be identified merely by observation of the head posture of
122
Chapter 4
Msete
Turn
Tilt
ilevatton
L
R
Up
Down
Down
Up
L
R
L
L
R
__
Up
Down
Down
Up
R
L
R
L
R
L
R
L = teft; R right.
Subjective Testing
Subjective comitancy testing, when feasible, is
usually more precise than are objective testing
methods. The patient may be able to notice a very
small displacement of two images resulting from
misalignment of the visual axes. Observations of
small deviations sometimes is difficult for the
examiner, making objective testing less sensitive.
This is particularly true for cyclo deviations, for
which subjective testing must often be relied on for
accurate diagnosis.
There are, however, disadvantages to subjective
testing. This type of examination is greatly dependent on the cooperation of a capable and aware
patient. An uncooperative, dull, or unperceptive
patient gives either invalid or no results. Objective
testing must be relied on in such cases. The presence of anomalous retinal correspondence (ARC)
also may invaldate subjective findings, because
the objective and subjective angles are different.
Moreover, the subjective angle itself is often variable when this condition is present. (ARC is discussed in Chapter 5.)
Single-Object Method
The traditional way to make a patient aware of
pathologic diplopia is by using a single target (see
Chapter 1). If a patient has an exotropic deviation,
a bright penlight in a darkened room should be
perceived by that patient as a double image. A
deviating right eye sees the image of a light to the
left of the fixated light seen by the left eye. This is
heteronymous (crossed) diplopia and the type normally expected with exo deviations. In contrast,
homonymous (uncrossed) diplopia is normally
expected with eso deviations.
Two rules apply when testing for noncomitancy
using the single-object method. First, the patient
should perceive the target seen by the deviating
eye in an opposite direction from that in which the
eye is deviating. Henee, an exotropic right eye
sees the image to the left, whereas an esotropic
Chapter 4
Two-Object Method
Two fixation targets are required for the two-object
method. Special filters, usually red and green, are
used. The right eye sees only one target (customarily through a red filter), and the left eye sees the
other target (customarily through a green filter ).
The Hess-Lancaster test may be custom-made by
drawing red lines on a white board to form a grid,
a rectangular coordnate tangent screen with a
white background and red lines and red fixation
spots (Figure 4-26). The red lines and spots are
invisible to the eye wearing the red filter. This is
123
124
Chapter4
Right Field
LeftField
fcR
FIGURE 4-27Form used for chartng results of the Hess-Lancaster test.
(IO = inferior oblique; IR = inferior
rectus; LR = lateral rectus; MR =
medial rectus; SO = superior oblique;
SR = superior rectus.)
with the red filter over the right eye. The spectacles stay in place throughout testing for both the
right and left fields. The room is dimly illuminated. While the examiner holds the green projecting flashlight, the patient holds the red one.
Test distance from the patient to the center of the
screen is 1 m. The deviation in the primary position s measured first. The examiner projects the
green light onto the central spot, and the patient
attempts to superimpose the projected red spot of
light (being seen only by the right eye) with the
green spot, which is seen and fixated only by the
left eye. An exotropic or exophoric patient with a
deviating right eye will point the red flashlight to
FIGURE 4-28Diagram showing patient's perception of superimposi,tion on the Hess-Lancaster test n an example of an exo deviation of
itod Targtt
Red Filter
the right eye. This could be either an exotropia of the right eye or an
exophoria that is decompensated by the dissociating red and green filters, and one n which the left eye s the dominant eye.
the right of the central target to achieve the perception of superimposition of the red and green
images (Figure 4-28). Note that a vertical streak
projected by each flashlight would be preferable
to a spot, because a cyclo deviation can be
revealed at each testing position.
If the patient is either esotropic or esophoric, the
red spot should be projected to the left of the fixated green spot. The rule is that the patient projects
the light in the same direction as that of the deviating eye. This is direct foveal projection; interpretation is facilitated by not having to think in reverse,
as in the single-object method.
If the patient does not understand this testing
procedure, which often is true of young children, it
is instructive to remove the colored spectacles and
to ask the patient to superimpose the projected
spots. Because there is no binocular demand, this
latter task should be accomplished easily. It is wise
to allow the parent of a young child to watch this
procedure. When the child feels confident about
superimposing the spots, the red-green spectacles
are put on. Because fusin is broken and the eyes
are now dissciated, the visual axes must be in
ortho alignment for superimposition to occur.
When a. deviation is present, the child will have
the perception that the spots are superimposed on
the screen, bt the parent can see that they actually are separated. This observation is helpful in
explaining the nature of a deviation to the parent
of a young patient.
After measuring the subjective angle n the primary position of gaze, the other eight positions
shoul,d be tested in a similar manner. For right-eye
field testing, the left eye remains the fixating eye.
For left-eye field testing, however, the examiner
Chapter4
Left Field
125
Right Field
El
f\
fe*
FIGURE 4-29Chart of the results of
the Hess-Lancaster test in the case of
a paretic right lateral rectus muscle.
(IO = inferior oblique; IR = inferior
rectus; LR = lateral rectus; MR =
medial rectus; SO = superior oblique;
SR = superior rectus.)
exchanges flashlights with the patient. The examiner directs the red spot to the central fixation circle, and the patient fixates with the right eye and
tries to superimpose the green spot with the red.
All nine positions of gaze are measured for the left
field, following the same procedure as is used n
testing the right field. It s important that the red filter remain over the right eye and the green over the
left eye, so that this method can be followed consistently; otherwise, nterpretation of results may
be confusing, particularly true when two or more
affected muscles are nvolved.
Exampies are provided to explain i nterpretation
of the measured deviations. Figure 4-29 shows the
charting of a paretic right lateral rectus muscle. In
right gaze, the paretic right lateral rectus is n its
DAF and s underacting. The left medial rectus s n
its DAF and is overacting (Hering's law). The As represent the positions of the spots seen by the deviat-
Left Field
Right Field
r.l
126
Chapter4
LEFT FIELD
RIGHT FIELD
Classification
Frequency refers to the amount of time a deviation
is manifest, which may range from 1 % to 100%. If
Chapter 4
Evaluation
There are two principal ways to evalate the percentage of time that there s a manifest deviation of
the visual axes: patient history and results of testng
procedures.
Patient History
Patient history information can come from reports
of how others see the patient. Parents of young children may report that a chld s "cross-eyed about
half the time, especially when he is tired" or "walleyed when he looks out the window or daydreamng." This information s important, because young
patents seldom report experiencing dplopa.
Older children and adults may gven an ndex
to the frequency of strabismus by reporting the
amount of time that diplopia is noticed. This,
however, s not always hghly correlated wth the
frequency of strabismus, because the individual
may use the antdiplopia mechanisms of suppresson and ARC. Questionng of the patient's selfperceived appearance of the eyes and that
observed by family and frends must, therefore,
be pursued.
127
Type of Strabismus
Constant strabismus tnternnttent
strabismus Periodic
Direct {strabismus at near)
ndirect (strabsmus atfar)
Certain cases of noncomi-
Percentaje of
Time Deviation
Is Manifest
100
1-99
Nonperiodk {unpredktabte
intermttence)
Nonstrabismus
Heterophoria (deviation
always latent under normaf
seelng conditions)
Orthophoria
Testng
Chapter 4
128
TABLE 4-12.
Deviation
Classification of Direction of
Deviation
Horizontal
Eso
Exo
Vertical
Hyper
Hypo
Torsional
Incyclo
Excyclo
Classification
Horizontal deviations n the majority of cases are
isolated, without a vertical or torsional component, when al I strabismus and phoria cases are
considered. In contrast, vertical deviations are different n that they often have a horizontal component (e.g., esotropa with hypertropia). Torsional
deviations (cyclo deviations) almost always have
both vertical and horizontal components.
Some clinicians speak only of hyper deviations,
thus avoiding use of hypo deviations. We believe
that this is misleading. For example, it s preferable
to cali a constant unilateral downward deviation of
a nonfixating right eye a right hypotropia rather
than a left hypertropia. In this case, the left eye s
the fixating eye and is not deviating upward, which
invalidates the diagnosis of left hypertropia.
Testing procedures to determine the direction of
deviation may be either objective or subjective
(Table 4-13).
Objective Testing
When there s a manifest deviation, direct observation, the Hirschberg test, or the Krimsky test s use-
Objective procedures
Direct observation
Hirschberg test
Krimsky test
Unilateral cover test
Altrnate cover test
Subjective procedures
von Graefe (vertical prism dissociation)
Colored filters
Maddox rod
Ph phenomenon
Chapter 4
Subjective Testing
The subjective angle of directionalization may be
determined with two targets (e.g., Hess-Lancaster
test) or, more commonly, with a single target,
using any of several methods for either phorias or
tropias. The horizontal subjective angle is easily
determined with the von Graefe method using vertical prism dissociation. This is performed routinely to measure phorias n primary eye care
examinations. As the patient sees the diplopic
mages of the single target (e.g., penlight), the
examiner introduces a sufficient horizontally oriented prism, either B! or BO, to crate vertical
alignment of the two images. This is the subjective
angle of directionalization.
Colored filters can be used n conjunction with
the von Graefe method, or they can be used without the vertical dissociation. If, for example, a red
lens s placed before a right esotropic eye that is
being suppressed, the filter creating a color difference between the eyes may serve to break the suppression. In some cases n which suppression s
very deep n the deviating eye, the red filter should
be switched to the fixating eye. This reduces the
intensity of the light entering the eye and acts as a
mild occluder, giving an advantage to the deviating
eye. In any event, assuming normal retinal correspondence, the patient should perceive homonymous (uncrossed) diplopia when there s an eso
deviation. If the patient has an exo deviation, the
perception should be heteronymous (crossed)
diplopia.
The Maddox rod can also be used to determine
both the direction of the subjective angle and the
magnitude. Although the original design by Maddox was a single, elongated, cylindric lens, most
clinicians prefer mltiple rods for dissociative testing. Nonetheless, this method that uses mltiple
rods s known as the Maddox rod (singular). If the
Maddox rod s placed with its axis at 180 degrees
(rod horizontal) before the right eye, the eye
should see a vertical streak. If, for example, the
patient is exotropic (or if exophoric), the vertical
streak should be seen to the left of the fixation
light. If the patient has an esotropa (or esophoria),
the vertical streak should be seen to the right of the
fixation light. The Maddox rod measurement of the
129
130
Chapter 4
O.S.
O.D.
O.D.
O.S.
O.D.
d, PATIENT'S PERCEPTION
C. PATIENTS PERCEPTION
Chapter 4
Cosmetic
Effect
Small (usually
acceptable)
Modrate
(somet mes
unacceptable)
Large (usually
unacceptable)
Esotropa
and
A
Exotropia ( )
131
Hypertropia
1-10
Magnitude
1-15
Esotropa
W
1-10
11-20
11-20
16-30
>20
20
>30
Classification
Classification of the magnitude of heterophoric
deviations s somewhat nebulous in that the deviation is latent and, thus, not cosmetically noticeable.
Although cosmesis s not of concern, binocular
function may sometimes be related to magnitude. In
general, a very large deviation tends to cause symptoms and may affect performance in school, work,
and play. There are many exceptions, however. For
example, a small esophoria may play havoc with an
individuaos comfort and performance when reading, f fusional divergence is nadequate and there is
an eso fixation disparity. On the other hand, we
have seen patients with relatively large esophoria
who are comfortable and perform well at school,
work, or play, possibly because of excellent fusional
divergence and the absence of fixation disparity.
The factors discussed in Chapter 2 relating to visual
skills efficiency must be taken into account when
correlating magnitude of heterophoria with comfort
and performance. Nevertheless, the magnitude
classifications that follow for strabismus may also
be useful as guidelines n heterophoria.
The question of what constitutes small and large
strabismus needs answering. The Classification of
von Noorden (as cited by Press16) states that an
acceptable surgical result n nfantile strabismus s
less than 20A, which s classified as small; an unacA
ceptable result exceeds 20 , which s classified as
large-angle strabismus. This Classification is based
mainly on cosmetic evaluation, and we concur with
the determination that a 20A finding should be considered large, as the deviation s usually noticeable
and may be a cosmetic problem. This is somewhat
Ixotropia
(A)
1-5
6-10
1-15
16-25
>25
Hypertropia
(A)
Small
Modrate
Large
Testing Procedures
Testing for magnitude can be undertaken with the
procedures listed n Table 4-13, which determine
the direction of a deviation of the visual axes.
132
Chapter 4
Unilateral
Aftemating
Although the magnitude may be measured by subjective and objective methods, there are times
when measurement by subjective means s preferable. This is because objective testing may lack necessary precisin, as in cyclo deviation. Subjective
testing, however, is not always reliable, especially
when there is deep suppression or ARC or the
patient is a poor observer.
Subjective methods designed for the determination of the magnitude of deviation are variations of either the single-object or the two-object
method. The measuring tools are either prisms or
calibrated scales. The scales may be in true space.
For example, in the Hess-Lancaster test, the
patient directly views the test targets, and their
separation can be converted into prism diopters
by using the measurement lines on the screen. In
contrast, when haploscopes such as the major
amblyoscope (discussed in subsequent chapters)
are used, the deviation is measured from scales
on the instrument.
ACCOMMODAT1VE-CONVERGENCE/
ACCOMMODATION RATIO
The AC/A ratio means that for every diopter of
accommodative response, a certain amount of
accommodative convergence is brought into play,
depending on the valu of the ratio. For example, if
the AC/A is 6A per 1.00 D of accommodative
response, a patient who accommodates 2.50 D
will have an increased convergence of 15A. In strabismus cases, the ca/cu/afecfAC/A is determined in
the same manner as was described in Chapter 3.
However, a gradient AC/A in strabismic patients
usually is not defined using phoropter measurements, although it may be determined by finding
the effect of spherical lenses (from a trial lens set)
EYE LATERALITY
In cases of strabismus, eye laterality refers to whether
only one eye or either eye is able to maintain fixation. This determination should be made at far and
near fixation distances. If only one eye is able to fixate, the strabismus is classified as unilateral, whereas
f either eye can fixate, t is an alternating strabismus
(Table 4-16). Alternation should be classified as
either habitual or forced. Habitual alternation means
the patient switches fixation naturally, without being
aware of doing so. In forced alternation, the patient
must made be aware of the need or instructed to
altrnate. The degree of forcing indicates the patient's
tendency to altrnate or not altrnate. This important
information should be included in the evaluation of
eye laterality.
Evaluation is made by such means as the Hirschberg test, unilateral cover test, patient history,
and direct observation of the patient. judgment is
made regarding whether a patient fixates with
either eye (and the frequency of fixation with each)
or whether fixation is confined to one eye. An
interesting characteristic of many strabismics is
alternation of fixation on lateral versions. The clinician can observe whether a patient switches fixation at the midline with lateral pursuits to the
right and left. For example, in left gaze, an esotropic patient may prefer the right eye for fixation,
whereas in right gaze, the left eye may be preferred. The presence of such a midline switch
Chapter 4
133
COSMESIS
In addition to magnitude, its variability, and strabismic i ntermittence, certain anatomic factors affect
cosmesis. The list of such factors presented in Table
4-1 7 ndicates whether each s favorable or unfavorable to the appearance of patients with esotropa or
exotropia.
Clnicans should not judge cosmesis exclusively on the bass of the magnitude of the devaton. Rather, all factors must be considered. For
example, the recommendaton to undergo surgery
for cosmetic reasons may be given to a patient hav-
134
Chapter 4
REFERENCES
1.
2.
Favorable for
Esotropa,
Unfavorable for
Exotropia
Favorable for
Exotropia,
Unfavorable for
Esotropa
3.
4.
5.
6.
7.
8.
A
ing an esotropa of 20 . However, surgery for cosmetic reasons alone may not be necessary for such
a patient if he or she has a large positive angle
kappa, a narrow bridge, no epicanthal folds, a
large interpupillary distance, and a narrow face.
Under these conditions, the eyes are likely to
appear cosmetically straight. It s possible that the
eyes would appear exotropic if the eso deviation
were significantly reduced by means of surgery.
Consequently, it is always wise to observe the
patient carefully and weigh the various factors
influencing appearance before reaching any conclusin regarding extraocular muscle surgery.
The effect of eyewear on cosmesis should also be
taken into account. A certain spectacle frame may
either help or hinder the strabismic individual's
appearance. Trial of different sizes and patterns and
keen observation of the patient's appearance are the
rules to follow.
9.
10.
11.
12.
13.
14.
15.
16.
Suppression 135
Cnaraetenstics of Suppression 136
Testing for Suppression 139
History 140 Red Lens Test
140 WorthDotTest 140
Ambiyoscope Workup 141
Amblyopia 143
Classification 144 Strabismic
Amblyopia 144 Anisometropic
Amblyopia 144 Isoametropic
Amblyopia 145 Image Degradation
Amblyopia 145
Amblyopia as a
Developmental Disorder 145
Case History 148
Visual Acuity Testing 149 Snellen
Charts 149 Bailey-Lovie Chart 151
Psychometric Charts 151 Tumbling E
and Pieture Cards 153 Infant Visual
Acuity Assessment 154 Visually
Evoked Potentials 158
Interferometiy 159
Fixation Evaluation 159 Description o
Eccentric Fixation 160 Vsuoscopy
160
Several anomalous conditions can develop secondary to the onset of a deveiopmental strabismus,
particularly of early origin. These nclude Suppression, amblyopia, and anomalous Correspondence.
These conditions and the appropriate testing methods for them are discussed in this chapter.
Although t s customary to think in terms of the
deviation causing these adaptive conditions, t is
also possible that the process may work in reverse.
SUPPRESSION
When a strabismus occurs, the affected individual
may experience pathologic diplopia or confusin
(or both). Suppression is the defense mechamsm
136
Chapter 5
O.D
o.s.
c.
O.O. FUNDUS
Chapter 5
137
some cases, however (e.g., a large-angle strabismus with amblyopia of long standing), it appears
that most or all of the binocular visual field of the
deviating eye is pathologically suppressed.
How does the suppressing strabismic patient perceive visual objects in space? Such a patient does
experience continuity of visual space across the
visual field, similar to the individual having normal
binocular visin (Figure 5-2a). However, there may
be a slight decrease or increase in the horizontal
size of the visual field, depending on whether the
deviation is esotropic (see Figure 5-2b) or exotropic
(see Figure 5-2c), respectively. Fortunately, a strabismic patient who is free of ocular pathology perceives no gaps (missing portions) n the visual field.
Suppression of the turned eye occurs only within
the binocular overlap rea. Suppression s not obvious to the individual except indirectly, possibly
because of deficient stereopsis; a vivid spatial sense
of three-dimensionality often is missing, depending
on the extent and depth of the suppression zone.
The extreme peripheral lateral fields of each eye are,
however, normal. These temporal crescents, approximately 30 degrees on each side, cannot be suppressed. The crescents are neurally subserved only
by monocular fibers from the nasal retina of each
eye. The suppressed eye s unresponsive to binocular stimulation but s responsive to the "monocular"
stimulation of the peripheral nasal retina.
Foveal suppression may also be found n nonstrabismic patients. Anisometropia may cause image
size difference on the retina of each eye (aniseikonia) and also a difference n clarity. Suppression s,
therefore, necessary to elimnate the confusin arisng from the resulting supermpositon of dissimilar
ocular images (.e., one image being larger than the
other). The suppression zone in such cases is relatively small and encircles only the fovea, as there is
no extrafoveal point zero. Therefore, confusin, and
not diplopia, s the problem. Foveal suppression is
found also n patients with large heterophoria if
fusional vergence compensaron is poor. The mechan ism is not fully understood, but t s likely that vergence stress or fixation disparity can initiate a
suppression response.
Suppression may be classified by size and intensity. In regard to size, suppression s classified as
being either central or peripheral. If a patient has
central suppression, the edge of the suppression
zone can extend to 5 degrees from the center of
the fovea. Beyond this limit, suppression s considered to be peripheral (Table 5-1). It must be
138
Chapter 5
Binocular
overlap
rea
Chapter 5
QassJficatlon
Central Foveal
Parafoveal
Paramacular
Peripheral
TABLE 5-2.
Natural
Method of Testing
Diplopia n free spaee
Vectographic methods
Septums
Septums with optical systems
Coiored filters
Unnatural
sion will be found. If anomalous retinal correspondence (ARC) s present, these relations do not
necessarily apply, because ARC s also an antidiplopia mechanism that partially obviates the need
for suppression.
Suppression is usually shallow in noncomitant
strabismic patients. Intensity is less because the
magnitude of the deviation is continuously changing as fixation shifts from one field of gaze to
another. This means that point zero (the target
point) is not at a fixed site on the retina; thus,
diplopia is more likely to be perceived. Fortunately, the accompanying diplopia with noncomitant deviations can warn individuis of possible
neurologic problems that require immediate health
care attention.
Naturalness of
Testing
139
Intensity of
Suppression
Instrumentation
Ordinaryobjects
Penlight
Pota-Mlrror
Vis--vs (Griff in) test
Vectograms
Torvlle test
Bar reading
Brewster stereoscope
Wheatstone stereoscope
Red lens test
Worth four-dot test
Shatlow
Deep
140
Chapter 5
Creen Filter
Red Fllter
with amblyopia, strabismus, and uncorrected anisometropia. The vis--vis test, introduced by Griffin,
is similar to the Pola-Mirror test except that there s
no mirror; rather, the patient and doctor face each
other from a distance of approximately 50 cm, with
both wearing crossed-polarizing filters. Suppression
is indicated f one of the doctor's eyes appears darkened. (Refer to Chapter 12.)
History
Strabismic patients should be questioned f they
notice diplopia under natural viewing conditions:
Are the double images only at a particular distance
or n a certain field of gaze? Are the double images
present at all times or just occasionally? Is diplopia
noticed only when the patient s thinking about t
and ignored at other times?
Red Lens Test
Por the red lens test, the patient, wearing a red filter
over one eye, views a fixation light in a normally
lluminated testing room at a distance at which the
strabismus s manifest. The patient s asked whether
one or two lights are visible. Seeing two lights
under these conditions indicates that the suppression is either relatively shallow or s absent. If one
light s reported, a red lens or filter should be
nserted before the fixating eye, and the patient
should be asked whether he or she sees one light
that is either red or white (a suppression response),
Chapter 5
141
142
Chapter 5
FOR MODEL 2051
KEY
MECH ANI C AL
1.
2.
controla (2).
3.
4.
5.
Chinrest.
6.
Forehead rest.
7.
Breathshield.
1.
2.
3.
4.
5.
6.
7.
8.
35
19.
20.
21.
22.
Central lock.
32.
Haidinger's
29.
30.
31.
33.
34.
35.
36.
37.
38.
39.
40.
50.
42.
43.
44.
45.
46.
On/Off switches.
Reversing switches (2).
Speed controls (2).
Plug and socket connections to motors (2).
Motors and rotating polaroid discs (removable from
Instruments) (2).
47.
48.
49.
FIGURE 5-4Clement Clarke Synoptophore, Model 2051, with key for labeled parts. (Courtesy of Clement Clarke, c/o Haag-Streit UK, Edinburgh
Way, Harlow Essex, United Kingdom, CM 20 2TT.)
the suppression. Flashing and moving the suppressed target can also provide an ndex to the
intensity of suppression. (These methods for breaking suppression are discussed in the sections on
therapy in Chapter 12.) Subsequent to this evaluation, the extent and depth of the suppression zone
are recorded.
Chapter 5
BASE-OUT
143
EXAMPLES OF SUPERIMPOSITION
SLIDES FOR THE SYNOPTOPHORE.
G1 SOLDIER
G2 SENTRY BOX
G47 FISH
G48-TANK
a.
O.S.
O.D.
BASE-IN
b. .X
G73 EX
G74 SQUARE
developmental loss of acuity during early childhood due to one or more of the preceding etiologic factors. For consistency with health science
classifications, amblyopia must be described by
the associated etiologic factors.
The prevalence of any condition depends on
how the condition is defined and the sampling
characteristics of the surveyed population. For
these reasons, there s considerable variation n the
prevalence of amblyopia reported in the professional literature. In a major review of the topic by
Ciuffreda et al., 12 their most accurate estimates
were 1.6% for military personnel, 1.8% for preschool and school-aged children, and 2.3% for
AMBLYOPIA
Amblyopia is defined as the condition of low or
reduced visual acuity not correctable by refractive
means and not attributable to ophthalmoscopically
apparent structural or pathologic anomalies or proven
afferent pathway disorders.1 The word amblyopia literally means "dullness of visin." Best correctable
visual acuity worse than 20/30 (6/9) is considered to
meet a descriptive criterion for amblyopia. Generally
speaking, amblyopia of 20/30-20/70 s mild (shallow), 20/80-20/120 is modrate, and worse than
20/120 s marked or deep.
Amblyopia also is defined by a difference in
visual acuity between the two eyes. For clinical
purposes, if the acuity difference s two lines of letters on the Snellen chart, amblyopia of the poorer
eye may be present. For example, if the better eye
s 20/15 (6/4.5) and the poorer eye is 20/25 (6/7.5),
this aspect of the definition is met. Ciuffreda et
al.12 made the important point that amblyopia is
not merely any reduction of visual acuity but that
the etiology of the acuity loss must be some recognized amblyogenic factor (e.g., constant unilateral
strabismus, anisometropia, or high refractive error
bilaterally [isoametropia]). Amblyopia refers to a
144
Chapter 5
Classification
Ambiyopia usually is considered to arise from a
deprivation of form visin, abnormal binocular
interaction (i.e., suppression), or both during early
development, probably before 7 years of age. The
form deprivation can be either unilateral or bilateral
but most often occurs unilaterally. Those patients in
whom visual acuity is reduced significantly due to
obvious ocular disease or in whom there is proven
pathology in the visual pathways are classified as
having low visin, in contradistinction to ambiyopia. Organic ambiyopia, however, is the term sometimes used (rather than low visin) in certain cases
of reduced visin in which ocular pathology is not
obvious (even though there may be a small central
scotoma in some cases). Examples include a reduction of acuity from nutritional factors, tobceo, alcohol, salicylates, and other toxic agents. Another type
of reduced visual acuity that often is labeled as psychogenic ambiyopia is due to causes such as hysteria or malingering. It is fairly common in children
and adolescents and occurs sometimes in adults
who are in stressful situations. Perimetric studies
usually reveal tubular fields. In this book, however,
we discuss developmental ambiyopia due to form
deprivation and suppression rather than organic and
other causes of reduced visual acuity.
A current classification system for ambiyopia is
based on the specific etiology of the condition:
strabismic ambiyopia, anisometropic ambiyopia,
isoametropic ambiyopia, and image degradation
ambiyopia.
Strabismic Ambiyopia
Chapter 5
amblyopia ncidence of 50% for hyperopic anisometropes of 2 D and of 100% incidence for 3.5 D
or greater. Most nvestigators have found a strong
correlation between the amount of hyperopic anisometropia and severity of amblyopia9'22'23; however, rt
is possible for a patient with only a small amount of
anisometropia and no strabismus to have deep
amblyopia.12 Generally speaking, binocular fusin
becomes weak and stereoacuity decreases in proportion to the depth of anisometropic amblyopia,
according toTomac and Birdal.24
Myopic anisometropia does not generally result
in deep (or as prevalent) amblyopia as does the
hyperopic variety. The uncorrected hyperopic
anisometrope typically focuses to the level of the
least hyperopic eye, leaving the more hyperopic
eye permanently deprived of a clear image. The
uncorrected myopic anisometrope, on the other
hand, often alternates fixation, because each eye is
independently in focus at a different near distance.
Tanlamai and Goss21 reported an amblyopia incidence of 50% among myopic anisometropes of 5
D and of 100% for 6.5 D and greater. If reduced
unilateral visual acuity s found associated with a
small degree of myopic anisometropia (e.g., oculus
dexter, -2.00 20/60; oculus sinister, plano 20/20)
and strabismus is absent, then the clinician should
suspect an organic or other cause of reduced acuity until proven otherwise.
Generally, anisometropic amblyopia s not
highly associated with EF, although there are many
exceptions. In most cases, the fixation s central
but unsteady. There appears to be increased spatial
uncertainty regarding visual direction, but the
time-averaged position of fixation usual ly s not
shifted away from the fovea.
Uncorrected astigmatic anisometropia of 1.50-D
cylinder or greater early n Ufe can also result in
amblyopia for sharp contours in the deprived meridional orientation. Meridional amblyopia is usually
not severe. Patients frequently show significant
improvement after a few weeks or months of wearing the appropriate spectacle or contact lens correction. Part-time occlusion of the dominant eye also
promotes rapid progress n these cases, unless the
ametropia s of long duration since early childhood.
Isoametropic Amblyopia
Isoametropic amblyopia s relatively rare. Agatston25
reported this condition n approximately 0.03% of
Army draftees. It is secondary to high symmetric
refractive error (hyperopia, myopia, or astigmatism)
145
Congenital cataracts
Ptosis
Corneal opacties
Other media opacities
Occlusion (iatrogenic cause)
Amblyopia as a
Developmental Disorder
Amblyopia may be considered to be a developmental disorder of spatial visin caused by some type of
146
Chapter 5
responses
Subtle afferent and efferent pupilary defects
Defective accommodation: increased latency, inaccurate dynamk responses, fnconsistent responses,
poor sustaining abflity Deficient accommodativ
convergence with the
amblyopic eye f ixating Deficient or
absent disparity vergence
Chapter 5
with retinal mage defocus. In strabismic amblyopia, however, the dficits in contrast sensitivity are
often asymmetrically distributed across the visual
field in a way consistent with the pattern of suppression found in strabismics.
According to the review by Cuiffreda et al., 12
amblyopia is also characterized by marked spatial
uncertainty. The amblyopic eye has a relative inability to judge position, width, and orienta tion of
detailed forms. In anisometropic amblyopia, the loss
n spatial judgment is consistent with the reduced
resolution and contrast sensitivity of the amblyopic
eye. In contrast, strabismic amblyopes show an extra
loss in positional acuity, often accompanied by
monocular distortions (.e., contractions and expansions) of space perception. 32 The reviewers suggested that this intrinsic cortical spatial distortion n
strabismic amblyopia may be due either to loss of
neurons or to scrambling of signis secondary to the
abnormal binocular interactions found in constant
developmental strabismus. One interesting implication of this concept is that there may be a causal
relation among ARC, monocular distortions, and EF
in strabismic amblyopia.
A survey of anatomic and physiologic studies of
the visual pathways of animis and humans with
amblyopia ndicates markedly disturbed cortical
function. 12 In anisometropic amblyopia, the specific cortical dysfunction appears to be related to
those neurons subserving contrast sensitivity. In
strabismic amblyopia, there is a dramatic loss of
cortical connections of the amblyopic eye. The lateral geniculate nucleus often shows shrinkage of
cells n layers connecting the amblyopic eye, a
defect believed to be secondary to the cortical
changes through retrograde degeneraron. Electroretinographic studies suggest that retinal abnormalities are not a fundamental characteristic of
amblyopic eyes. Amblyopia apparently results
from the effects of at least two mechanisms during
early visual development: cortical competition for
connections from the two eyes and cortical inhibi tion (suppression) when there is asymmetric binocular input to cells.
Besides the sensory dficits n visual acuity, contrast sensitivity, and spatial temporal processing, an
amblyopic eye has several deficiencies in monocular eye movements, some of which are characteristic of the condition. One characteristic feature
found in most amblyopic eyes is an unsteady fixation pattern. Normal fixation appears steady only
by gross nspection. With magnification, normal
147
fixation s seen actually to be composed of microdrifts from perfect fixation, corrective microsaccades, and physiologic tremor. The abnormal
component of microscopic eye movements n an
amblyopic eye appears to be the microdrifts having an increased amplitude and velocity. 33 Schor
and Flom34 proposed that there is an increased
"dead zone" for corrective saccades n amblyopia:
Because there s reduced detection of a fixation
error, the amblyopic eye drifts from foveal fixation
farther and faster (due to increasing velocity with
distance) than does a normal eye. Therefore, one
component to reduced visual acuity in amblyopia
might be the reduced and variable resolution of
nonfoveal retinal points.
EF s considered to be an extrafoveal time-averaged position of fixation. Rarely does one find a
perfectly steady EF pattern in strabismic amblyopia
when fixation is attempted with the amblyopic eye.
In most cases of strabismic amblyopia, unsteady EF
is the usual observation. It is also seen, unexpectedly, in some patients having solely anisometropic
amblyopia. In cases of EF, patients believe they are
looking directly at the target although they are, in
fact, fixating with an extrafoveal point or rea: The
principal visual direction of the amblyopic eye (also
called the straight-ahead direction) has shifted away
from the fovea. The monocular spatial distortions
found in strabismic amblyopic eyes and described
by Bedel I and Flom35 may be the pathophysiologic
basis for an EF pattern. These monocular spatial distortions occur only when both amblyopia and strabismus are present; they have not been found in
amblyopes without strabismus or in strabismics
without amblyopia.36'37
Saccadic and pursuit eye movements of an
amblyopic eye are usually defective, as one might
suppose. In amblyopic eyes, three abnormalities of
the saccadic system have been reported: (1) increased
latency, (2) reduced peak velocity, and (3) dysmetria
(inaccuracy). The ncreased latency (slower reaction
time) often exceeds 100% and s considered by
Guffreda et al. 12 to reflect a slowing in the sensory
pathways that process visual nformation subsequently used by the oculomotor system in generating saccadic eye movements. Large horizontal and
vertical saccades of an amblyopic eye are usually
hypometric (undershoots), mltiple, and variable.
Also, in deep amblyopia, 20% of such eyes make
saccades that are unequal in size; the amblyopic
eye follows the dominant eye but not to the same
degree. These nonconjugancies (lack of exact comi-
148
Chapter 5
Case History
An in-depth case history should be obtained rom
every amblyopic patient. Diagnostic conclusions
Chapter 5
Ageat
Onset of
Amblyopia
(yrs)
iir th- t
Age at Irtitiattofl
of Therapy {yrs)
1
Prognosis
Good
Birth-1
Birth-1
Brth-1
Birth-1
1-2
1-2
2
3-4
5-6
>7
2-3
4-5
Fair te good
Fair
Fair to poor
Poor
Good
Fair to good
1-2
1-2
2-4
2-4
6
2:7
4-6
7
Fatr
Fair to poor
Good
Fair to good
treatment for amblyopia began. Table 5-5 summarizes theoretical prognostic expectations based on
these factors, which reflect our clinical experience
n working with patients. The later the onset of
amblyopia, the less profound s the loss of acuity
during the critical period of acuity development.
The earlier the appropriate treatment begins after
149
Chapter 5
150
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Chapter 5
151
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iii c
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Chapter 5
152
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154
Chapter 5
mam
EDE
RES
20
40
_
_
12
The
Lea
symbol charts have proven their merit in
screening for amblyopia in young children;
however, these charts are reported to yield better
acuity by one Une (e.g., 20/30 versus 20/40) as
compared with Landolt Cs or Bailey-Lovie letter
charts.45
Infant Visual Acuity Assessment
ChapterB
155
156
ChapterB
Chapter 5
157
O
RCURE 5-18Lighthouse symbob for visual acuity testing.
20
50
20
50
20
SO
BGL'RE 5-19Example of a preferential looking test. a. Front view. b. Back view showing examiner's peephole and dial for stimulus presentations.
Courtesy of Optical Technology Corporation, Lawrence, KS. Similar testing equipment s available from Vistech Consultants, 4154 Littie York Road,
Oa*ton,OH45414.)
158
Chapter 5
LU O
o.
msec
<
LATENCY
FIGURE
5-22
Transient
visually
evoked potentials graph showing normal amplitude for each eye and
normal latency for the right eye (oculus dexter [O.D.]) but increased
latency for the left eye (oculus sinister [O.S.]), a difference
indicative of optic nerve demyelination, as n mltiple sclerosis.
O.D.
o.s.
normal latency for each eye and normal amplitude for the right eye
(oculus dexter [O.D.]) but reduced amplitude for the left eye (oculus
sinister [O.S.]), as in optic atrophy.
ChapterS
159
O.D
Interferometry
The interferometer s a useful instrument for evaluatng the visual acuity of an amblyopic patient. It uses
the principie of nterference fringes, as with a lser,
to produce a spatial frequency Une grating that is
projected onto the patient's retina. A dial is turned
on the instrument to change the spatial frequency of
the grating over a large range, each setting corresponding to Snellen visual acuity. The advantage of
using a coherent light source is that the projected
image is not affected by mi or opacities of the
media or by refractive errors. The acuity determination s quick and s obtained by asking the patient to
dentify the orientation of the grating (vertical, horizontal, or diagonal) at the various acuity settings.
The acuity determination s independent of eccentric or unsteady fixation, similar to the VEP. Therefore, in cases of amblyopia, the acuity estmate can
be useful n making a diagnosis and, possibly, in
estimating the prognosis for success of therapy.
Selenow et al.52 compared pretherapy interferometry visual acuity with pre- and post-therapy
optotype measures of visual acuity in a group of 37
patients with amblyopia. They found that, n most
cases, the pretherapy interferometry acuity and the
post-training Snellen acuity were in cise agreement. Ninety-percent were with i n two acuity Unes
of each other and, n 75%, they were within one
line. If further nvestigations support these impressive results, interferometry may prove to be an
important prognostic tool n the assessment of
amblyopia. A popular clinical nstrument, for
example, s the SITE IRAS Interferometer (available
20/160
from Bernell Corporation; see Suppliers and Equipment n Appendix J) (Figure 5-24). Interferometers
typically use four-choice targets (Figure 5-25).
Fixation Evaluation
Fixation s normal when the center of the fovea s
used for fixation and when fixation is steady. If any
other rea of the retina is used (eccentric fixation),
or if there is significant unsteadiness, fixation is considered to be abnormal. Eccentric fixation, then, is
considered to be an abnormality of monocular fixation in which the time-averaged position of the
fovea s off the fixation target. Unsteadiness refers to
the presence of nystagmuslike oscillations (usually
irregular flicks and drifts) of the affected eye. These
oscillations are often noticeable on careful direct
observation but are more easily observed during
visuoscopy. An eye with 20/20 (6/6) or better visual
acuity necessarily has central fixation that s relatively steady, whereas an eye with poor visual acuity
may have eccentric or unsteady fixation.
Chapter 5
Central fixation
Eccentric fixation (EF)
Chapter 5
161
a.
b.
c.
162
Chapter 5
RIGHT EYE
b.
HAIDINGER'S BRUSHES (H.B.)
(PERCEIVED BY PATIENT).
PATIENT USES
POINTER TO INDCATE
WHERE HE PERCEIVES
THE H.B.
FIGURE 5-28The Bernell Macular Integrity Tester-Trainer. a. Drawing of the nstrument; clear slide with fixation spots placed before the
illuminated circular window. b. Example of central fixation, n which
case the patient sees the Haidinger brush and the fixation spot as
superimposed. c. Example of eccentric fixation, whereby the Haidinger brush and the fixation spot are not superimposed. This response
would indcate nasal eccentric fixation of the right eye. If this
response were found when testing the left eye, temporal eccentric fixation would be indicated.
Chapter 5
163
Refraction Procedures
Subjective refractive techniques are usually unreliable when testing an ambiyopic eye, due to the
abnormal fixation pattern and the deficient spatial
resolution. Consequently, cycloplegic retinoscopy
is often necessary for determining the refractive
error. We generally use one drop of 1% cyclopentolate preceded by a drop of 0.5% proparacaine.
In most patients, the cycloplegic effect is suffi ciently strong to reveal the full amount of hyperopia, if it exists. We prefer not to rely completely on
a phoropter in cases of ambiyopia (or strabismus).
It is easier to monitor the fixation by directly viewing the patient. The refractive error is determined
with trial-case lenses or a lens bar. To ensure accuracy, care must be taken that the retinoscopic
beam on the ambiyopic eye is directly on axis. The
correct visual axis can be estimated with a penlight
by moving to a lateral position at which angle
kappa of the ambiyopic eye equals that of the normal eye. In cases of ambiyopia associated with
esotropa, on-axis retinoscopy is easily accomplished by scoping the ambiyopic eye from the
opposite side (e.g., n a case of a right esotropic
ambiyopic eye, scoping from the patient's left
side). In cases of anisometropic or strabismic
ambiyopia, correction of the full refractive error
usually is prescribed even when a patch s to be
worn. Undercorrecting hyperopia can be a mistake, because the accommodative responses of an
ambiyopic eye are usually deficient.
til
n
164
Chapter 5
Automated visual field testing is usually unsuccessful or unreliable due to the poor fixation responses
of an amblyopic eye. Ordinary tangent screen field
testing has some advantages over the automated
techniques. Unsteady fixation of the amblyopic
eye can be reduced if no central fixation target is
used. As an allernalive, four strips of masking tape
or paper can be applied to the tangent screen atine 3-, 6-, 9-, and 12-o'clock positions approximately 10 degrees away from the cenler of ihe
screen; ihis pattern indcales a virtual fixalion
poinl. The palient holds the amblyopic eye sleady
on ihe virtual point at which the four lines would
theoretically inlersect; then ihe field lesting of the
blind spol, periphery, and cenlral reas proceeds
in the usual manner. Testing wilh a 1- or 2-mm
while target at 1 m is generally sufficient lo determine whelher a scoloma exisls. During this procedure, the patienl should wear spectacles, contact
lenses, or trial-case lenses to correct fully any significanl refraclive error. The visual field of ihe
amblyopic eye is compared wilh that of the normal
eye.
Amsler grid testing for central field defects is
also recommended. As in langenl screen lesling,
ihe visual fields of ihe two eyes are compared for
consistency. For lesling an amblyopic eye, we
recommend Ihal a +2.50-D nearpoint add (a trialcase lens) be used along with any needed spectacle
correclion, because monocular accommodalion
of an amblyopic eye is usually deficienl. Even if
ihere is significant unsteady EF, ihe fovea will
usually fall somewhere on the grid pattern and a
central visual field defecl, if il exisls, may be
noliced by ihe patient.
Schapero17 believes ihat deleclion of a cenlral
absoluto scoloma (no lighl perceplion wilhin ihe
scotomatous rea) indcales an organic lesin or
amblyopia wilh an organic componenl and ihat
the prognosis for allaining beller acuily is limiled
by the potenlial acuily of Ihe retina! rea surrounding the absoluto scoloma. In conlrasl,
Irvine 54 reporled Ihal a relalive central scoloma
(depressed sensilivily) is an indicalion of a funclional reduction of acuity Ihal is polentially
Chapter 5
for example. An organic lesin would be suspected f the visual acuity of the poorer eye
decreases from 20/50, for example, to 20/200,
nearly a 55% decrease n visual efficiency. The
rate of decrease is much faster n cases of macular pathway lesions as compared with functional
ambiyopia. If the poorer eye, however, showed
only a 20% or lesser decrease in visual efficiency
with the neutral-density filter, functional ambiyopia would be indicated. (See Appendix F for conversin scales.)
Tesis of Retinal Function
Two other tests may be helpful n making the distinction between a pathologic reduction of acuity
and functional ambiyopia. These are monocular
color visin and electroretinography. Several diseases of the retina and optic nerve result in subtle
monocular color visin defects. Retinal disease
tends to produce subtle blue-yellow defects,
whereas acquired optic atrophy often results n subtle red-green defects. Monocular color visin can
be tested n most children of at least 10 years of age
using the Farnsworth panel D-15 test. However, a
good blue-yellow differential diagnostic test for
younger children may not be available. Using the
Farnsworth test, the color visin responses of each
eye are inspected for differences that ordinarily are
not found. If a defect s found with this test, it represents a strong defect. The desaturated panel D-15
may be necessary to pick up the initial signs of color
visin defects attributable to eye disease.
Another test of retinal function that may help in
the differential diagnosis is the electroretinogram
(ERG). Although the research literature is very
mixed, consistent differences are not apparent in
the ERG responses between normal and amblyopic
eyes.2 If abnormal ERG responses or significant differences between the eyes are found, the condition
is unlikely to be functional ambiyopia. For example, the pattern ERG s abnormal n cases of Stargardt's macular dystrophy (a juvenile rod-cone
dystrophy), which may be confused with ambiyopia during its early stages. The ERG procedure usually requires referral to a visual functions testing
clinic at a medical or optometric center, as most
primary care doctors do not have the relatively
expensive instruments used for this evaluation. The
expense of this test often is justified if there is a
reasonable suspicion of retinal disease, because
patching of the sound eye can be a very frustrating
procedure for a patient even when the chance of
165
166
Chapter 5
FIGURE 5-29Examples of
conditions detected with the
PhotoScreener, a photorefractive
instrument that shows how various anomalies are dentified.
(Courtesy of Marco Ophthalmic,
Jacksonville, FL.)
ANOMALOUS CORRESPONDENCE
Anomalous correspondence s a sensory defense
mechanism against diplopia that preserves rudimentary binocular visin in response to a strabis-
Chapter 5
167
VISUAL AXIS
LINE OF THE
SUBJECTIVE ANGLE
OF DEVIATION
A-0
V. FOVEA AND
POINT "a"
COINCIDENT
TO OBJECTIVE ANGLE TO
ACHIEVE SUPERIMPOSITION
Oassification
ARC s an antidiplopic sensory adaptation that s
prevalent in developmental strabismus. Its presence
indicates a significant difference between the horizontal objective angle of deviation (H) and the subjEctive angle of directionalization (S). The difference
between these two angles s the angle of anomaly
(A). Some measurement error must be allowed; otherwise, a false-positive diagnosis may result (.e., a
diagnosis of ARC when actually there s normal retinal correspondence [NRC]). In small-angle strabismus, allowance of a 1-2A error may be necessary and
A
upto 5 should be allowed for large angles of strabismus when comparing H and S. The larger the strabismus, therefore, the more allowance is made for
measurement error. In theory, angles /-/and S should
be exactly the same in NRC (angle A being zero n
magnitude). Clinical measurements, however, are not
168
Chapter 5
PAT1ENTS
PERCEPTION
(CYCLOPEAN
PROJECTION)
___ J
cates S = O (or a valu cise to zero) when a strabismic deviation s present. HARC is suspected
n such cases. An example of HARC s as follows
(see Figure 5-32):
H = 25A S = 0A /4 =
25A-0A
Not all cases of ARC are harmonious. Assume
that a patient has an esotropa of the right eye of
25A and that S equals 12A (as measured by subjective tests such as the dissociated red lens test). The
fact that H and S are different suggests ARC. Figure
5-33 Ilstrales this example by depicting points f,
a, and zero (also called point O in the deviating
eye). This example represents a case of unharmoni-
Chapter 5
169
H = 25A S=12A
POINT "a"
PATIENT'S
PERCEPTION
(CYCLOPEAN
PHOJECTION)
170
Chapter 5
TARQET MOVED TO BASE-IN
POSITION TO ACHIEVE
SUPERIMPOSITION
Characteristics
Horopter n Anomalous
Retinal Correspondence
Flom 65 demonstrated that the dentical visual
direction horopter in strabismic patients having
ARC has an irregular shape that may help to
explain many of the characteristics of the condition. The peripheral horopter n ARC cases was
similar in shape and location to that n nonstrabismic patients with NRC and, in that sense, these
patients can be said to have peripheral fusin (Figure 5-37). The nonstrabismic's horopter goes
through the point of fixation. When an ntermittent
esotrope with NRC lapses into a strabismic deviation, the horopter shifts from the plae of the target
to a point where the visual axes cross (the centration point). Images then in the plae of the target,
ncluding the target, appear to be diplopic f there
s no suppression (see Figure 5-37b). However, f
there s esotropa with ARC, the horopter beyond
the rea between the visual axes remains n the
plae of the target of regard, and the world
appears fused even though there may be some
central suppression (see Figure 5-37c). This s a
very convenient adaptation for the strabismic individual, because diplopia s eliminated. Peripheral
stereopsis may be present if angle H is small (see
Figure 5-3 7d) and fusional vergence eye movements can still occur.
Chapter 5
171
POINT '
PATIENTS
PERCEPTION
(CYCLOPEAN
PROJECTION)
fovea
NRC
UNHARC
PARC I
HARC
172
Chapter 5
Chapter 5
173
Singleness
Horopter
Horopter (NRC
Horopter)
R. zero
Identical
Visual
Direction
Horopter
b.
IVD horopter
R. zero
FIGURE 5-37Idntica! visual direction (IVD) horopter. a. Bifixating person, in whom the horopter passes through the centration point and th e
location of the target. b. Esotropic person with normal retinal correspondence (NRC), n whom the identical visual direction horopter passes
through the centration point but not through the location of the target. c. Esotropic person with harmonious anornalous retin al correspondence, in
whom the central notch approaches the centration point but the peripheral portion of the horopter passes through the location of the target. d. Same
as c, but the magnitude of the esotropa is small, allowing for an almost normal binocular field of fusin. Note that the dashed line is shown crossng anteriorly to the eye: The visual axis and this line should be crossing the center of rotation of the eye but, because of the very small angle of the
strabismus, the angles are shown n this manner only for the purpose of illustration. (f = fovea.)
174
Chapter 5
TRANSLUCENT SCREEN
PROJECTOR
fusionis has been associated with "macular evasin,"69 patients needing psychotherapy,70 intractable diplopia,71 and aniseikonia.72 Not much has
been published on this condition, and the mechanism has been uncertain.
We believe this condition is almost always associated with ARC. An inspection of the horopter in
ARC gives a clue to the nature of this binocular
anomaly. Aniseikonia, indeed, appears to be a factor. The fovea of the fixating eye seems to be associated with many points in the strabismic eye and
vice versa. For example, as shown in Figure 5-37c,
it is as though the fovea of the left eye is associated
with a series of points between points zero (same
location as point a in HARC) and f of the right eye,
creating an intolerable magnification effect. Flom65
explained horror fusionis in subjects with esotropa
and ARC on the basis of nonuniform, relative distributions of corresponding retinal points (irregularly shaped horopter). He explained the horror
fusionis movement of the images when superimposition is attempted, as in the Synoptophore: A sudden movement occurs when the target of the
deviating eye is moved across a limb of the notch
of the horopter; it is not due to any eye movements. Flom65 explained, "This jumping phenomenon is commonly observed by strabismics with
ARC when viewing constantly illuminated firstdegree targets, one of which is moved toward the
other to obtain superimposition."
Etiology ofAnomalous
Retinal Correspondence
The neurophysiologic basis for ARC is unknown, but
most authorities assume that the visual cortex mediates binocular visual direction. The binocular striate
neurons seem capable of comparing the images
from the two eyes, detecting disparities between
them, and linking corresponding retinal points.73 The
traditional view is that normal correspondence is
new coupling of noncorrespondmg cortical elements. Visuall y mature individuis, older than 6
years or so, who acquire a strabismus later in life are
almost always incapable of developing ARC.
According to Burian,75 "ARC is acquired by usage ...
the acquisition of an anomalous correspondence
represents an adaptation of the sensory apparatus of
the eyes to the abnormal position of the eyes." The
earlier the onset of the strabismus and the longer an
individual "practices" ARC (a learned response), the
deeper the ARC adaptation is established. This view
has come to be known as the adaptation theory of
ARC. This theory would predict that ARC would tend
to be found in early-onset, constant, comitant strabismus and less often in late-onset, intermittent, or
noncomitant strabismus. Substantial clinical evidence confirms this prediction.
Morgan76 proposed that ARC is a motor phenom-enon
(rather than merely a sensory adaptation) and
stated, "Thus anomalous correspondence might
depend not on a sensory adaptation to a squint but
rather on whether the basic underlying innervational pattern to the extraocular muscles was one
which registered itself in consciousness as altering
egocentric direction, or whether the pattern was
one which was 'nonregistered' in consciousness as.
altering egocentric direction." A nonregistered
innervation would imply NRC, whereas a registered
pattern would imply ARC. This notion is called the
motor theory of ARC. It implies that at the time of
strabismus onset, the moment the eye turns, an
abnormal neural circuit allows the change in vergence eye position to be "registered" in the perceptual mechanism subserving visual direction. Kerr77
suggested that the fundamental error in the neural
Chapter 5
175
176
Chapter 5
Afterimages
Testing
Correspondence can be assessed indirectly by
comparing the measured angles H and S. The
angle of anomaly (A) s simply calcuiated by subtracting the subjective angle (5) from the objective angle (/-/). It s often convenient clinically to
use the altrnate cover test results at farpoint for
angle H and the dissociated red lens test results at
farpoint for angle S. The angle of anomaly, A, can
also be measured directly without reliance on
calculation from H and S. Entoptic phenomena,
such as the Haidinger brush and Maxwell's spot,
may be used, but instruments for these tests are
not commonly found n a primary care practice.
The most frequently used direct measure of A s
done with Ais. Next in frequency s visuoscopy,
performed with the patient under biocular viewing conditions (discussed later in the section
Bifoveal Test of Cppers). Most other clinical tests
for ARC determine A indirectly by calculating the
difference between H and S.
The Hering-Bielschowsky test s the most frequently used Al method of ARC testing and directly
measures angle A, the angle of anomaly. An ordinary electronic flash attachment to a camera can
be modified to serve as an Al generator (Figure 540a). The face of the flash is masked with
opaque tape to produce a long narrow slit. A small
piece of tape also s placed across the middle of
the slit to serve as a fixation target. The unit is held
at a distance of approximately 40 cm (16 in.) from
the patient when the flash s triggered. A 100-watt
lightbulb can aiso be modified if a sustained stimulus s desired (Figure 5-40b). The patient should fixate the masked lightbulb for 30 seconds to
produce a vivid, sustained Al for each eye. The
procedure s as follows:
1. The nondominant eye is occluded while
the patient fixates a central mask on a
horizontal line strobe flasher or a masked
lightbulb. The exact center should be
Chapter 5
177
Portionof
Flash Etemem
Unmaskedby
Tape
a.
Central Rxation
Ma* (Masked
svithTape)
QnSwtteh
FIGURE 5-40Afterimage generators. a. Camera flash attachment. b. Homemade device using light bulb and a mask.
b.
2.
3.
4.
5.
178
Chapter 5
AFTER-IMAGE
SEEN BY O.D.
AFTER-IMAGE SEEN BY
O.S.
PATIENTS
PERCEPTION
(CYCLOPEAN
PROJECTION)
AFTER-IMAGE
SEEN BY O.S.
MEASURED A
PATIENTS
PERCEPTION
(CYCLOPEAN
PROJECTION)
Lf
AFTER-IMAGE,
SEEN BY O.D.
Chapter 5
179
AFTER-IMAGE
SEEN BY O.S.
AFTER-IMAGE
SEEN 8Y O.D.
I1
POINT "a"
AND
POINT "8"
PATIENTS PERCEPTION
(CYCLOPEAN PROJECTION)
AFTER-IMAGE
SEEN BY O.S.
AFTER-IMAGE
SEEN BY O.D.
FIGURE 5-44Esotropa with harmonious anomalous retinal correspondence and nasal eccentric fixation, n
which the angle of eccentric fixation
and the angle of anom aly are
unequal. Angles A and E must be
summed to determine the true angle
of anomaly. (f = fovea; O.D. = oculus
dexter; O.S. = oculus sinister.)
POINT e
;V ^--ANGLE E
. ^MEASURED
ANGLE A
PATIENTS PERCEPTION
MEASUREDA (CYCLOPEAN PROJECTION)
180
Chapter 5
blackdo
t and
HB
Opaque
Occluder
flashing
light
MITT
Chapter 5
181
b.
a.
DOCTOR SUSPENDS
VISION IN O.S.
ISUSCOPE WITH
STAR QRATICULE
DOCTOR SUSPENDS
VISION IN O.S.
O.S. FOVEA
O.D. FOVEA
PATIENTS PERCEPTION
(CVCLOPEAN PROJECTION)
C.
STAR SEEN BY DOCTOR
PHOJECTED ONTO
PATIENTS FUNDUS
d.
STAR SEEN BV DOCTOR
PROJECTED ONTO
PATIENTS FUNDUS
STAR QRATICULE
IN VISUSCOPE
STAR GRATICULE
IN VISUSCOPE
DOCTOR SUSPENDS
VISION IN O.S.
DOCTOR
SUSPENDS VISION IN
O.S. rO.O. FOVEA
O.S. FOVEA
O.S. FOVEA
PATIENTS PERCEPTION
(CYCLOPEAN PROJECTION)
-- PATIENTS PERCEPTION
(CYCLOPEAN PROJECTION)
FIGURE 5-46The bifoveal test of Cppers. a. Doctor's right eye views the patient's right eye by means of visuoscopy. The star is seen by the doctor
and the patient. An angled mirror (or a large base-out [B.O.] prism) before the patient's left eye avoids obstruction to seeing by the left eye. b. Exam ple of normal correspondence. c. Example of anomalous correspondence. d. Star must be projected onto point a in order for a p atient with anomalous retinal correspondence to achieve superimposition of the penlight and the star. (O.D. = oculus dexter; O.S. = oculus sinister .)
182
Chapter 5
O D. Fundus
18%
FIGURE 5-47Useful
dimensions
of
the
fundus for estimating
Temporal
disc
margin
Center of
optic disc
Nasal disc
margin
Chapter 5
183
184
Chapter 5
C.
e.
f.
Chapter 5
185
REFERENCES
Color Fusin
Color fusin s also known as luster. The most efficacious way to evalate whether color fusin s
present is by having the patient wear colored filters
(usual ly red on the right eye and green on the left
eye) while viewing a brightly illuminated, translucent, gray screen containing no contours. Normally, the patient reports a mixture of the red and
green, perceived as a muddy yellow or brown,
with some color rivalry taking place. Testing at the
centration point helps to elicit this response n
many esotropic patients. The centration point addition lens (add) n diopters (Dcpa) s calculated by
dividing the farpoint horizontal objective angle
(Hf) at farpoint (6 m) by the interpupillary distance
n centimeters (IPDcm).
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
1 7.
Hofstetter HW, Criffin JR, Berman MS, Everson RW. Dictionary of Visual Science and Related Clinical Terms, 5th ed.
Boston: Butterworth-Heinemann; 2000:15-16,234,488.
von Noorden CK. Binocular Vision and Ocular Motility,
4th ed. St. Louis: Mosby; 1990:202,252-253,339.
Smith EL, Levi DM, Manny R, et al. The relationship
between binocular rivalry and strabismic suppression.
Invest Ophthalmol Vis Sci. 1985;26:80-87.
Norcia AM, Marrad RA, Brown RJ. Changes in cortical
activity during suppression n stereoblindness. Neuroreport. 2000;11:1007-1012.
Braddick O. Binocularity in infancy. Eye. 1996;10:182-188.
Kumagami T, Zhang B, Smith EL, Chino YM. Ef fect of
onset age of strabismus on the binocular responses of
neurons n the monkey visual cortex. Invest Ophthalmol
Vis Sci. 2000;41:948-954.
Oguz V. The effects of experimentally induced anisometropia on stereopsis. J Pediatr Ophthalmol Strabismus.
2000;37:214-218.
Yildirim C, Altinsoy Hl. Distance alternate-letter suppres
sion test of objective assessment of sensorial status in
ntermittentexotropia. EurJ Ophthalmol. 2000;10:4-10.
Jampolsky A. Characteristics of suppression in strabismus.
Arch Ophthalmol. 1955;54:683-696.
Pratt-Johnson JA, MacDonald AL. Binocular visual field in
strabismus. Can J Ophthalmol. 1 976;11:37-41.
Pott JW, Oosterveen DK, van Hof-van Duin J. Screening for
suppression in young children; the polaroid suppression
test. J Pediatr Ophthalmol Strabismus. 1998;35:216-222.
Ciuffreda KJ, Levi DM, Selenow A. Amblyopia: Basic and
Clinical Aspects. Boston: Butterworth-Heinemann; 1991:
13-17,24,26,43-136.
Schalij-Delfos NE, de Graaf ME, Treffers WF, et al. Long
term follow up of premature infants: detection of strabis
mus, amblyopia, and refractive errors. Br J Ophthalmol.
2000;84:963-967.
von Noorden GK, FrankJW. Relationship between ambly
opia and the angle of strabismus. Am Orthopt J.
1976;26:31-33.
Helveston EM. The incidence of amblyopia ex anopsia in
young adult males in Minnesota n 1962-63. Am J Oph
thalmol. 1965;60:75-77.
Glover LP, Brewer WR. An ophthalmologic review of
more than twenty thousand men at the Altoona Induction
Centn Am J Ophthalmol. 1944;2 7:346-348.
Schapero M. Amblyopia. Philadelphia: Chilln; 1971:6062,162.
186
Chapter 5
18. Flynn JT, Cassady JC. Current trends in amblyopia therapy. Ophthalmology. 1978;85:428-450.
19. Smith EL, Hung LF, Harwerth RS. The degree of mage
degradation and the depth of amblyopia. Invest Ophthalmol Vis Sci. 2000;413774-3781.
20. Weakley DR. The association between nonstrabismus
anisometropia, amblyopia, and subnormal binocularity.
Ophthalmology. 2001 ;108:163-171.
21. Tanlamai T, Goss DA. Prevalence of monocular amblyo
pia among anisometropes. Am J Optom Physiol Opt.
1979;56:704-715.
22. Kivlin JD, Flynn JT. Therapy of anisometropic amblyopia. J
Pediatr Ophthalmol. 1981 ;18:47-56.
23. Ingram RM, Walker C, Wilson JM, et al. A first attempt to
prevent amblyopia and squint by spectacle correction of
abnormal refractions from age 1 year. Br ] Ophthalmol.
1985;69:851-853.
24. Tomac S, Birdal E. Effects of anisometropia on binocular
ity. J Pediatr Ophthalmol Strabismus. 2001;38:27-33.
25. Agatston H. Ocular malingering. Arch Ophthalmol.
1944;31:223-231.
26. Pratt-Johnson JA, Wee HS, Ellis S. Suppression associated with esotropa. Can J Ophthalmol. 1967;2:284291.
27. Brent HP, Lewis TL, Maurer D. Effect of binocular deprivation from cataracts on development of Snellen acuity.
Invest Ophthalmol Vis Sd. 1986;27(suppl):51.
28. Norcia AM, Tyler CW. Spatial frequency sweep VEP:
visual acuity during the first year of life. Vision Res.
1985;25:1399-1408.
29. Keech RV, Kutschke PJ. Upper age limit for the develop
ment of amblyopia. J Pediatr Ophthalmol Strabismus.
1995;32:89-93.
30. Worth CA. Squint: Its Causes, Pathology and Treatment.
Philadelphia: Blakiston; 1903.
31. Levi DM, Klein SA. Equivalen! intrinsic blur in amblyopia.
Vision Res. 1990;30:1995-2022.
32. Yu C, Levi DM. Naso-temporal asymmetry of spatial interactions in strabismic amblyopia. Optom Vis Sci. 1998;75:424432.
33. Ciuffreda KJ, Kenyon RV, Stark L. Increased drift in amblyopic eyes. BrJ Ophthalmol. 1980;64:7-14.
34. Schor CM, Flom MC. Eye Position Control and Visual
Acuity n Strabismus Amblyopia. In: Basic Mechanisms of
Ocular Motility and Their Clinical Implications. Lennerstrand G, Bach-y-rita P, eds. New York: Pergamon Press;
1975:555-559.
35. Bedell HE, Flom MC. Monocular spatial distortion in strabis
mic amblyopia. Invest Ophthalmol Vis Sci. 1981;20:263268.
36. Levi DM, Klein SA. Difference in discrimination for gratings between strabismic and anisometropic amblyopes.
Invest Ophthalmol Vis Sci. 1982;23:398-407.
37. Bedell HE, Flom MC. Normal and abnormal space perception. Am] Optom Physiol Opt. 1983;60:426^35.
38. Maxwell GF, Lemij HG, Collewijn H. Conjugacy of saccades in deep amblyopia. Invest Ophthalmol Vis Sci.
1995;36:2514-2522.
39. Kenyon RV, Ciuffreda KJ, Stark L. Dynamic vergence eye
movements in Strabismus and amblyopia: asymmetric
vergence. BrJ Ophthalmol. 1981;65:167-176.
Chapter 5
187
ESTABLISHING A DIAGNOSIS
The first part of a complete diagnosis of Strabismus
s the test results of each of the nine variables of
deviation of the visual axes: comitancy, frequency,
direction, magnitude, accommodative-convergence/
accommodation (AC/A) ratio, variability, cosmesis,
eye laterality, and eye dominancy. The next part
includes associated conditions: suppression, amblyopia, abnormal fixation, ARC, horror fusionis, and
any visual skills inefficiencies.
A case history also helps establish the exact
diagnosis and is necessary for a valid prognosis.
Furthermore, time of onset, mode of onset, and
190
Chapter 6
Prognosis
Poor
Poor to fair
Fair
Fair to good
Good
61-80
81-100
duration of strabismus, refractive history, treatment given, and developmenta! history of the
patient are all vitally important in determining the
prognosis. The doctor must also assess the results
of additional evaluative procedures such as prism
adaptation, special cover testing, vertical and
cyclo deviation testing, prolonged occlusion, and
testing for sensory fusin at the centration point.
A good diagnostic statement is not a listing of clinical data but rather a succinct and understandable
account that includes the distinguishing features and
nature of the condition. The diagnostic statement
must be well written in clinical records and reports,
not only for conceptual clarity but also for medicolegal purposes. One acid test of a good diagnostic
statement is whether it can be communicated completely and concisely. Examples are given in this
chapter to Ilstrate succinct diagnostic clarity.
PROGNOSIS
Prognosis is the prediction for success by a specified
means of treatment. As to binocular anomalies,
prognosis pertains to the chance for a favorable outcome by the use of tenses, prisms, occlusion, visin
training, surgery, medication, mental effort, or any
combination of these methods of treatment. After all
necessary testing has been completed and a thorough diagnosis has been made, the doctor makes a
prognosis of the case. From this, appropriate recommendations for the patient can be made. There are
two types of prognoses depending on the goal of
treatment. The doctor can describe the chances for
either a functional cure or a cosmetic cure.
therapy for many years.1 Flom's criteria made feasible the comparison of results from various studies.
Flom,2 however, later modified the criteria for clinical purposes. In the past, the criteria for functional
cure of strabismus, according to Flom,1 included the
presence of clear, comfortable, single, binocular
visin at all distances, from the farpoint to a normal
nearpoint of convergence. There should be stereopsis, although Flom1 did not specify the stereoacuity
threshold. The patient also should achieve normal
ranges of motor fusin. The deviation may be manifest up to 1% of the time, providing that the patient
is aware of diplopia whenever this happens (i.e.,
patient knows the deviation is not latent but is manifest at that time). This should mean that the strabismus may occur only approximately 5-10 minutes
per day and that the patient has clear, single, comfortable binocular visin during the rest of his or her
normal waking hours. Corrective lenses and small
amounts of prism may be worn, but prismatic
power is limited to 5A. In a later publication, Flom 2
dropped the requirement for stereopsis, diplopia
awareness, normal ranges of motor fusin, and the
limit of 5A, stating that "a reasonable amount of
prism" meets the criteria.
Flom usted another category of cure that he
called almost cured. The criteria for this classification allow for stereopsis to be lacking and for the
deviation to be manifest up to 5% of the time.
Fairly large amounts of prism may be used as long
as there is comfortable binocular visin. The
remaining criteria for functional cure must be met.
The third category was called modrate improvement The stipulation here was that there must be
improvement in more than one defect. Flom's
fourth category of cure was s//gh improvement,
which indicated improvement in only one defect
(e.g., amblyopia reduced). A final category was
that of no improvement as a result of therapy.
Flom's current criteria for functional cure are as
follows: (1) maintenance of bifoveal fixation in the
ordinary situations of life 99% of the time; (2) clear
visin that is generally comfortable; (3) bifixation
in all fields of gaze and distances as cise as a few
centimeters from the eyes; and (4) wearing of corrective lenses and a reasonable amount of prism. 2
We concur with the new cure criteria set forth
by Flom,2 in which his former category of almost
cured can be incorporated. We also recommend
keeping Flom's categories of modrate improvement and slght improvement.
Although not included within the stated cure criteria, we believe the level of stereopsis is clinically
Chapter 6
useful n evaluating functional success. Manley3
indicated that a stereothreshold of 67 seconds of are
(for contoured tests) s the differentiating valu
between monofixation pattern and bifoveal fusin
and, for example, that on the Stereo Fly tests "central
fusin (bifixation) must be present for cirels 7 to 9
to be answered correctly." This compares closely
with the findings on the Pola-Mirror test, n which
central suppression was found n al I patients whose
stereoacuity on contoured tests was worse than 60
seconds of are, whereas al I those whose stereoacuity was better than 60 seconds passed the PolaMirror test.4 Therefore, we believe the cutoff valu
of 67 seconds or are s reasonable and should be
included n the criteria. This stereoacuity criterion
can be one of the means of determining whether
strabismus is completely eliminated (.e., when
there s bifoveal fixation without suppression). A
realistic cutoff for noncontoured stereoacuity tests
would be 100 seconds of are. Although there are
exceptions, the general rule is that stereoacuity is
the "barometer" of binocular status.
It should be pointed out that a patient who has
made either modrate improvement or slight
improvement may not be much better off from a
practical standpoint. These labels are sometimes
nothing more than academic, as they are useful
only n statistical analyses of reported studies. For
example, suppose ARC is temporarily eliminated
but the patient still has esotropa, suppresson, and
the like. The important queston that should be
answered by the doctor is whether the patient s
actually any better off as a result of having had an
improvement. There are, however, possible psychological benefits for these patents when they
feel they have been helped. These results should
be evaluated and put in their proper perspective.
However, most reported studies giving rates of
cure have not incorporated such complete and
defintive criteria as those of Flom.1'2 Consequently,
it is difficult to evalate their significance. One of
the exceptions, however, s the survey by Ludlam.5
In this study of 149 strabismic patients, the previous
criteria of Flom were followed strictly. Treatment did
not nclude surgery or drugs, whch kept the study
"clean" as compared to most others, n which the
effects of surgery cannot be delineated from nonsurgcal methods. According to Ludlam,5 the reported
functonal cure rate was 33%, and the almost-cured
rate was 40%, with the remaining percentage being
dstributed among the other categories.
Ludlam's study took place at a large teachng
clnic setting with many nherent disadvantages for
191
192
Chapter 6
Type
Prognosis
many cases, the etiology of this type of strabismus remains uncertain. Some causes are clinically well established. For example, a sensory
obstacle to fusin, such as a unilateral cataract
or anisometropia, usually results in an esotropa
in young children. In contrast, exotropia is likely
in older individuis with sensory obstacles to
fusin. Psychogenic causes of strabismus can
also occur; these cases are almost always esotropic, although psychogenic exotropia is possible.
For example, an emotionally disturbed child
with a large exophoria may learn how to let his
or her deviation become manifest, purposefully,
for the sake of gaining attention, recognition, or
sympathy.
Accommodative strabismus is usually esotropic, often due to uncorrected hyperopia and a
high AC/A ratio. However, mere can be accommodative exotropia in cases of divergence excess.
This is the condition in which the exo deviation at
far is much greater than the exo deviation at near,
indicating a high AC/A ratio. For example, a
patient with uncorrected modrate hyperopia
may be orthophoric at near but exotropic at far.
This, therefore, can be thought of as an indirect
type of accommodative strabismus.
The prognosis in most cases of accommodative
strabismus is usually good, provided that effective treatment is administered without delay.
Constant strabismus of long duration makes the
prognosis considerably worse. If the sensory
adaptive anomalies (e.g., suppression, amblyopia,
or ARC) become deeply embedded, the prognosis
may be only fair or even poor: An example of a
deteriorated accommodative esotropa is the
Favorable factors
Good cooperation
Intermittent strabismus
Exotropia rather than esotropa
Small rather than large angles of deviation
Comitancy rather than noncomitancy
Family history of strabismus
Patient's age between 7 and 11 yrs
Late onset
Early treatment
Strabismus of short duration
Unfavorable factors
Eccentric fixaton
Amblyopia in esotropa (but not as bad in exotropia)
Cyclotropia
Anomalous retina! correspondence in esotropa (but
not an unfavorable factor in exotropia)
No motor fusin range {unfavorable in esotropa but
not unfavorable in exotropia)
Suppression n esotropa (but not as bad in exotropia)
Constant strabismus
Early onset
Delay of treatment
Strabismus of long duration
Source: Modified from MC Florn. The prognosis in strabismus.
AmJ Optotn Arch Am Acad Optotn. 19S8;35:509-514; and MC
Flom. tssues in the Clnical Management of Binocular Anomalies. In:
Principies and Practce of Pediatric Optometry. AA Rosen-bloom,
MW Morgan, eds. Phladelphia; Lippncott; 1990:242.
Chapter 6
193
TABLE 6-4. Model for Estimating the Probability of Functional Correction of Different Types of Squint and
Associated Factors
Esotropa
Occasional
NRC
0.60
Exotropia
Occasional Constant
ARC
NRC
0.50
0.30
Constant
ARC
0.10
()
{)
O
0
0
(-)
(-)
(-)
o
O
o0
(-)
Eght Basic
Squint Types
Constant
ARC
Constant
NRC
Basic probabili-
0.40
0.50
0.70
0.80
{)
( )
(_)
{_)
(_)
(_)
(_)
(_)
,ties
+ Factors (add
0.1)
Good seconddegree fusin
Family historyof
squint
No amblyopia
Deviation <!&*
- Factors (subtractO.1)
Marked suppression
Marked incomttancy
Deep amblyopia
Estimated probability
Occasional Occasional
ARC
NRC
(-)
(-)
O
(_)
O
(_)
(-)
(-)
<-)
(-)
Chapter 6
and other factors, and then use professional judg194 ment to arrive at the most correct prognosis
for the patient. This requires an tem analysis
of each factor in the prognosis and evaluation of
the total combined effect (possible only after
extensive clinical experience).
Prognostic Variables of the Deviation
I
difficult, therefore, to make prognostic generalizations about the AC/A ratio.
Variability of the deviation may be favorable if
the magnitude of the deviation changes from time
to time. As regards the sensory aspect, variation in
the magnitude may keep suppression and ARC
from becoming too deeply embedded, but such an
outcome cannot be assumed in many cases. As
regards the motor aspect, however, a widely varying magnitude can be a surgeon's nightmare.
Similarly, the factor of cosmesis can be a blessing or a curse. If cosmesis is good, this is a blessing
for the patient. However, this causes complacency
and is often the reason patients do not enthusiastically seek a functional cure, which creates problems for the doctor treating the strabismus.
As to eye laterality, traditional thinking is that
treatment of an alternating strabismus is more difficult than is treatment of a unilateral condition. This
conclusin has been prevalent because altrnate
fixation is common in cases of infantile esotropa.
Findings in this group of patients have led to equating alternaton with poor prognosis. Most recent
studies show that alternation s not a deterrent to a
good prognosis and may be slightly favorable
when all types of strabismus are considered.1'2 This
may be true in part because individuis with alternating strabismus do not become ambiyopes.
Eye dom'mancy is probably not a factor in strabismus prognosis. However, it can be a consideration in the strabismic's perceptual adjustment to
everyday seeing and may be related to certain eyehand or eye-foot coordination tasks.
Associated Conditions
Chapter 6
195
that the prognosis may be somewhat better if indirect occiusion is tried initially.
Chavasse14dscussed the concepts of ambiyopia of
arrest and ambiyopia of extinction. Ambiyopia of
arrest s a failure n the development of visual acuity
due to strabismus, anisometropia, or other conditions
(e.g., cataract). In any event, the development of
visual acuity s arrested at the time of onset of the
causative condition. The prognosis for improving
visual acuity in a documented case of ambiyopia of
arrest is considered to be very poor. This s probably
true if the patient is beyond the developmental age
(probably 6 years or older). However, f the same
type of case is treated at a much earlier age, the prognosis may be better. Ambiyopia of arrest, therefore, is
not always a deterrent to treatment if the patient is
very young; but if treatment is delayed until the child
is older, the prognosis becomes worse.
The prognosis for a case of ambiyopia of extinction s thought to be good regardless of the age at
which treatment is begun. However, an older
patient may require a rnore lengthy therapeutic
program than a younger patient. Ambiyopia of
extinction s a condition in which visin has deteriorated because of suppression resulting from
either strabismus or anisometropia. The visin that
was once lost can usually be recovered through
the re-education process of visin therapy.
Chavasse's concepts14 are not undisputed. Many
authorities have refuted them on the basis of findings that ambiyopic therapy results do not always
correspond to the level of visual acuity that s traditionally expected. Often in cases of relatively
early-onset ambiyopia, better acuity s achieved
than was believed possible, which would appear
to contradict the concept of ambiyopia of arrest.
However, f modern normative visual acuity levis
expected for certain ages are properly matched
with the time of onset, the concept of ambiyopia of
arrest is on solid ground. The apparent mismatch
arse because of the od assumption that an infant's
visin is poorer than it actually is. Chavasse 14
believed that the acuity level of a 4-month-old
child s normally approximately 20/2500, but
research has shown this to be untrue: Infants'
visual acuity is much better than was expected in
the past. This may explain why treatment n cases
of early onset s often successful; perhaps the condition being treated s not ambiyopia of arrest but
rather ambiyopia of extinction.
The presence of ARC is a very unfavorable factor
in the prognosis of esotropa. Flom1 reported that
196
Chapter 6
whereas ARC is highly unfavorable in cases of constant esotropa, it is of less significance in cases of
constant exotropia. The cure rates of Ludlam 3 were
reported to be 23% for esotropes with ARC and
86% for esotropes with NRC. Exotropes with ARC
had a cure rate of 62%, as opposed to 89% for
those with NRC. Etting 6 reported a cure rate of
10% for esotropes with ARC, as opposed to 75%
for esotropes with NRC. The cure rate for exotropes
with ARC was 50%. It appears that ARC is a serious factor in cases of esotropa but is less influential in exotropia.
Lack of correspondence is considered to be
extremely unfavorable. Current therapies offer no
hope for a functional cure in the older child or
adult who has a complete lack of correspondence.
The best recommendation in such cases is either
no treatment or an attempt at cosmetic cure.
In cases of horror fusionis, the usual recommendation is no treatment because the prognosis is
poor. If the ARC can be broken, however, horror
fusionis may not be a significantly adverse factor
for functional cure, assuming that the horror fusionis was produced by the ARC. (See Chapter 5.)
Accommodative infacility is not an unfavorable
factor in strabismus; however, itfrequently accompanies amblyopia with eccentric fixation. Accommodative flexibility training (so-called rock) often
is used as part of amblyopia therapy, and considerable time may be required before both the fixation
and accommodation improve.
There are poor fusiona! vergences in strabismus.
Sensory fusin must be attained so that disparity
vergence can be established. When this is accomplished, fusional vergence ranges can often be
increased by means of visin training. The prognosis for functional cure of strabismus, therefore, is
not necessarily poor because of poor fusional vergences prior to visin therapy.
Other Factors
The time of onset, mode of onset, and duration of
strabismus, previous treatment, developmental
history, and additional evaluative procedures all
play important roles in determining the prognosis
in any case of strabismus. The prognosis is better
when the onset of amblyopia or strabismus is later
rather than earlier. A short duration is better than
a long one, as immediate therapy increases the
chance for cure. Existing anomalies that were
once successfully treated often are easily elimiriated by re-education. Furthermore, develop-
Chapter 6
197
Target at infinity
+2.50 D
198
ChapterG
a.
c.
Heterophoria
The prognosis for improving existing visual efficiency skills in heterophoria s almost always
good, provided that there is adequate cooperation and motivation on the part of the patient. If a
patient demonstrates outstanding motivation, that
patient can be told the prognosis is "excellent."
Such superlatives, however, should be used sparingly. Heterophoria therapy is usually effective in
Chapter 6
199
For all patients, whether strabismic, heterophoric, or orthophoric, testing for and diagnosing
deficiencies of other visual skills (e.g., saccades,
pursuits, fixations, accommodation [sufficiency,
facility, stamina], and the status of fixation disparity) should be undertaken. The prognosis s generally good for resolving problems in these reas by
means of visin therapy.
Lenses
The first consideraron in the treatment of any binocular visin condition is full correction of the
refractive error, as a defocused or distorted image
to either eye (or possibly to both eyes) is an obstacle to fusin. Lens additions (plus and minus) are
also used in the treatment of certain types of strabismus and heterophoria. Lens therapy is discussed n PartTwo of this book.
200
Chapter 6
VISION THERAPY
Pharmaceutical
Treatment
sensory-motor
Pleoptics
(Specialized Therapy
for
amblyopia
with eccerrtric
fixation)
Cure of Deficient
Binocular Visual Skills
Enhancement of
Binocular Visual Skills
Prisms
For more than 100 years, prisms have been used to
compnsate the angle of strabismus. The primary limitation has been the amount that can be effectively
incorporated nto spectacle lenses. Prisms often
become impractical due to their weight and distortion when more than 10A per lens is required. With
the advent of Fresnel prisms, the limit has increased
to 30A per lens which is usually sufficient as most
strabismic deviations measure less than 60A n magnitude. However, Fresnel prisms appear, at best, to be
only a temporary solution because of optical distortion, reduced visual acuity, and loss of contrast. Furthermore, compensating prisms do not help (but
hinder) the cosmetic aspect of strabismus, which
exacrbales this major concern of most strabismic
patients. The use of reverse (inverse) prisms, however,
may be attempted to improve the cosmetic appearance n some strabismic cases. When a borderline
Occiusion
Occiusion (i.e., opaque patches or attenuating filters) s used to treat amblyopia (Chapter 10), ARC
(Chapter 11), suppression (Chapter 12), and com-
Chapter 6
201
Vision Training
When more than lenses, prisms, and occlusion are
necessary to achieve the desired results, visin
training techniques may be the therapy of choice.
Sometimes visin training s conducted without
other forms of visin therapy, but other modes of
treatment often are included n the visin training
program. Vision training relative to binocular
visin disorders historically has been called
orthoptics, which etymologically means "straight
sight." Orthoptic techniques are usually successful
in breaking suppression, building fusional vergence ranges, and improving the reflex aspects of
ocular motility. For this reason, orthoptics has the
greatest utility in cases of intermittent strabismus,
heterophoria, and deficient oculomotor skills.
Many orthoptic techniques (ncluding monocular regimens) are used in the treatment of amblyopia, but pleoptics (literally "full sight") is a specific
type of training designed exclusively for amblyopia
with eccentric fixation. These techniques involve
light stimulation techniques to diminish the nfluence of the eccentric fixation point n the amblyopic eye and enhance foveal fixation. In some
cases of severe amblyopia of long duration, both
pleoptic and orthoptic techniques, as well as an
aggressive patching (occlusion) program, are
required to achieve a successful outcome.
Visual perception training techniques to improve
information processing, for certain types of learning
disabilities, are not discussed n this text. However,
many perceptual training techniques (e.g., figureground, visual discrimination, and closure) are used
to treat amblyopia.
b.
FIGURE
6-4
Extraocular
muscle
surgery nvolving a rectus muscle. a. Recession as a weakening
procedure. The insertion of the tendn is removed and reattached
posteriorly n the globe. b. Resection as a strengthening procedure.
The tendn or muscle s cut and a portion is removed; then t is
rejoined.
briefly as one of several alternatives for treating binocular anomalies. Many fine books covering the
details of surgical procedures for extraocular muscles and other anomalies affecting ocular motility
are available for reference purposes. Particularly
good among these are publications by Hugonnier et
al.,20 Hurtt et al.,21 Mein and Trimble,22 von
Noorden,23 and Dale.24 In addition, several case
reports are ncluded n the treatment chapters of this
book that describe various surgical approaches.
General Approach
The general approach to extraocular muscle surgery is that the action of a particular muscle should
be made either weaker or stronger. Examples of
weakening procedures include recession, tenotomy, tenectomy, myotomy, and myectomy. When
the muscle is recessed, the nsertion is moved from
the original site and transplanted to another location to produce less mechanical advantage (Figure
6-4a). Another weakening procedure is tenotomy,
either marginal or free (i.e., disinsertion at the
scleral attachment). In many varieties of controlled
tenectomies, the tendn s appropriately cut for
weakening the action of an overacting muscle.
202
Chapter 6
Chapter 6
203
geon's knots and the muscle tendn adheres permanently to the sclera during the healing process.
This procedure can be used with any of the rectus
muscles and the superior oblique tendn. Both vertical and horizontal muscles can be put on adjustable
sutures when strabismus s present n both directions. Adjustable sutures are particularly appropriate
when the outcome s not readily predictable (e.g.,
cases of previous unsuccessful surgery) or when the
patient has fusin potential and precise alignment is
critical to a successful outcome, as n cases of thyroid ophthalmopathy. Some strabismus surgeons use
adjustable sutures n nearly every case of rectus
muscle surgery. Efforts have been made to extend
the time between the operation and the postsurgical
adjustment using medications,35 but there s little
change in the final outcome by delaying the adjustment until 24 hours as opposed to only a few hours
postoperatively.36 The reoperation rate after conventional surgery is estimated to be 19-35%, as compared with 4-10% using the adjustable suture
technique.37
Surgcal Consderations
Most patients and parents are natural ly apprehensive
about undergoing strabismus surgery. The doctor
must give realistic information regarding the potential
complications and what is involved in the procedure.
This nformation usually relieves some anxiety. The
patient should be encouraged to ask all possible
questions during the preoperative visit. For medicolegal purposes, the surgeon should document in the
patient's record the specific complications that were
discussed. Not every potential complcatin need be
mentioned, however. According to Helveston, 38 preoperative informed consent requires a discussion of
at least three possibilities: diplopia, loss of visin, and
need for reoperation.
Depending on the age and sensory status of the
patient, diplopia s a common occurrence during
the nitial postoperative phase of healing. Most
patients experience only transient diplopia that
disappears within a week or so after the operation.
Older patients tend to notice diplopia more often,
as one might expect. If the diplopia s debilitating,
the patient can wear a patch or be given a Fresnel
prism in an attempt to achieve sensory fusi n.
Many patients will notice diplopia only if they
consciously look for t n some extreme field of
gaze; this behavior should be discouraged. Diplopia that disrupts the normal course of daily activities is cause for concern.
204
Chapter 6
Pharmacologic Treatment
Although numerous pharmaceutical agents have
been used at one time or another for the treatment of
binocular anomalies, those n use today are relatively
few. Cycloplegics may be used for purposes of occlusion. Miotics for accommodative esotropa are sometimes used. The two more popular anticholnesterase
drugs are diisopropylfluorophosphate (DFP) and
echothiophate iodide (Phospholine). These two
agents greatly increase accommodation, without a
significant increase in accommodative convergence,
which results in a lower AC/A ratio.
Abraham39 p\oneered the use o DFP to reduce
esotropva. A. report by GeUman40 summanzed the
effectiveness o DFP by citing case reports \n
which the nearpoint eso deviation was reduced by
use of this drug. However, Phospholine has
become the more popular of these two agents, as it
apparently causes fewer side effects (e.g., formation of iris cysts) than does DFP. One effect that
should always be avoided is the cardiovascular or
respiratory failure that may occur when a drug of
this type is combined with those used for general
anesthesia. Bartlett and Jaanus41 emphasized that
Phospholine and DFP are very stable complexes
and produce action of long duration. Manley3
Chapter 6
Botulinum Toxin
Chemodenervation using botulinum toxin A injection
is another nonsurgical approach in strabismus management that is gaining respect and widening applications. Alan Scott et al.42 developed this procedure
as a method for weakening extraocular muscle function as though a surgical weakening procedure had
been performed. The toxin prevens relase of acetylcholine at the muscle-nerve junction, producing a
temporary paralysis of the psilateral antagonist. In
right esotropa, the rght medial rectus muscle usually
is injected, and for a few weeks, the patent experiences a rght exotropia that gradually resolves over
1-2 months to result in a smaller-angle eso deviation.
The therapeutic effect comes more from the stretching and relaxaton of muscles as they assume a new
poston than from any prolonged toxic effects.43
Botox, Allergan's form of botulinum toxin A (Dysport
injecton, Portn Laboratory Supplies, Salisbury,
England), has now proven its worth over the last few
years in selected patients. It has been used wth good
effects in unilateral fourth and sixth nerve palsies of
205
206 Chapter 6
Other Approaches
The doctor must serve his or her patients as a counselor regarding visual health and welfare. Sometimes,
the best interest of the strabismic patient is served by
doing nothing except monitoring the condition for
changes over time. For example, if the spectacle lens
prescription is current, the deviation is cosmetically
and functionally stable, and the patient is satisied
with the status of the strabismus, then the doctor
should not recommend treatment but rather should
describe to the patient the condition, its prognosis for
long-term changes, and any other practical considerations. Sometimes patients cannotfollow through on
a recommended visin therapy program for several
reasons and prefer simply to live with the condition
for the time being. The clinician has a duty to
explain, in a sensitive manner, any consequences
that may result from that decisin and how best to
manage the situation. It remains imperative for the
doctor to make recommendations based on the best
interest of the patient rather than to promote a particularly preerred mode of therapy.
The visin specialist must be sensitive to the
need for referral when it arises. Many types of strabismus and other binocular visin conditions can
be subtle indicators of active ocular or systemic
disease. Patients should also be encouraged to
seek a second opinin if any questions remain in
the mind of the clinician or the patient. Occasionally, visin specialists examine patients in whom
CASE EXAMPLES
The previous discussions focused on generalities
regarding the favorability of various prognostic factors. In this section, we present 12 specific cases
that illustrate typical diagnostic groups having a
prognosis for unctional cure ranging from poor to
good. Some clinicians may disagree with our prognostic judgments because of differences in clinical
experience. We tend to be slightly conservative, as
conventional wisdom dictates. A surprisingly successful cure after therapy is never unappreciated
by patients. The same cannot be said when therapeutic results do not match the expectations of
patients.
Poor Prognosis
Case 1
The patient is 10 years od with a history of esotropa of the right eye since birth. The strabismus has
been constant since then, although the magnitude is
lower now than in infancy. No previous treatment
has been given. Further history reveis possible traumatic injury during delivery. Developmental history
appears to be normal, other than that the child
always has difficulty abducting the right eye. The
refraction is
Chapter 6
207
Case 2
The patient is 9 years od with a history of constant
esotropa since the age of 1 year. No prevous
treatment has been given. The patient does not
report diplopa. Refracton is
OD: +2.50 - 0.50 x 180, 20/40 (6/12)
OS: plano, 20/20 (6/6)
Vision at near was commensurate with that at far.
The deviation s a comitant, constant, alternating, esotropa, with the left eye being preferred.
The devation s 45A at far and 35A at near, with a
low AC/A ratio (2/1). Cosmesis is poor. The associated conditions include deep peripheral suppression; shallow amblyopia with unsteady central
fixation; probable harmonious ARC; horror fusionis; and no motor fusin or stereopsis.
This case can be described as divergence insufficiency esotropa because of the larger deviation at
far. The prognosis for a functional cure by any or
all means of therapy is poor. The Flom prognosis
chart would indcate only a 10% chance for success (see Table 6-4). However, the prognosis for a
parta! cure s poor to fair, meaning that the large
manifest deviaton could be converted into a
smaller devaton by means of surgery. This implies
that peripheral fusin might be developed or reeducated, thereby helping the patent to hold the
eyes relatively straight. The patent would technically be strabismc but, f motor ranges could be
developed, the patient could function with at least
some degree of binocularty. This would be a
monofixation pattern. With a history of no previous treatment and a duration of 8 years of constant
esotropa, there is little hope for anything beyond
this expectation.
The shallow amblyopa s probably due to the anisometropia rather than the strabismus, as the deviation s alternating and not unilateral. The prognosis
for cosmetic cure by means of extraocular muscle
surgery s far to good. Prsm adaptation testing
would be useful in ths case to predetermine whether
the angle of devation would be stable after the operation. The patient should be advised that several
appontments are needed for further evaluation and
that visin training will be tried on a short-term basis,
approximately 5 weekly visits, to determine whether
there s any improvement in visual acuity. Correcting
lenses should be worn during this time, along with
constant patching of the left eye in an attempt to
improve the acuity of the right eye. After lenses and
visin training have achieved the mximum results,
208
Chapter 6
Chapter 6
209
Fair Prognosis
Case 6
The patient s 9 years od and has had a slightly
noticeable esotropa of intermittent onset of the
right eye since the age of 3. The strabismus is occasionally observed by family members when the
patient s looking far away. No previous treatment
has been given. Refractive history is ncomplete,
but the patient was taken for an eye examination at
age 5. No treatment was given then, and the
advice was that the strabismus would "eventually
go away." The present refraction is
Dry subjective:
OD: +1.00 DS, 20/30 (6/9)
OS:+1.00 DS, 20/20(6/6)
Wet subjective (1 % cyclopentolate):
OD: +1.50 DS, 20/30 (6/9)
OS: +1.50 DS, 20/20 (6/6)
Vision at near was commensurate with that at far.
The deviation s a comitant, intermittent (constant at far and estimated 75% of the time at near),
unilateral esotropa of the right eye of 15A at far
and 4A at near. Cosmesis s good because of a positive angle kappa and a relatively wide IPD of 65
mm. The AC/A rato is low (2/1). Associated conditions include ntermittent, deep, central suppression; shallow amblyopia; small (foveal off-center)
nasal eccentric fixation; harmonious ARC (covariation at near); and good second-degree fusin but
limited motor range. Some peripheral stereopsis
was occasionally elicited at near.
This patient has a divergence insufficiency
esotropa. The prognosis for functional cure by
means of therapy s fair. The Flom prognosis chart
would indcate a 50% chance for functional cure
(see Table 6-4). Although there is deep central suppression, the factor of ntermittence helps the prognosis immensely. The primary purpose of visin
therapy in this case is to improve the presently
existing visual skills that are at play at least some of
the time at near distances. Binasal occlusion for
farpoint seeing may be tried, as well as the possibil ty of base-out prisms, followed by antisuppression training and the development of adequate
fusional divergence. A certain amount of training
to improve monocular fixation and accommodative facility would be helpful prior to the binocular
therapy rgimen.
The prognosis must remain somewhat guarded
because of the long duration of strabismus and
lack of previous treatment. The patient should be
210
Chapter 6
advised of the need for spectacles, occlusion therapy, and approximately 30 weekly office appointments along with ntensive home visin training.
Surgery should be recommended only f it is absolutely required for functional results.
Case 8
The patient is 35 years od and is reporting ntermittent diplopia of sudden onset after trauma to
the head in an automobile accident 3 weeks ago.
This resulted in a mild paresis of the left superior
oblique muscle. The refractive history s unremarkable with the exception of a small myopic
refractive error. The present prescription being
worn is
OD: -1.00 DS, 20/20 (6/6)
OS:-1.0005,20/20(6/6)
Vision at near was commensurate with that at far.
Chapter 6
Good Prognosis
211
Case 10
Case 11
The patient is 8 years od and has a history of intermittent exotropia at near that was first noticed at
age 6 years. The frequency of the deviation has
increased somewhat since that time. No previous
treatment has been given. Refraction is
212
Chapter 6
Case 2
The patient is a 22-year-old college student who is
reporting blurring of visin and asthenopia during
prolonged reading. The refraction is
OD: plano, 20/20 (6/6)
OS: plano, 20/20 (6/6)
Vision at near was commensurate with that at far.
The deviation is a comitant exophoria of 5 A at
far and 10A at near. The AC/A ratio s normal (4/1).
Motor fusin ranges are fair (vergences at far of 11A
base-in to 4A base-out and nearpoint vergences of
16A base-in to 3A base-out). The nearpoint of convergence is 12 cm. Associated conditions include
accommodative infacility (able to clear only three
cycles of 1.00-D lenses n 1 minute) and an exo
fixation disparity at near (associated exophoria of
2A). Noncontoured (random dot) stereoacuity was
20 seconds of are at near. The only other abnormal
clinical findings were low positive and negative
relative accommodation.
The prognosis for a functional cure by means of
visin therapy s good. Even though this s a case of
heterophoria and not strabismus, the patient does
not meet the criteria of Flom as being functionally
cured because of the blurring of visin and discomfort and the inadequate nearpoint of convergence.
(Note that in cases of strabismus in which the
patient is cured, the patient then is treated as in heterophoria therapy to effect a cure of any deficient
binocular visual skills and, it is hoped, to enhance
binocularity for efficient visual skills.)
REFERENCES
1.
2.
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10.
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19.
Chapter 6
20. Hugonnier R, Hugonnier S, Troutman S. Strabismus, Heterophoria, Ocular Motor Paralysis. St. Louis: Mosby;
1969:595-664.
21. Hurtt J, Rasicovici A, Windsor CE. Comprehensive
Review of Orthoptics and Ocular Motility. St. Louis:
Mosby; 1972:202-238.
22. Mein J, Trimble R. Diagnosis and Management of Ocular
Motility Disorders, 2nd ed. Oxford: Blackwell Scientific;
1991:166-195.
23. von Noorden GK, Campos EC. Binocular Vision and Ocu
lar Motility: Theory and Management of Strabismus, 6th
ed. St. Louis: C.V. Mosby; 2002:566-631.
24. Dale RT. Fundamentis of Ocular Motility and Strabis
mus. New York: Grue & Stratton; 1982:340-381.
25. Jampoisky A. A Simplified Approach to Strabismus Diag
nosis. In: Symptoms on Strabismus, Transaction of the
New Orleans Academy of Ophthalmology. St. Louis: C.V.
Mosby; 1971:34-92.
26. Aust W, Welge-Lussen L. Pre-operative and post-operative
changes in the angle of squint following long-term, preoperative, prismatic compensation. In: First Congress of
the International Strabismological Association. Fells P, ed.
St. Louis: Mosby; 1971:217.
27. Alpern MB, Hofstetter HW. The effect of prism on esotro
pa: a case report. AmJ Optom. 1948;25:80-91.
28. Postar SH. Ophthalmic Prism and Extraocular Muscle
Deviations: The Effect of Wearing Compensatory Prisrns
on the Angle of Deviation in Cases of Esotropa. Snior
research paper. On file in the M.B. Ketchum Memorial
Library, Southern California College of Optometry, Fullerton, Calif., 1972.
29. Crter DB. Effects of prolongad wearing of prism. Am J
Optom. 1963;40:265-272.
30. Jampoisky A. Adjustable Strabismus Surgical Procedures.
In: Symptoms on Strabismus, Transaction of the New
Orleans Academy of Ophthalmology. St. Louis: C.V.
Mosby; 1978:320-328.
31. Wygnanski-Jaffe T, Wysanbeek Y, Bessler E, Spierer A.
Strabismus surgery using the adjustable suture technique.
J Pediatr Ophthalmol Strabismus. 1999;36:184-188.
32. Chan TK, Rosenbaum AL, Hall L. The results of adjustable
suture technique in pediatric Strabismus surgery. Eye.
1999;13:567-570.
33. Bacal DA, Hertle RW, Maguire MG. Correlation of postoperative extraocular muscle suture adjustment with its
immediate effect on the strabismic deviation. Binocul Vis
Strabismus Q. 1999;14:277-284.
34. Rosenbaum AL, Metz HS, Carlson M, et al. Adjustable
rectus muscle recession surgery: a follow-up study. Arch
Ophthalmol. 1977;95:817.
35. Hwang JM, Chang BL. Combined effect of Interceed and
5-fluorouracil on delayed adjustable Strabismus surgery.
BrJ Ophthalmol. 1999;83:788-791.
36. Spierer A. Adjustment of sutures 8 hours vs 24 hours after
Strabismus surgery. Am J Ophthalmol. 2000;129:521524.
37. Siegel LM, Lozano MJ, Santiago AP, Rosenbaum AL.
Adjustable and Nonadjustable Recession and Resection
Techniques. In: Clinical Strabismus Management. Rosen-
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49.
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52.
53.
54.
55.
213
ACCOMMODATIVE ESOTROPA
The two general types of accommodative esotropa that often require different optical treatment
approaches are refractivo (normal accommodativeconvergence/accommodation [AC/A] ratio) and
nonrefractive (hgh AC/A ratio). There exsts an
accommodative component to most eso deviations
that occurs during the early developmental years; in
that sense, most cases of esotropa can be consdered
partially accommodative in etiology. Our dscussion
216
Chapter 7
Refractiva Esotropa
Mechanism
Onset
Ref ractive error
Constancy
Correspondence
Amblyopia
AC/A rato
Prognosis
Uncorrected hyperopia
Limited divergente
Most often at 2-3 yrs od
+4.75 DS
Usually ntermttent
Usuaily normal retina! correspondente
Rare
Normal
Good wfth correction of hyperopia
Refractive
Accommodative Esotropa
Characterstics
Both types of accommodative esotropa usually occur
between the ages of 2 and 3 years, concurrently with
the development and ncreased use of accommodation. However, the range of onset is broad, extending
from nfancy into young adulthood.1 The strabismus
can become manifest with illness, extreme emotion,
or eye fatigue. The etiology of refractive accommodative esotropa is better understood than that of al I
other developmental types of strabismus. Modrate or
high uncorrected hyperopia, usually between 2 and 6
diopters (D), forces an individual to accommodate
sufficiently to attain clear retinal images. An average
hyperopia of +4.75 D was reported for accommodative esotropes.2 There is usually a normal AC/A ratio,
but excessive accommodation, which is required to
overeme the hyperopia, evokes excessive convergence. If compensating fusiona! divergence is insufficient, a latenteso deviation becomes manifest, dueto
the combination of uncorrected hyperopia and inadequate fusional divergence ranges. The onset of
accommodative esotropa is usually gradual and
intermittent. Because of its intermittent nature, there
is usually normal retinal correspondence (NRC)
and seldom any amblyopia. If the manifest deviation
becomes constant at an early age, amblyopia, anom-
With early treatment, the prognosis is good for complete resolution of the strabismus, particularly f normal binocularty existed prior to the onset of the
deviation. Usually all that is necessaty is a prescription of lenses for the ful I optical correction of the
uncorrected hyperopia (and any significant astigmatic
component) as verified by cycloplegic refraction (Figure 7-1). The goal of optical treatment is not necessarily orthophoria. Some authorities recommend leaving
the patient slightiy esophoric so that there is a continuing demand for fusional divergence. 3 If the
patient's accommodation does not relax fully after the
prescription lenses are worn for a few days and if
there is significant blurred farpoint visin, the doctor
should also recommend accommodative rock training or administer a cycloplegic drug (atropine) if
absolutely necessary. The purpose would be to
reduce an accommodative spasm. Occasionally,
Chapter 7
217
Vision training is useful in many cases of accommodative esotropa f the child can cooperate.
Ratients who undergo visin training tend to maintain a good result longer than do patients who do
not receive visin training. If there s NRC, the
goals of visin training are to elimnate any amblyopia, break suppression, and buld fusional dvergence ranges with reflex control. (Refer to Chapter
13 for visin tranng techniques for eso deviations.) Often a patient who has completed visi n
therapy can remove the lenses for brief perods,
such as for swmming or other sports, and still
mantan fusional control of the devaton.
The use of motics or surgery n cases of refractive accommodatve esotropa s strongly discouraged. Miotcs are only a temporary solution at best
and are assocated wth many possible undesrable
side effects. They should be tred only after complete optcal treatment has faled to acheve alignment and fusonal control. For example, some
children initally refuse to wear the prescribed
lenses. Later, however, they may prefer the optical
treatment to daly instllaton of eye drops.
FIGURE 7-1Refractive accommodative esotropa without spectacle lens correction (a) and with lenses that fully correct the manifest
deviation (b).
In postsurgical cases of refractive esotropa, consecutive exotropia s a common fnding when lenses
are eventually worn for the hyperopia. Surgery may
be ndcated, however, n cases of partially accommodatve esotropa in whch there remains a conspicuous residual strabismus after ful I correction of
the refractive error. Surgery for any signficant associated hyper deviation or marked A-V pattern may
also be necessary and approprate.
218
Chapter 7
Management
Optical Treatment
FIGURE 7-2Proper segment height for a child with accommodative esotropa with a high accommodative-convergence/accommodation ratio.
Because of the high AC/A ratio in this type of strabismus, it s usually necessary to correct any manifest
hyperopia with lenses. Cycloplegic refraction should
be performed to reveal any latent hyperopia. In addition, the optimum bifocal lens power should be determined to promote fusin at the patient's nearpoint
working distance. This amount is, of course, determined under noncycloplegic testing conditions. Pluslens additions are used for the patient's preferred
working distance to determine empirically which
power will best align the eyes. In effect, this technique
uses the measured AC/A ratio (.e., lens gradient
method) to determine the optimum bifocal power.
When prescribing a bifocal lens for very young children, t s important to fit the bifocal une high, at midpupil, if the lens is to be used properly (Figure 7-2). For
older children and adults, the segment height can be
slightly lower. By age 8 years, the segment line can be
at the lower edge of the pupil. By teenage years, the
line can be atthe lower eyelid margin. For progressive
addition lenses, the fitting would be approximately 2
mm higher than a linear segment bifocal lens.
For older children and adults, bifocal contact
lenses may be considered as an alternative to bifocal
spectacles n the high AC/A type of accommodative
esotropa. The added near power s useful n all fields
of gaze, unlike spectacle bifocals, and many patients
do not report dfficulty wth the slight decrease in
contrast inherent n the bifocal contact lens design. 5
One recent longitudinal study, however, indicated
that more than 40% of optically aligned accommodative esotropes did not remain so over a 7-year
period.6 This finding Ilstrales the importance of
cise follow-up examinations and subsequent refractive and visin training management of such patients.
Another consideration that clinicians should
keep n mind when a previously corrected accommodative esotropa deterirales at near is the possibility of a psychological etiology resulting n a
spasm of the near reflex triad. 7 Such patients may
require palliatve therapy, such as a reading add,
and professional counseling.
Vision Training
After the optimum bifocal correction has been prescrbed to promote alignment at far and near, visin
training is recommended to build a reserve of
fusiona! vergence function. Vision therapy should
Chapter 7
be programmed to elimnate amblyopia and suppression and then to develop and improve fusiona!
divergente. Adequate fusional vergences serve to
improve control of the deviation at all viewing distances, which is important because the deviation
vares n magntude from far to near. (See Chapter
13 for visin training techniques.) Without adequate
visin training, these patients tend to lose control of
the deviation at near, and suppression can recur at
near fixation distances. The higher the AC/A ratio,
the more a patient tends to lose control of the deviation over time. 8 We do not recommend combining
miotic therapy with a visin training program.
Although some clinicians may disagree, our experience indicates that visin training progress s erratic
when miotics are used simultaneously. It s unclear
why this s so, but results are better when one or the
other therapeutic method s applied alone.
Miotics
If the nearpoint deviation cannot be adequately controlled using bifocals and visin training, miotics may
be considered as a treatment option. We believe that
topical anticholinesterase drugs have been overused
n the treatment of accommodative esotropa.
Because they have significant side effects and do not
offer a long-term solution, t seems prudent to try to
control the near deviation by other means, if possible. Miotics, however, may be effective initially to
achieve temporary ocular alignment when other
methods have failed. Introducton of more conservative visin therapy methods for long-term management of the deviation can then be made.
Common anticholinesterase eye drops such as
diisopropylfluorophosphate (DFP 0.025% ointment)
and echothiophate iodide solution (Phospholine
lodine [Pl], 0.03%, 0.06%, or 0.125%) produce an
accumulation of acetylcholine at the myoneural
junction of the ciliary muscle. This acetylcholine
buildup results in a decrease in the innervation necessary for effective accommodation and, therefore,
n a corresponding decrease of accommodative convergence. Vergence is effectively decoupled from
accommodation, so an increasing eso deviation at
near does not occur with accommodative effort. An
additional factor responsible for the reduction of
accommodation and accommodative convergence
is the miosis itself. Small pupils increase the depth of
focus so that near objects can be seen clearly with
much less accommodation than s needed by normal-sized pupils. Of the two commonly used agents,
219
220
Chapter 7
INFANTILE ESOTROPA
In the past, the term congenital esotropa was applied
to those cases of primary comitant esotropa (PCE)
Characteristics
Approximately half of all nfantile esotropa patents
have hyperopic refractive errors of at least +2.00
D.17 Ingram and Barr,18 however, reported a study of
1-year-old infants from a general pediatric practice
in which only 11% of patients had hyperopia in this
range. Although accommodation may be a factor in
the etiology of infantle esotropa, most nfantile
esotropa cases are not exclusively accommodative.
The angle of deviation s usually large (30A or more),
stable, comitant, and approximately the same magnitude at all dstances (whch indcates a normal
AC/A ratio). Characteristics of nfantile esotropa are
usted inTable 7-2.
Clnicians frequently observe crossed fixation n
infantile esotropa. The child uses the right eye for targets n the left visual field and the left eye for objects
n the right field. This crossed fixaton behavior
accounts for an apparent lmitation of abduction of
Chapter 7
221
Itechanism
spondence Usually
accommodative-convergence/accommodation.
each eye that s often observed. Testing ocular rotations adequately in extreme fields of gaze is difficult
in infants, particularly if they have developed the
habit of crossed fixation. Repeat testing and observation may be needed to differentiate a true paresis from
an apparent abduction limitation resultingfrom habitual crossed fixation. Observing abduction during the
doll's-head maneuver, left and right, may help one to
make the distinction between a lateral rectus paresis
and a pseudoparesis. The examiner holds the infant
directly in front and makes eye contact while rotating
the patient's head to the left and right. For example,
the examiner should look for abduction of the
patient's right eye as the head is rotated to the patient's
left. If the right eye is seen to abduct, pseudoparesis is
indicated. The unaffected, or less affected, eye should
be patched for a few days to determine whether
abduction rapidly develops in the other eye. If it does,
then pseudoparesis is confirmed. If, however, paresis
is present, there will be little or no abduction.
Amblyopia often is associated with infantile esotropa f the child habitual ly fixates with only one eye.
Two large clinical surveys of children with infantile
esotropa found amblyopia in 35% and 41% of the
samples, respectively.17-19 Established amblyopia in
infancy, if not dentified and treated early, will most
222
Chapter 7
Management
A cardinal principie n the management of nfantile esotropa s early ntervention. Generally, the
longer effective therapy s delayed, the worse s the
long-term prognosis (see Chapter 6). The ideal time
at which to initiate visin therapy is at the onset of
the condition. Prognosis for a functional cure of
very early nfantile esotropa approaches zero f
treatment is delayed beyond the age of 2 years.
Early treatment is not merely important; t s essential. Another principie s frequent examinations of
the child, because the visual status can change
dramatically and rapdly during the first few years
of life. General principies of clinical management
are as follows.
Optical Treatment
Corrective lenses to cover ful I cycloplegic, retinoscopic findings should be prescribed if there is a
significant refractive error. Spectacle lenses are
intended to correct any accommodative component of the deviation as well as any significant
astigmatism or anisometropia. Prescription for
even small amounts of hyperopia s warranted if
the lenses are intended also to provide a platform
Chapter 7
223
224
Chapter 7
Mechanism
Characteristics
The most important feature of PCE s patent age at
onset. (See Table 7-3 for characteristics of PCE.)
The later the onset, the better s the prognosis.
Onset is often gradual, and the child may pass
through a period of intermittent esotropa before
the strabismus becomes constant. The size of the
Chapter 7
deviation is usually between 20A and 70A, and the
magnitude may slowly ncrease over time. Refractive error often is ndependent of the onset of the
deviation, because many affected patients have little or no ametropia. However, there can be a partially accommodative component to the strabismus
that requires optical compensation.
The cause of PCE is believed to be a developmental innervational anomaly, possibly a multifactorial genetic trait, but the specific pathogenic
mechanism is unknown. A small number of PCE
cases orignate from a supranuclear tumor that
may be life-threatening.30 In most tumor cases,
however, the deviation is noncomitant and conspicuous. The clinician must be a very conscientious observer in cases of strabismus that develop
early in life, to ensure immediate detection.
Most cases of PCE are basic eso deviations,
which means they are characterized by a normal
AC/A ratio and approximately equal deviations at
far and near. A common exception, however, is DI
esotropa, n whch the AC/A ratio s low; the near
eso deviation s significantly less than that at far. It
is important for the clinician to distinguish DI from
divergence paralysis, which has serious neurologic
implications. Divergence paralysis originating
from a midbrain lesin often presents with a
greater eso deviation at far than at near, as in DI.
However, the deviation is usually noncomitant initially but may gradually evolve toward comitancy
over time. This feature can complcate the differential diagnosis between dvergence paralysis and
DI. Therefore, clnicians should closely monitor all
new patients presenting with characterstics of DI.
Neurologic examination and neuroimaging can
usually be deferred in the inital presentation of
low AC/A esotropa that s associated wth farpoint
diplopia, unless there are other neurologic signs or
symptoms.1'20
Management
Prognosis s generally good in cases of PCE if
there s early intervention with visin therapy
(often including surgery). The later the onset of
PCE, the better s the prognosis. Lang31 reported
that an onset of PCE after 1.5 years of age indicates a good prognosis after surgical alignment;
many patients can develop good random dot stereopsis. If visin therapy s delayed, however,
patients often develop amblyopia, ARC, suppression, increased magnitude of the esotropa, and
225
Characteristics
PCX has an etiology similar to that of PCE, an
innervational anomaly probably of multifactorial
genetic origin. Table 7-4 lists some of the features
of PCX. This condition is less prevalent than PCE
(approximately 33% as frequent) and reportedly
occurs more often in girls than n boys (66% more
frequent) for unknown reasons.33-34
Unlike esotropes, most exotropes are intermittent
(approximately 80%) throughout life. Jampolsky35
pointed out that the progression of exotropia is usually gradual, starting with an exophoria, then evolving to an intermittent strabismus, with only a small
portion of patients becoming constant exotropes.
He suggested that suppression s the mechanism of
decompensation from exophoria to exotropia.
Infantile presentations of exotropia, before age 6
months, are very rare (1 in 30,000) as compared
with infantile esotropa (0.5-1.0%).36 Nevertheless,
these few cases are not usually referred to as nfan-
226 Chapter 7
Mechanism
Innervational; familial tendency; female-male ratio 2
to1
Birth-8 yrs; usually gradual
Onset
Refractive error Wide variation; same as general
population
Approximately 80% intermit-tent;
Constancy
tendency to become constant over
A
time; angle, 20~70
Comitant horizontally; A or V
Comitancy
pattern in many cases
Usually normal retina! correspondente;
Correspondence f requent covar-iation of anomalous
retinal correspondence cases with the
intermittent deviation
Arrtblyopia Approximately 5% of cases
AC/A ratio Usually normal or low; high in
approximately 10% of cases
Symptoms Frequent photophobia, squinting
(eyelids), or asthenopia
Long-term prognosis Good if intermittent; poor if
constant
with
anomalous
retinal correspondence
AC/A - accommodative-convergence/accommodation.
Chapter 7
227
A AND V PATTERNS
The terms A and V patterns are used to describe
significant changes in the horizontal deviation (eso
or exo) as the eyes move from up-gaze to the primary position to down-gaze. A and V patterns are,
therefore, a form of noncomitancy of the horizon-
228
Chapter 7
a.
c.
d.
Characteristics
An A or V pattern is diagnosed by comparing the
altrnate cover test results in the primary position
to those found in the extreme up and down positions of gaze. By convention, an A pattern is indicated if the horizontal deviation changes 10 A or
Chapter 7
the oblique and vertical rectus muscles. For example, the most frequent cause of a V-pattern esotropa is the underaction of one or both superior
oblique muscles. In down-gaze, the eso deviation
is increased by the loss of abduction by the underacting superior obliques. In up-gaze, the eso deviation s decreased by the relatively increased
abduction by the normally acting or overacting
inferior obliques. Anatomic abnormalities of the
bony structure of the orbit and abnormal insertions
of muscle tendons have been cited also as etiologic factors in producing an A or V pattern. 11 A
and V patterns are frequently associated with
infantile strabismus, Duane retraction syndrome,
Brown syndrome, acquired bilateral fourth nerve
palsy, dysthyroid eye disease with inferior rectus
muscle contracture, and orbital malformations
found in Down syndrome. On the sensory side,
ARC can occur in strabismic patients with A and V
patterns; however, as the horizontal angle of deviation (H) changes n up- and down-gaze, the angle
of anomaly may covary with it.
If a strabismic individual can achieve normal
fusin in some field of gaze, that person usually
adopts a head posture that allows fusin to occur.
la patient presents with a habitual chin elevation
or depression, A and V patterns should be suspected. For example, a V-pattern esotrope who can
achieve fusin n up-gaze may present with a chin
depression and a "mischievous" appearance,
whereas a V-pattern exotrope may display chin
elevation and a "snobbish" appearance, because
the deviation s reduced n down-gaze.
Management
We recommend moving the patient's head back (chin
up) for measurement n down-gaze and the head
down (chin down) for measurement of angle H n upgaze. Clinicians can test for A and V patterns at either
far or near distances, whichever they prefer.
Significant A and V patterns can often be treated
surgically, usually by either operating on the oblique
muscles or transposing the horizontal rectus muscles.43 Surgical correction of an A or V pattern is indicated if the vertical noncomitancy contributes to
excessive fusiona! demands or unacceptable cosmesis in cases of horizontal strabismus. An esotropa
with an A pattern that has no oblique nvolvement
may be treated by recession of the medial recti and
transposed above the original nsertion, approximately a muscle-width. The specific surgical tech-
229
MICROTROPIA
The definition of microtropia is disputed, and clinicians disagree as to its characteristics. The terms
microstrabismus, monofixation pattern (or syndrome) , and subnormal binocular visin have al I
been used to refer to the same or similar conditions. Microtropia s our term of choice for the
condition having the characteristics described in
the following section.
Clinical Characteristics
We believe that manifest deviation must be 1A or
greater in magnitude to be classified as strabismus.
230
Chapter 7
TABLE7-5.
Characteristics of Microtropia
Mechanism
Unknown, often secondary to surgery or visin training for an
Infantile or prmary comitant
esotropa
Fronn
birtn or the time of therapeu-tic
Onset
intervention
Refractive error Probably no relationship
1-9A strabismic component; usually an
Deviation
additional phoric component; eso
deviations much more com-mon
than exo or hyper deviations
Usually
constant in all fields of gaze
Constancy
and at all fixation distances
UsuaHy comitant
Comitancy
Correspondence Usuatly anornalous retina! correspondence relative to the strabismic
component
Fusin Peripheral fusin with some ver-gence ranges,
some stereopsts, central suppression of the
devi-atng eye
Ambtyopia Shaltaw amblyopia f requently present
Usually none
Symptorm Poor for bifoveal fusin; usuaity a stable
Prognosis end-stage condition
A fixation disparity, however, s much lower in magnitude, usually not exceeding 20 minutes of are.
(See the discussion of fixation disparity in Chapter
3.) In our opinin, microtropia has been erroneously described by some clinicians as an "unusually
large fixation disparity." We prefer to use the term
mcrotropia to describe a frequently seen condition
that has most of the characteristics usted in Table 7-5.
There is a manifest deviation on the unilateral cover
test from 1A to approximately 8A or 9A. This angle
may show some variability in magnitude. Besides
the manifest deviation, there is often a latent deviation (a phoric component) seen on the altrnate
cover test. On this test, one eye or the other s
always being occluded, which reveis the fusionfree deviation. Clinically, the results of the unilateral
cover test are compared with those from the altrnate cover test. A larger magnitude is frequently
seen on the altrnate cover test, indicating a phoric
component to the strabismus (Figure 7-7). These
microtropic patients usually show foveal suppres-
sion of the deviated eye. Nevertheless, fusional vergence ranges can be measured and sometimes are
almost normally sufficient. Usually there is ARC that
is harmonious relative to the strabismic component
of the deviation. Similarly, there may or may not be
amblyopia. Peripheral stereopsis often is present,
but central stereopsis is absent or greatly reduced,
especially with random dot targets.
There are two major types of microtropia, primary and secondary. Primary microtropia is indicated if there is no history of a larger angle of
strabismus. The etiology of this condition is
unknown but, like PCE, there appears to be some
genetic basis. Secondary microtropia is often the
result of visin training or surgery for a larger angle
of strabismus, particularly in cases of early onset.
Other secondary causes may be aniseikonia,
anisometropia, uncorrected vertical deviations,
and foveal lesions.
Chapter 7
Lang46 reported that most patients with microtropia are microesotropes, but there are exceptional
cases of microhypertropia that usually result from
suigical ntervention of a large-angle hypertropia.
Secondary microtropia is much more prevalent than
primary microtropia.
There are specialized tests that help to dentify
microtropia. The unilateral neutralization test gives a
firect measure of the manifest deviation seen on the
wiilateral cover test (Figure 7-8). When there is a
phoric component, the altrnate cover test s no
longer useful n measuring magnitude of the strabismic component. To measure this horizontal angle of
s&abismus objectively, the examiner must simultaneously occlude the dominant eye and place the
correct amount of base-out prism (in a case of
esotropa) before the deviated eye to neutralize any
movement of that eye. Consider, for example, a
microesotropia of the right eye. The patient s
nstructed to look at a straight-ahead target while
the clinician occludes the left eye. A small outward
movement of the right eye is observed and estimated to be 5A. To measure this deviation, the doctor must simultaneously occlude the left eye and
place the correct magnitude of base-out prism
before the right eye to neutralize any movement of
that eye (see Figure 7-8). If 5A base-out s placed
before the right eye and there s no movement of
that eye when the left s covered, then 5A is the measured magnitude. If there is eccentric fixation, that
must be taken into consideration to calclate the
fin/e strabismic deviation (see Chapter 4). In microtropic patients who have a phoric component, the
total angle of deviation should be measured with
the altrnate cover test n the standard manner.
Another useful test for determining the clinical
characteristics of a microtropia is the Bagolini striated lens test. A transluminator light (or a penlight)
is the fixation target. The typical response of a
microtropic patient on this test is a report of the two
lines crossing at the light but a small gap observed
in the line clued to the strabismic eye. The microtropic angle of deviation can be directly observed by
using the unilateral cover test to verify the deviation.
Perception of intersecting lines at the light suggests
harmonious ARC (i.e., an angle S of zero in the presence of a strabismus). A gap in the line seen by the
deviating eye indicates central suppression. Harmonious ARC and deep central suppression are seen
frequently in cases of microtropia. If there is any
amblyopia, visuoscopy (also referred to as visuscopy) must be performed to check for the presence
231
FIGURE 7-8Unilateral neutralzation test. a. Preparing for the unilateral cover test for neutralization of an esotropic right eye with baseout prism. b. Simultaneously covering the left eye with an occluder
and the right eye with base-out prism. The prism power that equals the
esotropic angle of the right eye neutralizes the angle of deviation so
that eye movement does not occur.
Management
Microtropia in adults does not generally require
visin therapy. These patients are usually symptom-
232
Chapter 7
CYCLOVERTICAL DEVIATIONS
Cyclovertical deviations involve either the oblique
muscles or the vertical rectus muscles. Vertically
acting muscles have both vertical and cyclorotary
actions in most positions of gaze. Therefore, innervational or mechanical abnormalities of these
muscles usually result in both a vertical deviation
and a cyclo deviation. Hyper deviations are also
prevalent among patients with horizontal strabismus; nearly 40% of al I esotropes have a small vertical component.49 Although vertical deviations are
found frequently in combination with horizontal
strabismus, they can occur as isolated abnormalities. Because vertical fusional vergence s relatively
weak as compared with fusional convergence or
divergence, a small vertical deviation of even 1A or
2A may cause disturbing symptoms of diplopia,
ntermittent blur, eyestrain, and nausea. Moreover,
a small vertical component can be the primary
obstacle to fusin in some cases of horizontal strabismus. Most cyclovertical deviations are noncomitant (see Chapters 8 and 15). In the next section,
however, we discuss comitant vertical deviations.
f233
SENSORY STRABISMUS
A blind eye usually becomes a turned eye. When
sensory fusin is lost, strabismus usually results.
Severely reduced visual acuity in one or both eyes
can be an insurmountable obstacle to sensory
fusin. When the primary cause of a strabismus is
loss of visin, then the term sensory strabismus is
used to describe the condition. The causes of sensory strabismus are therefore as varied as the causes
of blindness or severe low visin. Some of the common causes in early childhood include ocular
trauma, congenital cataracts, optic atrophy or hypoplasia, congenital ptosis, and high anisometropia.
The second most common presenting sign of retino-
234
Chapter 7
CONSECUTIVE STRABISMUS
Consecutivo strabismus refers to an eye turn that
changes from one direction to the opposite direction (e.g., when an exotropia becomes an esotropa
postoperatively). There are very few spontaneous
cases reported that are independent of a specific
event, such as eye surgery or ocular trauma. Consecutive esotropa occurs almost exclusively after
surgical overcorrecton of an exotropia.
A common surgical goal in management of
exotropia is to leave the deviation slightly on the eso
A
side of alignment, approximately 10 eso, as there is
a tendency for the eyes to diverge during the heal'mg
process. Occasionally, the overcorrection is excessive, and a cosmetic esotropa is evident. When this
occurs, patients often report postsurgical diplopia.
The reported prevalence of surgical overcorrections
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25. von
IngRP.
MR.
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tim'mg
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accommodative
esotropa.
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Vis Sc. Strabismus.
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Ophthalmol.
1988;105:1-10.
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esotropa.
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21. Lang
J. Der kongenitale oder fruhkindliche Strabismus.
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8. Ludwlg
1H, Parks J,
MM,
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PR,
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26. Ophthalmologica.
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MA,
Hahm
KH,
Han
SH,
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JM.
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the AC/A
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23. Taylor DM. Congenital Esotropa: Management and Progno
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10. Raab EL. Difficult Esotropa Entties: Principies of Man
agement. In: Cnical Strabismus Management: Principies
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eds. Phladelphia: Saunders; 1999:139-151.
11. Mein J, Trmble R. Diagnosis and Management of Ocular
Motility Disorders, 2nd ed. London: Blackwell Scientific;
1991:219-220,276-278.
12. Semmlow J, Putteman A, Vercher JL, et al. Surgical modification of the AC/A ratio and the binocular alignment
("phoria") at distance; its influence on accommodative
esotropa: a study of 21 cases. Binocul Vis Strabismus Q.
2000;15:121-130.
13. Pratt-Johnson JA, Tlllson G. The management of esotropa
with high AC/A ratio. J Pediatr Ophthalmol Strabismus.
1985)22:238-242.
14. N\xon RB, Heiveston ESA, SAiUer K, et ai. incidence o Strabismus in neonatos. Am J Ophthalmol. 1985;10Q-.79&801.
i. Enedrich D, deDecker W . Prospec tiv e Sludy o the
Deve\opment o Strab\smus During the First 6 KAonths o
Lie. \n: Orthoptic Horizons: Transactions of the Sixth
International Orthoptic Congress. Lenk -Schaer tv\, ed.
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16. von Noorden GK. Binocular Vision and Ocular Motility:
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235
11ll
236
Chapter 7
Neurologa and muscular diseases affecting effciency of binocular visin are discussed in terms
of clinical diagnosis and management. A team
approach often s required for proper management of these disorders.
NEUROGENIC PALSIES
General Considerations
Noncomitant strabismus is considered neurogenic
palsy f it results from damage to one or more of the
238
Chapter 8
Nerve VI Nerve IV
Nerve III
Paretic
Strabismus
Causes
18
17
18
15
4
Source: Modfied from JA
Rush, UR Younge. Paralysis 27
19
32
8
4
2
36
21
15
15
12
14
23
Mode Of onset
Usually sudden
Age of onset
Any age
in
Diplopia
Cornitancy
Head posture
Amblyopa
Correspondente
Common
Noncomitant
but can .
become
comitant
with time
Usually
abnormal
Rare, only if
early onset
Usualty normal
retina! correspondence
Common
Developmental
Strabismus
Usually gradual
or shortly
after birth
Between birth
and approximately age 6
yrs
Uncommon
Comitant; AorV
pattern may
be present
Usually normal
Common
Anomaious
retina! correspondence
common
Uncommon
Chapter 8
239
240
Chapter 8
an underactive left superior oblique muscle, possibly due to fourth nerve palsy. This is true even when
there is spread of comitancy.
Patients with a fourth nerve palsy who choose to
fixate with the paretic eye demnstrate the falling
eye syndrome (more correctly, falling eye sign)
(Figure 8-1). When the patient fixates with the
affected eye, particularly in adduction, excessive
innervation to the superior oblique muscle is necessary to maintain fixation. Because of Hering's
law, the yoked contralateral inferior rectus muscle
overacts, making the fixating eye appear to drop.
von Noorden et al.4 reported that 21% of traumatic fourth nerve palsies in a large clinical series
were bilateral. Other authors have reported even
higher proportions of bilateral superior oblique
involvement.5 Severity of the paresis is often asymmetric (one eye higher than the other), which can
mask the bilateral nature of the condition. One distinguishing feature of bilateral involvement is finding
a right hypertropia on left gaze and left hypertropia
on right gaze. Another differential observation is a
positive Bielschowsky head-tilt test on either right or
left tilt. For example, in a case of bilateral involvement in which the patient presents with a right
hypertropia in the primary position, the right hypertropia increases on right tilt; on left tilt, a left hypertropia manifests and increases. Another particularly
sensitive diagnostic indication of bilateral trochlear
palsy is the patient's observation of a double excyclo
tilt on a double Maddox rod test,
Chapter 8
New axons that are misdirected innervate inappropriate muscles, resulting in the paradoxical ocular
movements and pupillary reactions characteristic
othis syndrome.
Acquired third nerve palsy is a fairly common
neurologa condition. Depending on the site of the
lesin, the entire nerve can be affected (resulting
in the characteristic signs described earlier for
congenital third nerve palsy), or only a particular
divisin or isolated root of the nerve can be damaged. Isolated palsies of various extraocular muscles supplied by the third cranial nerve occur less
commonly than a more generalized condition.
Any degree of paresis can be present. Deficiencies
in elevation, depression, and adduction, along
with ptosis, occur in various combinations with or
without pupillary involvement. When there is
extraocular muscle weakness along with pupillary
involvement, the condition is called infernal ophtialmoplegia. However, externa] ophthalmoplegia
K indicated when extraocular muscle weakness
exists without pupillary involvement.
Isolated superior rectus palsy is usually congenital. When the uninvolved eye fixates in the primary
position, a hypotropia of the affected eye s seen. The
hypotropic deviation increases maximally when the
patient moves the affected eye into the field of action
o the superior rectus muscle, the superior temporal
field. Because most such palsies are congenital, the
patients do not usually report any symptoms. The
recommended surgical procedure for an isolated
superior rectus palsy consists of an appropriate
amount of inferior rectus recession and superior rectus resection in the involved eye. A 4-mm recession
of the inferior rectus, by itself, may give up to 15A of
vertical correction in the primary position.7 A recesskwi-resection operation of the same amount may
provide as much as 40A of vertical correction.
Isolated medial rectus, inferior rectus, and inferior oblique muscle palsies are extremely rare.
These three muscles all are innervated by the inferior divisin of the third nerve, so damage to that
root tends to involve all three muscles. However,
isolated palsies do occur occasionally for inexplicable reasons. In solated medial rectus palsy, a
noncomitant exotropia is seen along with limited
adduction. The corrective surgical procedure is
usually recession-resection of the horizontal muscles in the affected eye. The extremely rare isolated
inferior rectus palsy can be congenital or acquired.
When it is acquired, the cause s usually head
trauma (e.g., a blowout fracture to the orbital
241
242
Chapter 8
"
<v
MYOGENIC PALSIES
Myasthenia Gravis
Myasthenia gravis s a chronic, progressive disease
characterized by skeletal muscle weakness and
fatigue and has a predilection for the muscles of mastication, swallowing, facial expression and, particularly, eyelid and ocular motility (Table 8-4). Ptosis and
are
encountered, but the course of the condition in
infants and children differs from that in adults, as
children exhibit a wider range of muscular involvement. The condition characteristically s variable,
marked by periods of exacerbation and remission.
Muscle function may change within minutes, hours,
or weeks.2
Myasthenia gravis is a skeletal muscle autoimmune disorder distinguished by a reduction of the
available postsynaptic acetylcholine receptor sites
on the end plates at myoneural junctions. The antiacetylcholine receptor antibody is present in
approximately 80% of patients with the generalized disease and n approximately 50% of patients
with myasthenia restricted to the ocular muscles. 11
Diagnosis of myasthenia gravis s based on demonstration of easy muscular fatigability and its rapid
relief by systemic administration of an anticholinesterase agent such as edrophonium chloride
(Tensilon). A period of 5-10 minutes of closing the
eyes and resting also can temporarily restore functions; this can be helpful for differential diagnosis
from causes other than myasthenia gravis.
Treatment of myasthenia gravis falls within the purview of a neurologist. Systemic anticholinesterase
medications are given to treat the disease, but these
are rarely successful n completely controlling ptosis
and diplopia. In the purely ocular form of the disease,
the administration of corticosteroids (e.g., prednisone) on an alternate-day schedule has yielded
remarkably good results, approaching 90-100%.12
Due to the variable nature of the condition, prism
therapy s usually unsuccessful; the clinician often
resorts to occluding one eye to relieve diplopia.
Although myasthenia gravis may mimic any single or
combined extraocular muscle palsy, including supranuclear and intranuclear ophthalmoplegia, eye muscle surgery s generally not indicated unless the
deviation s stable over a long period of observation.
A ptosis crutch fitted to a frame to elimnate the
drooping lid or lids s occasionally beneficial. Frequent changes of Fresnel prism power can also be
used to relieve diplopia. Thus, the ocular manifesta-
Chapter 8
243
orly (.e., Dalrymple's sign). Eyelid retraction associated with proptosis s so specific to Graves' disease
that it s used as the primary clinical indicator of the
condition. Day18 noted this finding n 94% of his
series of 200 cases. In proptosis of nonthyroid origin,
patients usually do not have eyelid retraction,
although exceptions do occur. Because of the eyelid
retraction, the patient may have the appearance of
staring or being startled. Infrequent and ncomplete
blinking often occurs. On down-gaze, the upper eyelids usually lag, exposing sclera superiorly (.e., von
Graefe's sign). Exophthalmos is not always pathognomonic of thyroid eye disease. Many other conditions
(e.g., high myopia, steroid use, Cushing's syndrome)
result in proptosis or a pseudoproptosis. However,
the combination of bilateral exophthalmos, eyelid
retraction, stare, and an enlarged thyroid are virtually
pathognomonic of Graves' disease.14
Proptosis in Graves' disease is caused by extraocular muscle enlargement. The muscles are usually
enlarged two to five times their normal size due to
fatty infiltrates, lymphocytes, macrophages, mast
cells, and interstitial edema.19'20The increased muscle
size s not due to the muscle fibers themselves,
which histologically appear normal, but to inflammatory infltrales, cells, and edema. Orbital connective tissue and extraocular muscle antibodies have
been detected in the serum of patients with Graves'
ophthalmopathy.21 The immunologic mechanism of
involvement is not well understood. Because of the
enlarged muscles, there s a resistance to retropulsion (pressing the eye back into the orbit). The most
commonly involved extraocular muscles in thyroid
eye disease, in order of frequency, are the inferior
recti (80% of patients), medial recti (44%), superior
recti, and lateral recti.22 Oblique muscles rarely are
involved.
Inferior rectus nvolvement results in a tethering
of the eye, restricting movement n up-gaze. In this
case, the forced duction test s positive for a restrictive myopathy of elevation. Patients often report
diplopia in up-gaze and, eventually, n the primary
position; in fact, the most common cause of spontaneous diplopia n middle-aged or older patients
is Graves' disease.14
Increased intraocular pressure (IOP) can occur
due to the pressure of the muscle against the eye on
attempted up-gaze. Some i nvestigators believe that
a 4-mm ncrease in IOP between inferior and superior gaze is highly suggestive of restrictive myopathy.
Gamblin et al.23 observed that al I patients with
long-standing thyroid exophthalmos had increased
Chapter 8
244
TABLE 8-5.
Graves'Disease
Class
Definitton
No signs or symptoms
Ony signs (upper eyelid retraction and stare
w\th or w'rthout eyeVid lag or proptosteV, no
symptoms
Soft-tissue
invoivement (symptoms and signs)
2
Proptosis
Ixtraocular
muscle involvement
3
Chapter 8
MECHANICAL RESTRICTIONS
OF OCULAR MOVEMENT
Noncomitancy may be caused by restriction of
traocular muscles. Several causes are discussed
in this section.
245
246
Chapter 8
Right Gaze
Left Gaze
Chapter 8
fibrosis of the
Extraocular Muscles
Generalizad fibrosis syndrome s usual ly an autosomal dominant anomaly n which all the extraocular muscles, including the levator, are fibrotic.
Both eyes are tethered downward, and the patient
devates the chin to fixate. A bilateral ptosis s usually evident. Surgical treatment s often unsatisfactory. One surgical approach s to recess both
inferior rectus muscles and perform bilateral fron -
247
Adherence Syndromes
Johnson38 described two very rare restriction anomalies called adherence syndromes. These are usual ly
acquired, often introduced by previous eye surgery;
however, a few congenital cases have been reported.
In the lateral adherence syndrome, the muscle
sheaths of the lateral rectus and the inferior oblique
muscles are joined by abnormal fascial tissue attachments. This unin produces a limitation of movement n the field of action of the lateral rectus (i.e.,
abduction). The forced duction test reveis a lateral
restriction to passive rotation of the eye.
In the superior adherence syndrome, there s
abnormal adherence between the superior rectus
muscle sheath and the superior oblique tendn that
produces a limitation of movement n the field of
action of the superior rectus. Diagnosis is often established during surgery using the forced duction test.
Treatment for these adherence syndromes requires
loosening the adhesions by forcefully rotating the
globe after detaching the lateral or superior rectus
muscle.
Orbital Anomalies
A blowout fracture of the orbit may occur as a result
of blunt trauma to the soft tissues of the eye, as
when an eye is hit with a tennis ball or a fist or the
248
Chapter 8
TABLE 8-6.
INTERNUCLEAR AND
SUPRANUCLEAR DISORDERS
Lesions between the nuclei of the third, fourth, and
sixth cranial nerves, as well as lesions above these
nuclei, are discussed.
Internudear Ophthalmoplegia
A lesin in the medial longitudinal fasciculus (MLF)
blocks information from the pontine gaze center and
the sixth nerve nucleus to the contralateral third
nerve nucleus. A lesin in this long internuclear pathway produces a characteristic set of clinical manifestations known as ntemuclear Ophthalmoplegia
(INO) (Table 8-6). The patient presents with deficient
or absent adduction of the eye on the affected side on
attempted versin. In the subtle form, the adduction
defect may be apparent only as a mild decrease n
the velocity of adducting saccades. There s abduction nystagmus of the eye opposite the lesin on
attempted versin. The nystagmus may be present in
the abducting eye only, or in both eyes, with the
abducting eye having a larger amplitude of nystagmus. The dissociated or asymmetric horizontal nystagmus n these patients appears to be a secondary
compensatory response to the weakness of adduction and appears not to be caused directly by the
central defect.37 I NO is named for the side of the
MLF lesin that s indicated by the eye with deficient
adduction on conjgate gaze: For example, a left
INO is indicated when the left eye lacks adduction
and the right eye shows abduction nystagmus on
attempted right gaze. In bilateral cases, there is usually abduction nystagmus of both eyes on lateral
Chapter 8
249
basilar artery and often is accompanied by vrtigo and other brainstem symptoms. 41 Other rare
causes of INO have been reported; these nclude
brainstem and fourth ventricular tumors, hydrocephalus, infections (including those associated
with the acquired mmunodeficiency syndrome),
pernicious anemia, head trauma, and drug intoxications (e.g., narcotics, tricyclic antidepressants,
lithium, barbiturates, and other psychoactive
drugs).42
Treatment options for INO are limited. Ocular
manifestations are managed on a symptomatic
basis. Patients usually do not present with a strabismus n the primary position and therefore do
not report diplopia except on lateral gaze. They
compnsate by turning the head rather than the
eyes for lateral fixation. Comfortable reading and
safe driving, however, may require patching an
eyeeither total or partial occlusion. There may
be some spontaneous or slow recovery of function with healing f the cause is of vascular origin.
Patients with mltiple scierosis frequently experience periods of remission and recovery of some
motor functions during the course of the disease.
However, no treatment for mltiple sclerosis is
yet available that has proven effective in the long
term.
Supranuclear Horizontal
Gaze Palsy
Frontal Eye-Feld Lesions
The two most common causes of lesions n the frontal cortex (Brodmann's rea 8) are acute cerebrovascular accident (stroke) and head trauma. The frontal
eye fields initiate voluntary saccadic eye movements,
so a lesin on one side results in a conjgate turning
of the eyes (and, usually, the head) toward the side of
the lesin; the contralateral rea 8 has unopposed
250
Chapter 8
action. If the lesin s isolated and the patient is sufficiently conscious, pursuit eye movements can be
demonstrated on either side. Because the vestibular
pathway s intact, the eyes can move into the field
opposite the lesin by applcatin of the doll's-head
maneuver. Eventually, this gaze palsy may partially
resolve, possibly as a result of other systems (e.g.; the
superior colliculus) generating saccades.43
Brainstem Lesions
Brainstem lesions affect the descending fibers in
the brainstem, from the cortical reas subserving
pursuit and saccadic eye movements to the lateral
gaze centers n the pons, specifically, the paramedial pontine reticular formation (PPRF). Stroke s
the most likely cause of lesions n the rostral brainstem, whereas lesions at a lower level in the pons,
involving the PPRF, can arise from several sources
(e.g., vascular origin, demyelinating disease, and
43
tumors). If these descending fibers are interrupted, both pursuits and saccades are deficient or
absent on the side of the "deprived" lateral gaze
center. If a lateral gaze center itself s damaged,
vestbulo-ocular responses can also be affected, as
Parinaud Syndrome
Often the first sign of Parinaud syndrome s up-gaze
saccadic dysfunction. Initially, the patient finds that
making up-gaze eye movements requires much
effort; the eyes may swing back and forth in a serpentine movement when elevation s attempted. With
elevation effort, the eyes often converge while simultaneously retracting into the orbits. Many patients
later have convergence-retraction nystagmus with
oscillopsia. The nystagmoid movements can be exaggerated by rotating OKN stripes downward, thus
requiring upward saccades. Convergence-retraction
nystagmus on vertical OKN testing is a common sign
in Parinaud's syndrome. Other common signs
include dilated pupils that are unresponsive to light,
anisocoria, light-near dissociation (i.e., pupil constriction to a near stimulus but not to light), and
papilledema (Table 8-7). The sluggish pupillary light
response and nystagmus are indicators that the upgaze restriction s not orbital in nature, as t s in
Graves' disease. High-resolution CT scanning and
magnetic resonance imaging are generally helpful in
the differential diagnosis. Parinaud's syndrome usually indicates a neuro-ophthalmologic emergency.
Parinaud syndrome can be congenital or
acquired. Its other ames, sylvian aqueduct syndrome and dorsal midbrain syndrome, indcate its
etiology. This syndrome frequently s caused by
sylvian aqueductal stenosis (i.e., a restriction of
cerebrospinal fluid that flows between the third and
fourth ventricles), resulting in hydrocephalus and
Chapter 8
Common
Deficiency or loss of saccades n up-gaze
Sluggish or tonic dilated pupils
Light-near dissociation; good constriction at near
Convergence-retraction nystagmus with oscillopsia
(increased by rotating optokinetk nystagmus
stripes downward)
Papilledema ess common *
Disturbances of down-gaze saccades
Skew deviation
Eyelld retraction (Collier's sign)
Fourth nerve palsy (trochlear palsy) ;
Loss of up-gaze pursuits
251
252
Chapter 8
Characterlstic
Observations
NYSTAGMUS
The appearance of nystagmus in early childhood or
later in life causes considerable distress for patients,
family, and friends. Its presence usually is interpretad
as a sign of serious visual dysfunction or, possibly,
brain damage. Nystagmus (i.e., the involuntary rhythmic oscillations of one or both eyes) may indeed be
the presenting sign of either a pathologic afferent
visual pathway lesin or a disorder n oculomotor
control. Thirteen percent of cerebral palsy patients
have nystagmus, among many other visual disor-
Physiologic Nystagmus
In a person who is very tired, it is not unusual for a
jerk nystagmus to develop in extreme positions of
gaze (Table 8-10). This s a normal type of nystagmus and of no particular consequence; it disappears
after a good sleep. The oscillations are of small
amplitude, conjgate, and rapid, and may be
unequal in each eye. It is present only at the
extremes of horizontal and, occasionally, vertical
gaze. Because the condition is related to fatigue, t
is usually ntermittent but, if sustained, it must be
distinguished from pathologic types of nystagmus. A
reasonable clinical guideline is to regard as physiologic the fine conjgate jerk nystagmus detected
beyond 30 degrees of gaze or beyond the range of
binocular visin, unless there is a good reason to
suspect otherwise. Alcohol intoxication causes
physiologic nystagmus to decompensate, and the
Chapter 8
UBLE8-10. Characteristics of
tiysiologic Nystagmus
:ion
ancy
sncy
ilrtude
I of gaze
t component
toms ted
conditons
nts
Jerk; conjgate
Usually horizontal; fast phase
of jerk toward side of gaze
Occasional, usually whert tred
Rapid Small, may be unequal
n each
eye Occurs in extreme
horizontal
fields of gaze beyond 30
degrees, occasionally in
vertical gaze Can occur in
extreme field of
gaze when binocular visin
is broken None None
Specifc mechanism unknown
but apparently caused by
extreme general fatigue
Common conditon relieved
by rest or sleep; no other
therapy recommended
Voluntary Nystagmus
Voluntary nystagmus might more properly be called
voluntary flutter, because t s not a true nystagmus.
H is a series of rapidly alternating saccades, usually
initiated willfully with a convergence movement,
and represents nothing more than a trick with the
cyes (Table 8-11).48 This voluntary flutter s accompanied by oscillopsia and s quite fatiguing. It can
be sustained for only a short period, 30 seconds or
less. Approximately 5-8% of the population can
demnstrate voluntary nystagmus, an ability that
seems to run in families. 49 It s unlikely that presehool children would discover this ability but,
occasionally, an older child has used this eye
maneuver as part of mangering behavior, an emotional episode, or an hysteric reaction. Cuiffreda 50
253
None
Latent component
OsciHopsia,
rnay
be associated with
Symptoms
malingering symp-toms (e.g., blurred
visin)
Associated condtions
None
Etology
Not a true nystagmus; back and
forth saccades without an
intersaccadic intervat; ability
possibly hereditary
A
trick
of
the
eyes
that is quite fatiguing, so
Comments
the oscillation bursts are of short dura-ton,
prevalence is approxi-mately
8%; may be associated with
malinger-ing behavior in
school-aged children
Congenital Nystagmus
The most common type of nystagmus s congenital
nystagmus, apparently affecting men twice as fre-
254
Chapter 8
TABLE 8-12.
Type
Directon Consta ncy
Frequency Amplitude
Field of gaze Latent
cornponent
Symptoms
Associated conditions
Etlology
Comments
Chapter 8
TABLE 8-13.
Type
Directon
Constancy
Frequency
Amplitude
Red of gaze Latent
component
Symptoms
Associated conditions
Etiology
Comments
255
TABLE8-16.
(continued)
PAN
Associated
neurologie
signs or
eonditions
Etiology
Seesaw Wlystagmus
Bitemporal hmianop-
Sellar or parasellar
tumor disease of
the mesodiencephalic junction,
trauma, vascular
disease
Lesin in frontal
gaze center or
brainstem projections or pontne
gaze centers
Upbeat Nystagmus
Posterior fossa
disease
>'' ''
Comments
Acquired PAN
treated successfully with
baclofen (antispastic agent);
may continu
during sleep; can
occur as a side
eff ect of some
anticonvulsve
drugs
Asymmetry between
the two eyes, which
distinguishes t f rom
gaze paretic type; little or no nystagmus
in unaffected eye
Nystagmus possibly
increased by barbiturates, phenothiazides, phenytoin
sodium (Dilantin)
Dowrtbeat
Nystagmus
Mltiple sclerosis,
hydrcephalus
Compressions at
foramen magnum level
(Arnold-Chiari
malformation).
encephalitis,
alcohol, spinocerebellar
lesions, magnesium deficiency
May be congenital
or acquired;
reports of
improvement
using base-out
prisms in spectacles and drug
therapy (clonazepam)
Chapter 8
Ihe fixating eye moves toward the primary position and nto abduction. Generally speaking, the
eatment of nystagmus and esotropa n nystagmus blockage syndrome s more difficult than
onanagement of either condition ndependently.
Surgery often s necessary to compnsate for both
ie head turn and the strabismus.
Nystagmus "blockage" compensation can also
occur with induced fusiona! convergence by
using base-out prisms. Binocular visual acuity
tnay improve significantly. (See the section Optical Management n Chapter 15.)
latent Nystagmus
A conjgate jerk nystagmus evoked by occlusion of
one eye is a latent nystagmus (Table 8-14). It often is
associated with strabismus, particularly congenital
iintantile) esotropa, double hypertropia (dssociated
etical deviation), and amblyopia.57This congenital
condition might occur ndependently of other visual
conditions; however, a latent component to congenital nystagmus often s seen, and a jerk pattern
can be superimposed on a pendular waveform. The
jerk pattern of latent nystagmus s characterized by
atast phase n the direction toward the fixating eye
and by the ncrease of nystagmus amplitude on temporal gaze. Visual acuity is better with both eyes
open than with either eye occluded. No specific
iherapy s indicated, as the condition is only manifestwith monocular occlusion.
259
REFERENCES
1.
Rush JA, Younge BR. Paralysis of cranial nerves III, IV, and
VI: causes and prognosis in 1,000 cases. Arch Ophthalmol. 1981;99:76-79.
2. Glasser JS. Neuro-Ophthalmology, 3rd ed. Philadelphia:
Lippincott Williams &Wilkins; 1999:392,471 -472.
3. Wishnick MM, Nelson LB, Huppert L, Reich EW. Mbius
syndrome and limb abnormalities with dominant inheritance. Ophthalmic Paediatr Cenet. 1983;2:77-81.
4. von Noorden GK, Murray E, Wong SY. Superior oblique
paralysis. A review of 270 cases. Arch Ophthalmol.
1986;104:1 771-1 776.
5. Neetens A, Janssens M. The superior oblique: a challenging extraocular muscle. Doc Ophthalmol. 1979;46:295303.
6. Dale RT. Fundamentis of Ocular Motility and Strabis
mus. New York: Grue & Stratton; 1982:294.
7. Jampolsky A. Vertical Strabismus Surgery. In: Symptoms
on Strabismus, Transaction of the New Orleans Academy
of Ophthalmology. St. Louis: C.V. Mosby; 1971:366.
8. Metz H. Double levator palsy. Arch Ophthalmol. 1979;
97:901-903.
9. Ziffer A. Monocular Elevation Deficiency (Double Elevator Palsy). In: Clinical Strabismus Management: Principies
and Surgical Techniques. Rosenbaum AL, Santiago AP,
eds. Philadelphia: Saunders; 1999:272-282.
10. Osserman KE. Ocular myasthenia gravis. Invest Ophthal
mol. 1967;6:277-287.
11. Soliven BC, Lange DJ, Penn AS. Seronegative myasthenia
gravis. Neurology. 1988;38:514.
12. Burde RM, Savino PJ, Trabe JD. Clinical Decisions n
Neuro-Ophthalmology, 2nd ed. St. Louis: Mosby; 1992:
246.
13. Graves RJ. Newly observed affection of the thyroid gland
n females. Lond Med Surg J. 1835;7:51 6-520.
14. Char DH. Thyroid Eye Disease, 3rd ed. New York: Churchill
Livingstone; 1997:7-11,24-25,32-33,46-56,150,157.
15. Jacobson DH, Gorman CA. Endocrine ophthalmopathy:
current ideas concern'mg etiology, pathogenesis and treat
ment. Endocr Rev. 1984;5:200-220.
16. Gorman CA. Temporal relationship between onset of
Graves' ophthalmopathy and diagnosis of thyrotoxicosis.
Mayo Clin Proc. 1983;58:515-519.
1 7. Jamamoto K, Itoh K, Yoshida S, et al. A quantitative analysis of orbital soft tissue n Graves' disease based on Bmode ultrasonography. Endocrinol Jpn. 1979;26:255261.
18. Day RM. Ocular manifestations of thyroid disease: cur
rent concepts. Trans Am Ophthalmol Soc. 1959;57:572601.
19. Kroll HA, KuwabaraT. Dysthyroid ocular myopathy. Arch
Ophthalmol. 1966;76:244-257.
20. Daicker B. The histological substrate of the extraocular
muscle thickening seen in dysthyroid orbitopathy. Klin
Monatsbl Augenheilkd. 1979; 1 74:843-847.
21. Kendall-Taylor P, Perros P. Circulating retrobulbar antibodies in Graves' ophthalmopathy. Acta Endocrino!.
1989;121(suppl2):31-37.
22. Scott WE, Thalacker JA. Diagnosis and treatment of thy
roid myopathy. Ophthalmology. 1981 ;88:493^J98.
260
Chapter 8
thalmology.
PART TWO
TREATMENT
PHILOSOPHIES
Throughout antiquity, many attempts were made to
cure strabismus because t is a disfiguring condition. The ancient Egyptians recommended exotic
ointments such as ground tortoise brain and Oriental spices rubbed nto the eyes. The classical
Creeks prescribed general body exercise and physcal conditioning for relief of eyestrain. In medieval
Europe, where strabismus was associated with the
"evil eye" and witchcraft, hats with colored tassels
were worn in an attempt to straighten the wandering eye. In the sixteenth century n Germany and
France, "squint masks" were worn, which featured
eye holes positioned n such a way as to make fullfield visin impossible except when the eyes were
actually aligned (Figure 9-1). Although squint
masks were cosmetically unattractive, this procedure may have been the first effective visin therapy technique for ntermittent strabismus. The
masks provided patients with a visual feedback
264
Chapter 9
FIGURE 9-2Louis Emile Javal (1839-1907). (Reprinted with permission from WB Saunders Co. and CV Mosby Co.)
Chapter 9
265
i!
266
Chapter 9
A. Sensory obstacles
1, Dioptric obstacles
a. Uncorrected errors of refraction
b. Opacities of the media
2, Protanged uniocular actvity
a. Unilateral ptosis
b. Occlusion for one reason or another (e,g.,
Injury)
3, Retinoneural obstacles (lesions in the visual
pathways}
B. Motor obstacles
1. Abnormalites of the orbit and adnexa (e.g.,
tumor that Is space-takng)
2. Conditons affectng one or more of the extrinslc
ocular muscles
a. Congenital abnormalities (e.g,, faulty insertlon of a muscle)
b. Injury, partltularly to lateral rectus muscle n
birth trauma
c. Contractures in cases of paresis
d. Disease of the muscle itself
3. Conditions affecting the central nervous system
a. Congenital absence of the oculomotor nerves
or their supranuclear pathways
b. Head injury
c Inflarnmation (e.g., encephalitis) d.
Supranuclear lesions
4. Decompensation of an extrinsic ocular muscle
imbalance
C. Central obstacles
1. Psychogenic etiology
2. Hyper- or hypoexcitability of the central nervous
system
3, Central uniocular inhibition
4, Inability of the infant to learn
Source: Reprinted with permission from TK Lyte, G] Bridgeman.
Worth and Chava$se'$ SquintThe Binocular Refeces and the
Treatment of Strabismus, 9th ed, tondon; Balliere, Tindall and
Cox; 1959.
Chapter 9
267
268
Chapter 9
PRINCIPIES
Several principies of visin therapy apply generally
to the practical implementation of a training program designed to remedate anomalies of binocular visin. This section will discuss these mportant
principies and therapeutic options available to the
clinician.
Chapter 9
269
a skilled strabismus surgeon in the hope of achievng a cosmetically acceptable result. Postoperatively,
these patients are closely monitored for changes in
the deviation or a recurrence of amblyopia.
On the other hand, f there are indications that
ARC can be eliminated with visin therapy, we
prefer to attempt a functional cure of the strabismus, which means that there will also be a cosmetic cure. Certain patients respond well to ARC
therapy (e.g., the small-angle comitant esotrope
using the divergence training technique n the
major amblyoscope, most comitant exotropes, and
most other esotropes with minimally embedded
ARC). (See Chapter 11 for a discussion of ARC
therapy indicators and techniques.)
The next step in the sequence of strabismus
management s antisuppression training. When a
patient has gone through ARC therapy, usually relatively little suppression remains. ARC is a form of
binocular visin, an antidiplopia mechanism; relatively little suppression is necessary. Techniques
used to remedate ARC are also powerful antisuppression methods, so by the time NRC is firmly
established, central suppression usually has been
eliminated. However, most strabismic patients n
whom NRC s part of their original diagnosis have
developed suppression to prevent diplopia. These
patients, as well as those who have gone through
monocular amblyopia therapy, usually require an
Chapter 9
271
Chapter 9
Sliding vergence occurs when second- or thirddegree fusin targets are set at a particular accommodative demand and are disparated slowly in a
continuous manner. The most common example of
this method is the measurement of fusional vergence ranges with Risley prisms. Blurpoint, breakpoint, and recovery point are recorded routinely.
This testing method becomes a training technique
when the patient s instructed to make a conscious
effort to hold the targets single and clear for as long
as possible with repetition. The speed of vergence
tracking s not usually the goal, but effort is
directed to increasing the horizontal or vertical
vergence ranges as well as the smoothness and
accuracy of vergence responses. The amblyoscope
and Mirror Stereoscope are particularly suited to
this method of training in cases of strabismus; split
Vectograms and Tranaglyphs often are used in heterophoric cases. The training targets typically contain suppression controls. If suppression occurs
during the training technique, disparation s temporarily stopped and suppression s broken before
proceeding. To monitor progress, the patient's best
vergence ranges each day are recorded at the end
of the training session.
Step Vergence Training
272
Chapter 9
Chapter 9
273
Open-Environment versus
Instrument Training
Whenever possible, the practitioner should assign
open-environment training techniques as opposed
to nstrument training. Closed-box type instruments
such as the amblyoscope, Brewster stereoscope,
and cheiroscope have some inherent disadvantages. They often stimulate spurious accommodative and vergence responses. Also, visual skills
learned inside an instrument do not always transfer
well to the open environment. For example, t is
preferable and more effective to train an exotropic
patient to fuse at near fixation distances using gross
convergence techniques rather than working on
vergence ranges around the angle of deviation in
an amblyoscope.
Nonetheless, an amblyoscope or Brewster stereoscope has its place n many visin therapy programs. These Instruments are particularly effective
in establishing NRC n cases of ARC, breaking suppression, and n building fusiona! vergence ranges.
Vision training for esotropes and amblyopes often
involves the use of an amblyoscope or other boxtype instruments, but most other binocular visin
anomalies can be managed more efficiently using
open-environment instruments and techniques
(e.g., televisin trainers, Vectograms, Tranaglyphs,
and prism flippers).
Patient Motivation
Proper patient motivation is indispensable to the
success of a visin training program. For patients
without a real desire for success, compliance with
visin training techniques falters and fails. For
many adults, particularly those who are well educated, simply knowing that they can overeme
their binocular deficiency or ameliorate their
visual symptoms is motivation enough to comply.
Nevertheless, some adult patients who would otherwise qualify for a binocular cure with visin
training may not want to make the prerequisite
effort or cannot find enough time in their busy
schedules. For these patients, everything that can
be done with lenses and prisms should be done.
The doctor should simply explain to the patient the
condition and treatment options, make appropriate
recommendations, and then give the patient time
to make a considered decisin.
Preschool and elementary school children usually comply with visin therapy to please the parents or the doctor. The doctor's rapport with the
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Chapter 9
Chapter 9
1970s.25 Some general conclusions from that work
may be applicable to visin training. Learning any
ew skill seems to progress most rapidly and effectve\y when the demand response is rewarded
immediately, frequently, and regularly. Initially, little
steps in the correct direction are reinforced; later,
larger steps toward mprovement are rewarded. As
skills, behaviors, and altitudes are shaped and corectly learned, the most effective reinforcement
schedule of rewards seems to be intermittent and
ariable.26 The visin therapist may want to apply
Aese Skinnerian concepts in a concerted way if the
j child seems to be losing nterest, slacking n effort,
r making slow progress during the training program. Table 9-6 lists several rewards to which chilen have responded that have resulted in
fceightened motivation n a visin therapy program.
Bewarding children for cooperating in visin therpy should not be considered a bribe. Children
often find visin training difficult and demanding;
ierefore, a parent or visin therapist should reward
achild's effort, endurance, and self-discipline.
A number of computer-based visin training proffams are commercially available. Two popular sysleins are Computer Orthoptics and Computerized
AkJed Vision Therapy (see AppendixJ). These progarns are designed to break suppression, ncrease
fcisJonal vergence ranges and facility, improve
accommodative skills, train oculomotor skills, and
enhance certain perceptual skills. The training tasks
oten are structured n an nteractive game format, for
wtiich children seem to have a natural affinity. Some
parents believe that computer games have become a
national obsession. Although the addictive quality of
fese games may be some parents' nightmare, computer visin training just may be the visin therapist's
dream come true. In our clinics, we have successfully
used computer visin training with children as a
highly prized reward for home training compliance
and after the completion of other difficult in-office
tEchniques. The enormous potential of computer
visin training, for office and home, is being realized.
In summary, we believe that a visin therapist can
successfully maximize a patient's motivation to
particpate fully in a visin therapy program by
building rapport, communicating effectively, and
using rewards judiciously.
275
276
Chapter 9
REFERENCES
1.
Chapter 9
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
277
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modation; (4) breaking suppression and building sensory and motor fusin; and (5) improving VA to
normal or near-normal levis. If the patientwith functional amblyopia does not respond to the use of
optics, occlusion, and conventional visin training,
trien pleoptics and other special techniques may be
tried in a last attemptfor visual rehabilitation.
In this chapter, we discuss the use of amblyopia
remedial methods in sequence, their advantages
and disadvantages, and their efficacy, and we
address several important issues in the overall
implementation of amblyopia therapy. Table 10-1
lists the general sequence of amblyopia therapy
and training objectives; this sequence serves as the
organizational structure for our discussion. Specific training techniques are numbered for easy reference (T10.1-T10.23) as they are introduced.
MANAGEMENT OF
REFRACTIVE ERROR
Correction of any significant refractive error, particularly anisometropia and astigmatism, is fundamental to effecting a cure of functional amblyopia.
The patient's refractive error is often an important
(if not the most important) factor in the etiology of
amblyopia. Successful, efficient, and enduring visual
rehabilitation requires the elimination of all
amblyogenic factors. Even small amounts of refractive error (e.g., 0.75 diopters [D] of anisometropia
and astigmatism) can be significant in some cases.
The clinician should remember that there is often a
latent component to hyperopia that may need to
be revealed with cycloplegia. We believe the
importance of correcting the full refractive error
cannot be overemphasized. If a patient continually
refuses to wear a needed optical correction or
demonstrates persistent noncompliance, the doctor may be forced to dismiss the patient from
amblyopia therapy and reschedule only when
cooperation can be fully enlisted. An alternative,
however, is pharmaceutical treatment, which
requires relatively less cooperation (as discussed
later in this chapter).
Many practitioners find that, for various reasons,
frequent changes in the lens prescription may be
necessary for the amblyopic eye.1 Objective cycloplegic refractive procedures usually are required
that may lack sufficient accuracy, depending on
the skills of the clinician and other factors. The
refraction may not be precisely on the visual axis
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281
OCCLUSION PROCEDURES
Several variables are nvolved n the management of
occlusion therapy for amblyopia. Many forms of
occlusion have been recommended to remedate
amblyopia (Table 10-2 and Figure 10-1). Patching of
the nonamblyopic eye s called direct occlusion, and
patching of the amblyopic eye s inverse occlusion.
Occlusion can be total or partial; total usually means
that the entire visual field is blocked out (e.g., bandage occluder or a prate patch), whereas partial
occlusion means that only part of the visual field is
occluded (e.g., a sector occluder). An occluder can
be opaque (blocking out all light) or translucent, to
degrade form visin. Each type of occlusion has its
own clinical merits and disadvantages.
Direct Occlusion
The oldest and most popular therapy for amblyopia is direct, opaque, total occlusion (e.g., patch-
282
Chapter10
TABLE10-2.
1. Constant (full-time)
2. Intermittent (part-time)
D, According to which eye s occluded
1. Drect {patching the better eye)
2. Indrect (patching the amblyopic eye)
3. Altrnate (switching the patch from one eye to
the other in a prescribed manner)
fer
1 oa
o-
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283
284
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Types of Occluders
Age (yrs)
1
2
3
4
5
6
7
Days of Direct
Patching
1
Days of I n verse
Patching
1
2
3
4
5
6
Constant
1
1
1
1
1
0
TABLE10-4.
Types
The type of occluder chosen for a particular amblyopic patient depends on a number of factors (Table
10-4). The bandage occluder and tie-on patch are
opaque and totally exclude light. Most clinicians
prefer these occiuders in the hope that a vigorous
patching program will bring rapid therapeutic
results. The bandage patch conveniently fits under
spectacle lenses. This occluder is taken off at night
and changed daily. At night, a moisturizing cream
(e.g., Nivea ointment) can be applied to the skin
around the eye to prevent or reduce irritation from
the adhesive. Many patients prefer to wear a less
cosmetically obvious patch and cooperate better
using a clip-on or translucent occluder. Our preference, however, in most cases of amblyopia is to use
a bandage occluder, full- or part-time, depending
on the case. Adults may choose to wear the tie-on
patch because it lacks adhesive and is therefore
more comfortable; in addition, many come in
designer colors. A contact lens occluder is our next
preference if a child persists in resisting bandage
occlusion. If neither of these alternatives is acceptable, penalization (attenuation) methods should be
considered. Children who resist bandage occlusion
often look around a tie-on, clip-on, or translucent
occluder, thus compromising the therapy program.
When peripheral fusin needs to be preserved, as
in most cases of anisometropia or ntermittent strabis-
Types of Occluders
Features
Advantages
Disadvantages
Some allergic reactions to adhesive; sometimes, unacceptable cosmesis
Lose; moveable; difficult to
wear with spectacles
Children peek around the
occluder; can be too easily
removed by a child
Children tend to peek around
lens
Bandage
Optidude, Elastoptast
(opaque)
Tie-on
Total occlusion
Clip-on
Translucent
Filters
Contact tens
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285
way. Johnny's patch may provide a good opportunity for the teacher to talk about the eyes and the
"wonders of visin."
Teenagers vary considerably in their compliance
with patching. Some are very mature and make a
personal choice to improve their visin regardless
of comments from their peers. Others are absolutely terrified of "looking different." In the latter
cases, a contact lens occluder may be the only
realistic alternative to enlist cooperation with
visin therapy. Another alternative that can be proposed to self-conscious patients is to initiate the
patching program during vacations from school,
when peer interactions may be more controlled.
Patching Progress
In most cases of functional amblyopia, there is an
initial rapid increase in VA and improved fixation
pattern of the amblyopic eye in response to conventional direct occlusion. Most mprovement
occurs during the first 3 months. In a study of 350
amblyopic children, Oliver et al. 5 reported an
average increase of approximately four lines of VA
on Snellen charts during the initial 3 months of
direct occlusion. Approximately one additional
line of mprovement occurred n the next 3-month
period, and only marginal mercases accrued thereafter. A recent report by Cleary6 confirmed that the
optimum results of occlusion occurred n the first 6
months.
After a patient begins to follow the occlusion
schedule, regular office visits are indicated to monitor progress, build motivation, and coordnate
visin training techniques that shorten the total therapy time. We suggest weekly office visits nitialiy, to
ensure that the occluson and visin training are
correctly applied and effective. If a plateau n acuity
or fixation pattern occurs for 4 weeks, we suggest
changing the thrust of the therapy. If the patient
develops steady EF, the clinician may consider
switching to inverse occlusion, applying different
active therapeutic approaches (e.g., afterimage [Al]
transfer techniques), applying pleoptics, or using
red-filter techniques, monocular prism methods, or
a monocular telescope. (These approaches are
explained later n this chapter.)
If, however, there is no progress n VA or the fixation pattern after 2 or 3 weeks of occlusion with
full patient compliance, the clinician should suspect either amblyopia of arrested development or a
possible pathologic etiology. In such cases, prog-
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The most important barriers to successful amblyopia therapy past age 5 years are more psychological and managerial than physiologic. 19 Clinicians
must continu making the recommendation for
preschool treatment of amblyopia primarily
because t can be done with more acceptance and
will help in the establishment of normal binocular
visin; however, they should also emphasize that
many patients with amblyopia can be treated successful ly at any age.
Vision training to remedate amblyopia and EF is
an important and effective adjunct therapy to
occlusion. There are several detailed case reports
n the literature of patients who, unsuccessful with
direct occlusion, responded successfully to visin
training.1'15'20"22 Cenerally speaking, the reported
success rate in studies that augmented occlusion
therapy with active therapy (e.g., visual tracking,
foveal tag, and antisuppression techniques) are
usually higher (70% or better) than those using
occlusion alone.23"28 One study by Francois and
James28 directly compared results of one group of
amblyopes using occlusion alone (N = 100) with
another group (N = 100) treated with occlusion
and visin training. The final success rates were the
same, but the visin training group took significantly less time. Another comparative study by
Leyman26 of 62 amblyopes reported a success rate
of 72% for occlusion alone, 50% for pleoptics
alone, and 93% for a combination group of occlusion and monocular and binocular visin training.
One reason for the higher success rate when visin
training augments optical correction and occlusion
is that the overall treatment time is reduced by as
much as 50%.27-28 Patient compliance with patching tends to diminish over time, so anything that
can be done to speed progress promotes the best
overall outcome. We strongly recommend that, in
addition to occlusion, amblyopic patients be given
at least some of the visin training techniques
described later in this chapter.
Besides acuity mprovement, additional benefits
of amblyopia therapy include increases n stereopsis
in approximately half of anisometropic patients29'30
and improvement in monocular and binocular contrast sensitivity in all types of amblyopia.31
Penalization
One alternative to standard total occlusion when a
child refuses to wear a patch s some form of
penalization. Penalization refers to the use of drugs
287
Penalization Methods
Each penalization method has a place n the management of some amblyopic patients. Generally
speaking, these methods are used more often n
strabismic amblyopia than n anisometropic amblyopia, with the exception of farpoint penalization,
which has been used with both types f normal
fusin s the goal.
Penalization without Spectacles
When a child s totally uncooperative with either
conventional occlusion or spectacle wear, pharmaceutical penalization provides the practitioner with an
effective but somewhat risky alternative. Atropine (1 %
drops or salve) is nstilled in the nonamblyopic eye
once daily whereas a miotic (e.g., 0.025% diisopropylfluorophosphate, 0.06% echothiophate iodide, or
1% pilocarpine drops, twice daily) is used n the
amblyopic eye. There is some pain associated with
instillation of miotics, so some clinicians recommend applying the ointment or drops when a
young child is asleep or at bedtime. The cycloplegic effect of the atropine prevents the patient from
focusing for nearpoint objects with the nonamblyopic eye, whereas the miotic pupil increases the
depth of field of the amblyopic eye. Like a pinhole
camera, the amblyopic eye has a clear image for
objects for most distances. Spectacle correction of
the refractive error, therefore, may not always be
necessary using this method. The clinician does
need to monitor the patient closely for drug side
effects, particularly with this method, because of
their common occurrence with the protracted use
of miotics (e.g., iris cysts, brow pain, headaches,
conjunctival rritation, anterior subcapsular cataract). The mximum ncrease of acuity in the
amblyopic eye usually occurs at between 3 and 6
months of drug therapy, depending primarily on
the patient's age and depth of amblyopia. Significant improvement of acuity has been reported in
more than 75% of patients, irrespective of age. 32
288
ChapteMO
00
33 cm.
33 cm.
I +3 D Add
33cm.
33 cm.
+3 D AddI
1% Atropine
1% Atropine
Normal
Amblyopic
Near Penalization
Near penalization often is preferred to the other methods for patients having deep strabismic ambiyopia.
Atropine drops or salve (1 %) is nstilled in the nonambiyopic eye once daily. The spectacle correction for
the dominant eye is worn to give good far acuity and
prevent occiusion ambiyopia. A single-vision, +3.00D add is prescribed n addition to the refractive correction for the amblyopic eye (Figure 10-3). The effect
of this add is to promote clear visin and fixation with
the amblyopic eye for all nearpoint viewing distances
and to blur far distances sufficiently to forc alternation to the dominant eye for farpoint viewing, thus
preventing occiusion ambiyopia. The goal is to
achieve altrnate fixation, but the child must wear the
eyeglasses to obtain mximum benefit. Near VA
needs to be monitored during near penalization to
ensure that the amblyopic eye has better acuity than
oo
full hyperopic
Normal
Amblyopic
ChapteMO
289
CO
co
33 cm.
33 cm.
+3 D Add I
(spectacles or
contact lens)
Normal Previously
Amblyopic
FIGURE 10-6Far
eyes in addition
to the overcorrection.
The 16 patients wore these spectacles on altrnate
days for 1-4 years, depending on the child's
age. All patients maintained 20/50 acuity or better
n the formerly amblyopic eye. The investigators
recommended maintaining this rgimen of optical
penal-zation until the age of 6-8 years, at which
point the visual system s fairly mature. They
observed that the recurrence of amblyopia s
possible as late as the early teenage years n some
cases. Therefore, all young patients should be
monitored fre-quently for regression and, if it
occurs, optical penalizaron or a short course of
direct patching (or both) can be reinstated.
Penalization Management
Because atropine can have serious side effects in
some individuis, clinicians who use penalizaron
as an occlusion option must be vigilant in screening
patients for signs and symptoms of overdose. Table
10-5 lists systemic and ocular signs and symptoms
of atropine overdose of which clinicians must be
aware. This is not a trivial concern. There have been
six reported deaths of children aged 3 years and
younger due to topical application of atropine
drops.35 These children did, however, have some
central nervous system abnormality or were sickly,
so extra caution is appropriate in these cases.
It must be remembered that young children can
develop occlusion amblyopia in the atropinized eye;
von Noorden36 reported three such cases in children
no more than 2 years of age. Total penalization is a
form of visual deprivation. Because a patient can
form the habit of not fixating with the normal eye, a
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Chapter 10
Systemk
Thirst
Ataxia
Fever
Sleepiness or insomnia
Dryness of skfn, mouth, and throat
Red, flushed skin of the face and neck
Restlessness, irritability, or delirium
Tachycardiarapid and weak pulse
Urinary retention
Ocular
Chapter10
Levodopa Treatment
Over the last decade, a series of clinical reports
have noted mprovement of visual functions of
amblyopes who were administered levodopa or
similar centrally acting medications. 45 Although
the specific actions of these drugs on visual function have not been identified, several studies46'47
document improvements in VA (approximately one
and a half Snellen lines, on average), contrast sensitivity, and visually evoked potential amplitudes
(approximately 30%), and decreased suppression
scotomas. The medications typically are administered orally three times daily for 1 week to 2
months. The positive results n children and adults
persist for several months after cessation of medication. Direct occlusion conducted concurrently
does not seem to faciltate the positive effects, but
it extends the improved visual functioning of the
ambiyopic eye for periods up to a year. 48-49
Reported side effects of the medication are consid-
291
292
Chapter10
f
e
T
PVD
(c)
i,
1
I,
(a)
e f
(b)
opaque or graded. Pigassou and Toulouse 54 recommended applying an inverse prism before the
amblyopic eye while the nonamblyopic eye is
totally occluded with an opaque patch. Also using
inverse prism, Rubn55 recommended using graded,
direct occlusion with sufficient neutral-density filters to reduce the VA of the nonamblyopic eye by at
least two lines below that of the amblyopic eye.
The hypothetical rationale behind using inverse
prism n this monocular technique is to shift the
principal visual direction from the eccentric point
to the fovea. In the case of nasal EF of the right eye,
wearing a base-in prism causes the right eye to
abduct (Figure 10-7). This turning outward of the
eye puts the fovea in the straight-ahead or true primary position. The patient has a new opportunity
to establish the oculocentric direction at the fovea,
because the od directionalization pattern s disrupted by the prism. The recommended amount of
prism power slightly exceeds the amount of EF
(e.g., 6A base-in for 5A steady nasal EF). In less
prevalent cases of temporal EF, the prism (Fresnel
or clip-over) is applied base-out.
Several other versions of prism therapy for EF
have been suggested by various authors, 56 with and
without penalizaron, but there s little evidence
supporting their efficacy over conventional, direct
occlusion. For this reason, we suggest prism therapy
be tried only if standard patch i ng or penal ization
Perceived
Short-Term Occlusion
In the late 1970s, the ntroduction of the CAM (CAMbridge) stimulator therapy for amblyopia generated
excitement, because its use often seemed to result in
quick mprovement of VA.57 This rotating device consisted of seven high-contrast, square-wave, spatial
frequency gratings presenting an acuity range from
20/20 to 20/200. Each grating is viewed monocularly
with the amblyopic eye and rotated at the rate of 1
revolution per minute in ascending order (.e., from
low to high spatial frequencies). The total training
time per session is only 7 minutes. Snellen VA was
reported to increase approximately two lines on average after only a few sessions. However, controlled
studies that followed the initial positive clinical
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MONOCULAR
FIXATION TRAINING
The goals of monocular fixation and motility training with the amblyopic eye are to enhance these
visual skills through conscious patient effort and
performance feedback. Direct patching alone
forces the patient to practice a certain level of oculomotor skills, but amblyopic patients, when
patched, frequently do not attempt as many critical
seeing and eye-hand coordination activities as they
could possibly perform. These monocular training
techniques, however, can provide the patient with
293
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Chapter 10
case in which stable EF occurs, patching s temporarily switched to inverse rather than direct occlusion. Fixation training then is provided using foveal
tag techniques and pleoptic therapy (described
later). Fortunately, most patients progress well
without the need for foveal tag techniques or formal pleoptics.
ored pencils, the result s often quite stunning. Precisin and detail are desirable. The patient should
bring n all drawings and tracings for inspection by
the therapist. Progress in eye-hand coordination s
evident.
Connect-the-dots books provide other excellent
eye-hand coordination challenges to the amblyopic patient. The task requires accurate fixation,
visual search, and tracking. Dot-to-dot games are
available in many toy stores, bookstores, and educational supply stores.
Throwing and Hitting Carnes (T10.2)
To the delight of children and the chagrn of parents, throwing and hitting games are particularly
suited for the development of accurate foveal fixation and spatial localizaron. The nonamblyopic
eye is occluded during training activities. The
accuracy of the outcome is immediately apparent
to all (i.e., good visual feedback). There s constant
motivation to improve performance by adopting
compensating strategies. The reflexive eye-hand
movements involved in the game are also thought
to promote foveal localizaron. Some of the more
popular activities include basketball, baseball batting and catching, Ping-Pong, magnetic darts,
beanbag toss, tennis, badminton, and marbles.
With proper precautions, amblyopic children and
adults should be encouraged to particpate in these
games as part of their direct occlusion program.
This eases psychological acceptance of occlusion.
Several electronic fixation instruments are used in
developmental and sports visin training (for
example, Figure 10-8). In one mode, lights flash on
in a random pattern and the patient hits the appropriate spot or button to turn each light off. Speed
and accuracy are monitored by the instrument.
Because the activity develops reflexive eye-hand
coordination, t s ideally suited for training proper
localizaron with the amblyopic eye.
Video Game Tracking (T10.3)
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2000
296
Chapter 10
FIGURE 10-9Bat and Marsden ball for laterality and directionality training, combined
with occlusion of the nonamblyopic eye.
Various instruments can produce sounds indicatng the status of eye-hand coordination. The
Wayne Perceptuomotor Pen (see Appendix J), for
example, is a coordination device that gives auditory feedback when inaccurate manual tracking or
pointing occurs (Figure 10-10). With the nonamblyopic eye patched, the patient attempts to trace
curved line figures. For dot targets, the patient performs fast pointing. Many training tasks stimulate
accurate fixation, pursuits, saccades, and eye-hand
coordination. We have found T10.5 techniques to
be most effective when each task is timed, so that
the patient can work on both speed and accuracy.
opic eye sights along a line, makes accurate saccades, and follows it to its end. Initially, the patient
may require a pointer stick to help keep his or her
eye on the line but, as speed and accuracy develop,
only visual tracking s desired. Besides recording
the correct answers, the patient should also record
the completion time for each task. We have discovered that some children enjoy making their own
line mazes. An example of a design of a 9-year-old
patient is shown in Figure 10-11. The child feels a
sense of pride n the designs he or she has made. A
key is made up, and the patient can administer the
test to siblings or friends who do not always fare
well on some of the more elabrate patterns. This
sometimes provides a much-needed ego boost to
the amblyopic child who wears a patch. Groffman's
visual tracing patterns are also available on the
Computer Orthoptics system for in-office reinforcement of this skill.
Ann Arbor Publishers markets some printed materialsthe Ann Arbor Tracking Program, formerly
known as Michigan Trackingthat we have found
to be both motivational and effective in training
visual tracking. The basic task is to find and circle a
key sequence of letters, numbers, words, or symbols
in a large, seemingly random, set of such. The exercise s timed, and progress can be charted. The most
useful workbooks for training amblyopic patients
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297
JtL
298
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299
FIGURE 10-13Hart Chart, large for distant viewing and small for
near viewing. (Courtesy of Bernell Corp.)
magazine, newspaper) s held at a threshold distance from the patient while the patient reads for
meaning and enjoyment. The reading period
should be at least 5 minutes for elementary school
children and 10 minutes for older children and
adults. The goals are to improve the threshold acuity (read the material at farther distances or
progress from large print to small) and to ncrease
the reading time or rate (higher efficiency). This
technique can, however, be fatiguing and frustrating, because people ordinarily read print three
times larger than their threshold size for optimum
reading performance.67
A second reading technique s similar to word
tracking in the Ann Arbor Tracking Program. The
patient uses personally selected reading material
and circles key words (e.g., the, s, are, she, he, f)
or certain letters as they appear n the text. Again,
the material s held at a threshold distance. The
patient attempts each day to increase the number
of key words or letters dentified and circled within
a prescribed time (5 or 10 minutes).
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A tachistoscope is a projection device that flashes targets (letters, numbers, words) at rapid rates of exposure (e.g., 0.1 second or faster). The patient does not
have sufficient time to make a saccadic eye movement from one target to another for recognition
within 0.1 second. The device usually is used by educators to ncrease the span of recognition of poor
readers, but this technique is applicable for amblyopic patients also. The task s usually performed in
the office because of the special equipment required.
Using only the amblyopic eye, the patient attempts to
improve the speed (e.g., from 1.0 second to 0.1 second) and span (e.g., two-letter words to five-letter
words) of recognition and resolution. Targets can be
presented at a threshold size appropriate for the distance. Many educational supply companies market
tachistoscopes, ncluding inexpensive home training
models with a spring-loaded mechanism.
A similar technique involves the use of flash
cards depicting words or pictures of objects. The
therapist briefly shows the patient a flash card, and
the patient attempts to resolve and identify the word
or picture with the amblyopic eye. The cards are initially shown at suprathreshold acuity levis and, as
training progresses, at threshold. The goal s to
increase both the speed of recognition and VA.
Monocular Telescope (T10.12)
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301
302
Chapter10
get (e.g., pointer stick) is used to achieve central
fixation. The goal is for the patient to achieve
foveal fixation quickly without a guide target.
Haidinger Brush
. Haidinger brush
Haidinger Brush
Chapter10
303
letters (achieved by varying the distance) are presented, and more targets are added to the routine.
The goal is improved speed, as inaccuracies tend
to reduce the completion time.
Aftermage
304
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305
PLEOPTICS
Pleoptics s a form of ambiyopia therapy that was
very popular during the 1950s and 1960s but has
since lost much of its attraction. One of the major
appeals of these methods was the use of inverse
rather than direct occlusion. Patients patched the
amblyopic eye for 1 or 2 months before visin
training with pleoptic instruments and during subsequent therapy. Inverse patching was intended to
break the habitual pattern of EF and suppression
that the patient had established. During this patching rgimen, amblyopic patients, seeing with the
nonamblyopic eye, could go about their uves basically unencumbered by poor visin. The disadvan-
306
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Bangerter's Method
In 1953 in Switzerland, Bangerter ntroduced the
term pleoptics, which in its Greek derivation
means "complete sight." 72 Bangerter had been
using a bleaching and light-stimulating method to
treat amblyopia and EF during the 1940s.73 He
believed that EF was caused by a depression of
foveal acuity to a level below peripheral retina!
loci. He speculated that the decreased VA resulted
from a deep suppression scotoma in the strabismic
or anisometropic eye: In an attempt to see more
distinctly when the normal eye is occluded, the
amblyopic patient would select an eccentric point
or rea for fixation. However, subsequent research
has not supported Bangerter's hypothesis on the
etiology of EF. 63 Nonetheless, his therapeutic
methods have produced some mportant results
and inspired the development of other active
amblyopia therapies. The emphasis of his therapy
is to stimulate the development of the foveal light
sense and VA.
Bangerter designed the Pleoptophor (also spelled
Pleoptophore), which can accurately stimulate the
fovea with light. The technique s ntended to
develop the suppressed light sense of a deeply
amblyopic eye. The therapy consists of two phases,
the bleachng phase and the stmulating phase. The
method requires dilation of the amblyopic eye, as
do most pleoptic methods. During the bleaching
phase in the Pleoptophore, a macular "shield" is
placed over the fovea of the amblyopic eye so that
the eccentric point s bleached out with high-intensity light while the fovea is spared. The clinician
directly views the fovea's position and the macular
shield during the bleaching (dazzling) phase to
ensure that this result is effectively achieved. Thus,
the peripheral retina, including the eccenthc point,
is dazzled (.e., relatively desensitized). Next, an
Cppers' Method
In 1956 in Cermany, Cppers took pleoptic methods
a step further. He believed that the priman/ reason for
EF in an amblyopic eye was a shift of "straightahead" localization away from the fovea. The individual fixates with an eccentric point (or rea) because
he or she has a sense of looking straight at the target
with that extrafoveal point. Cppers believed that the
monocular shift in localization occurred secondarily
to the development of ARC in strabismus cases. In
ARC, there is an eccentric point or rea in the strabismic eye that corresponds in visual direction to the
fovea of the dominant eye. He believed that this
same point (or rea) also represented the straightahead direction under monocular conditions (i.e.,
oculocentric zero).62
Cppers developed the Euthyscope by modifying an ophthalmoscope so that the clinician could
bleach an eye while sparing the fovea. in this
respect, the technique is similar to Bangerter's
method on the Pleoptophor. Euthyscopes are not
currently being manufactured. However, a black
spot can be painted on the center of a reticule of a
direct ophthalmoscope to convert t into a simulated Euthyscope. The amblyopic eye is dilated,
and the nonamblyopic eye is occluded. The
peripheral retina, including the EF point, is dazzled as the clinician directly monitors alignment of
the foveal shield (black spot) on the fovea. After
ChapteMO
307
a.
c.
d.
Efficacy of Pleoptics
Availability of pleoptic instruments s limited. General ly, pleoptics s not recommended by most
authorities unless a patient has a large magnitude
of EF (4A or more) and has not responded well to
308
Chapter10
3 2 1 0
234,
opaque mask held before a floodlight with ares cut out for viewing by
the right eye with nasal eccentric fixation. b. Fovea (f) being protected
while point e is dazzled by the are on the right side of the mask.
PATIENT VIEWS
ARC ON RIGHT
SIDE
with pleoptics. If referral sources for pleoptic therapy are not available, we suggest using the custom-made pleoptic instruments and visin training
techniques described in the next section.
ChapteMO
b.
309
40 mm
frosted
L f -------- black
fixation
spot
black
disc
red
fixation
spot
light
bulb
MITT
BINOCULAR THERAPY
FOR AMBLYOPIA
Both antidiplopia mechanisms of ARC and suppression must be considered when binocular training
techniques are ntroduced in amblyopia therapy.
Anomalous Retinal
Correspondence Considerations
In most cases of amblyopia marked by a constant
strabismus and ARC, t does not make good sense
to switch from monocular amblyopia therapy to
binocular training. Frequently, the prognosis for
functional cure of constant strabismus and ARC s
poor, and the excessive training effort may not be
worth the effort to achieve a possible higher quality of binocular visin. ARC, it must be remembered, is a form of binocular visin in which there
is rudimentary peripheral fusin and, sometimes,
gross stereopsis but not central fusin. In such
cases, t seems appropriate to settle for a cure or
improvement of the strabismic amblyopia. The follow-up goal would be to maintain the improved
acuity in the ambiyopic eye over time. Periodic
occiusion of the nonambiyopic eye for a few hours
each month may be all that is necessary for this
purpose. Better yet, f the patient can practice
altrnate fixation, using each eye for fixation at different distances (e.g., with optical penalization),
310
Chapter 10
Antisuppression Techniques
for Amblyopia Therapy
The most effective antisuppression method for a
particular patient depends on the type of amblyopia (strabismic or anisometropic), VA level, and
depth and extent of suppression. More discussion
of specific antisuppression techniques can be
found in Chapter 12. Here we will identify only a
few techniques that we have found to be particularly effective with ambiyopic patients.
When suppression is deep and extensive, vigorous binocular light stimulation may be necessary
to establish the rudiments of binocular visin.
Strong light stimuli for breaking deep suppression
can be introduced by the use of (1) rapid altrnate
flashing (e.g., Alien Translid Binocular Interaction
[TBI] method), (2) a red lens with vertical prism
method, and (3) flashing fusin targets n an
amblyoscope in which the illumination gradient
favors the ambiyopic eye (see Chapter 12). Most
patients, however, do not require these intensities
of light stimulation. Standard instruments and
techniques can usually break suppression and
build fusiona! vergence ranges simultaneously.
We often use Wheatstone mirror stereoscopes
(e.g., Bernell Mirror Stereoscope), Brewster stereoscopes (e.g., Keystone Telebinocular), Tranaglyphs, Brock string and beads, Minivectograms,
and red-green or polarized televisin trainers. At
some point n fusin training of an ambiyopic
patient with the potential for normal fusin, practically all antisuppression methods are applicable
and can be used for variety to build motivation.
For ambiyopic patients, we recommend using the
three antisuppression techniques described next,
because they improve necessary tracking and resolution skills besides breaking suppression. These
techniques are particularly appropriate for anisometropic amblyopes in whom there is normal
fusin potential.
Red Filter and Red Print (T10.21)
Many of the Ann Arbor Tracking Program workbooks are printed in red ink, which makes them
appropriate for antisuppression training. A red filter
or lens is placed in front of the nonamblyopic eye.
(Red-green filter glasses also work well.) The contours of the workbook itself provide the binocula
312
Recommendations
Training
for
Binocular
Chapter10
313
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11,
12.
U.
14.
15.
1.
17.
18.
19.
20.
21.
FIGURE 10-21Psychometric visual acuity of an amblyopic eye before and after visin training. Results are shown on an original clinic chart from the
Southern California College of Optometry.
eye requues
fixation. The patient might simply patch the dom'tnant eye for 30 minutes once weekly while reading, watching televisin, or engaging in other
visual activities. Another approach would be to use
Abstract
314
Chapter10
OS: +4.25 DS
Subjective (dry):
OD: +0.75 DS, 20/20
OS: +4.00 DS, 20/200
Phorometry: suppression OS, no data obtained
far or near Amplitude of accommodation:
OD:7D
Poor response OS
Visuoscopy:
OD: steady central fixation
OS: 4A unsteady nasal and 1A superior fixation with +2A unsteadiness
Oculocentric direction associated with
eccentric point OS
Haidinger brush: OD, steady central fixation;
OS, no brush seen
Fields: full by tangent screen OD, OS full (used
tape to indcate center of the field OS) Amsler
grid: OD, normal; OS, indistinct Color visin:
(Farnsworth panel D-15) normal OD and OS
Tonometry: OD, 15 mm Hg; OS, 14 mm Hg
Impressions and Diagnosis
Mrs. Z can be described as having hyperopic, anisometropic, deep amblyopia and nasal, unsteady
EF of the left eye. There does not appear to be a
strabismus, although it is possible that she has a
small microtropia. There is deep suppression of the
left eye, and no stereopsis was elicited. Ophthalmoscopy, fields, tonometry, and color visin were
all within normal limits, so the eyes appeared
healthy. The visin loss of the left eye is probably
not due to an organic cause. She apparently had
substantial uncorrected hyperopic anisometropia
during early childhood that resulted in a lack of
development of high-frequency resolution chan-
Chapter10
315
316
Chapter10
Binocular Training
Chapter10
317
318
Chapter10
The 20/40 acuity appeared to be stable. No further improvement was expected, and Mrs. Z was
placed on a maintenance program. She read with
a polarized reading bar 30 minutes per day. She
was rescheduled for a progress check n 1 month.
At that progress check, there was no change n
her visual status, and she continued to be pleased
with the results. She was asked to continu to use
the reading bar approximately twice weekly for
the next 3 months, at which time another progress
check was completed. As a regular maintenance
and monitoring program, Mrs. Z agreed to use the
reading bar once weekly indefinitely. If she
noticed suppression or reduced resolution of the
left eye, she was nstructed to return for testing.
She was seen again in 6 months and, because
there was no deterioration in acuity or visual
skills, she was then placed on a yearly recall
schedule.
Unaided VA at 6 m:
OD 20/20; OS 20/200
Dry retinoscopy:
OD +3.50 DS; OS +5.00 DS
Dry subjective:
OD +1.25 DS, 20/20; OS +4.50 DS, 20/200
Wet retinoscopy:
OD +4.00 20/20; OS +6.00
20/60 Snellen; 20/68
Flom psychometric S-chart acuity
Cover test: constant, comitant, unilateral, left
esotropa of 20A at 6 m and 40 cm (without lenses)
Pursuits (4+ scale): OD 4+; OS 2+ Saccades
(4+ scale): OD 4+; OS 2+ Visuoscopy:
OD: central steady fixation OS:
central unsteady fixation
Correspondence testing:
Bagolini: suggests harmonious ARC HeringBielschowsky: unreliable results Major
amblyoscope: suggests NRC; angle H = 20A
base-out and angle S = 20A base-out Sensory
fusin:
Rendeer test: 150 seconds of are Amblyoscope:
suppression with second-degree targets Worth
dottest: unreliable results
Chapter10
Diagnosis
319
320
Chapter10
reader was performed to check on nearpoint suppression. For home training, patching was discontinuad, but monocular eye-hand coordinaron
activities were performed. Vergence training and
antisuppression home techniques included the
Lifesaver cards, the E series of Biopter cards, and
cheiroscopic tracings.
Final Results
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23. Ludlam WM. Orthoptic treatment of Strabismus: a study
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24. Flom MC. The prognosis n Strabismus. Am J Optom Arch
Am Acad Optom. 1958;35:509-516.
25. Shippman S. Video games and amblyopia treatment. Am
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26. Leyman IR. A comparative study in the treatment of
amblyopia. Am OrthoptJ. 1978;28:95-99.
27. von Noorden GK, Romano P, Parks M, Springer F. Home
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28. Frangois J, James M. Comparative study of amblyopic
treatment. Am OrthoptJ. 195 5; 5:61 -64.
29. Sen DK. Results of treatment of anisohypermetropic amblyo
pia without Strabismus. BrJ Ophthalmol. 1982;66:680-684.
30. Mitchell DE, Howell ER, Keith CG. The effect of minimal
occlusion therapy on binocular visual functions in ambly
opia. Invest Ophthalmol Vis Sci. 1983;24:778.
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31. Leguire LE, Rogers GL, Bremer DL. Amblyopia: the nor
mal eye is not normal. J Pediatr Ophthalmol Strabismus.
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33. Gauthier CA, Molden BA, GrantT, Chong MS. Interest of
presbyopes in contad lens correction and their success
with monovision. OptomVisSci. 1992;69:858-862.
34. von Noorden GK, Attiah F. Alternating penalizaron in the
prevention of amblyopia reoccurrence. AmJ Ophthalmol.
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35. Manny R, Jaanus SD. Cycloplegics. In: CHnical Ocular Pharmacology. Boston: Butterworth-Heinemann; 2001:154.
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37. Repka MX, Gallin PF, Scholz RT, Guyton DL. Determination of optical penalizaron by vectographic fixation
reversal. Ophthalmology. 1985;92:1584-1586.
38. Simons K, Gotzler KC, Vtale S. Penalization versus parttime occiusion and binocular outcome in treatment of strabismic amblyopia. Ophthalmology. 1997; 104:2156-2160.
39. Simons K, Stein L, Sener EC, et al. Fusional movements
revisited. Ophthalmology. 1998;105:1349-1351.
40. von Noorden GK, Milam JB. Penalization in the treatment
of amblyopia. Am J Ophthalmol. 1979;88:511-518.
41. Ron A, Nawratzki I. Penalization treatment of amblyopia:
a follow-up study of two years n older children. J Pedatr
Ophthalmol Strabismus. 1982; 19:137-139.
42. Repka MX, Ray JM. The efficacy of optical and pharmacological penalization. Ophthalmology. 1993;100:769-773.
43. Paris V. An alternative treatment for amblyopic Strabismus:
optical penalization. Bull Soc Belge Ophtalmol. 2000;
276:31-40.
44. France TD, France LW. Optical penalization can improve
visin after occiusion treatment. JAAPOS. 1999;3:341-343.
45. Chatzistefenou Kl, Mills MD. The role of drug treatment n
children with Strabismus and amblyopia. Pediatr Drugs.
2000;2:91-100.
46. PorciattiV, Schiavi C, Benedetti P, etal. Cytidine-5'-diphosphocholine improves visual acuity, contrast sensitivity and
visually evoked potentials of amblyopic subjects. Curr Eye
Res. 1998;17:141-148.
47. Gottlob I, Wizov SS, Reinecke RD. Visual acuities and
scotomas after 3 weeks' levodopa administration in adult
amblyopia. Graefes Arch Clin Exp Ophthalmol. 1995;
233:407-413.
48. Mohn K, Khanker V, Sarma A. Visual acuities after
levodopa administration in amblyopia. J Pedatr Ophthal
mol Strabismus. 2001 ;38:62-67.
49. Leguire LE, Rogers GL, Walson PD, et al. Occiusion and
levodopa-carbidopa treatment for childhood amblyopia.
J AAPOS. 1998;2:257-264.
50. Procianoy E, Fuchs FD, Procianoy L, Procianoy F. The
effect of increasing doses of levodopa on children with
strabismic amblyopia. J AAPOS. 1999;3:337-340.
51. Brinker WR, Katz SL. A new and practica! treatment of
eccentric fixation. Am J Ophthalmol. 1963;55:10331035.
52. Binder HF, Engel D, Ede ML, Loon L. The red filter treat
ment of eccentric fixation. Am Orthopt J. 1963;13:6469.
321
Therapy Precautions
323
Sensory and Motor Therapy
Approaches
324 Occlusion
Procedures
325 Constan! Total
Occlusion
325 Binasal Occlusion
325 Graded Occlusion Method
of Revell
326 Optical Therapy
327
Prism Overcorrection
327 Ludlam's
Method
328 Major Amblyoscope
328 Classic Amblyoscopic Techniques
329 Flashing Targets at the Objective Angle
(T11.1)
329 Macular Massage (T11.2)
331 Vertical Displacement of Targets
(T11.3)
331 Altrnate Fixation (T11.4)
331 Entoptic Tags (T11.5)
332 Open
Space Training with
an Amblyoscope (T11.6)
333
Divergence Technique for Esotropa
(Flom Swing) (T11.7)
333
Training in the Open Environment
336
Correspondence (T11.13)
340
binocular visin specialist. Many of the most effective techniques require the use of a major amblyoscope or other special instruments not ordinarily
found in a primary care practice. Most techniques
demand much concentration and effort by both
doctor and patient, which also transales into time
and money. In some cases, patients experience
severe eyestrain during therapy, and prolonged
double visin may be the sol outcome. The benefits of normal binocular visin to the patient must
be weighed against all these and other negative
factors. Patients or parents must be aware of the
costs and potential dangers before undertaking
specific therapy for ARC. The doctor and patient
324
Chapter 11
Chapter11
eye movements to straighten the eyes, thus stimulating covariation whereby ARC changes to NRC.
(See Chapter 5 for a more detailed discussion of
these theories.)
We believe that both the sensory and motor theories are, n part, correct. The nature of ARC is not
well understood at this time. In a particular patient,
one or both mechanisms may be factors in the etiology of ARC and strabismus. We will, therefore,
discuss rehabilitation regimens based on both
these approaches and suggest when one may be
more clinically appropriate than the other.
Before ARC therapy begins, amblyopia, if present,
should be treated (see Chapter 10). Even though
treatment is hampered by the patient's lack of 20/20
(6/6) visual acuity in each eye, it may be necessary to
begin binocular treatment despite reduced acuity of
an eye. At least 20/60 (6/18) acuity should be
achieved before proceeding with ARC therapy. As
discussed n Chapter 10, many patients show further
improvement in visual acuity of the amblyopic eye as
a result of appropriate binocular training.
Good monocular skills (saccades, pursuits, fixation, and accommodation) should be developed in
each eye before binocular treatment of ARC is initiated. Once monocular acuity and motility
approach normal levis of performance, therapy
for ARC s introduced, which may involve occlusion, lenses and prisms, instrument training, training in open space, and extraocular msete surgery.
OCCLUSION PROCEDURES
The purpose of occlusion in ARC therapy is to dislupt habitual ARC localizaron and prevent its reinforcement. Additional benefits of occlusion n
cases of strabismus include breaking suppression
and treating amblyopia. The method and schedule
of occlusion selected for a patient depends on the
age of the patient, the characteristics of the condibon, and several practical considerations.
325
Binasal Occlusion
Binasal occlusion is advocated by some clinicians
for the prevention and treatment of ARC associated
with esotropa. Opaque strps of tape are cut to
conform to the nasal reas of the patient's spectacle lenses. The tape can be tapered slightly to
allow for convergence at the nearpoint (Figure
11-1). As a criterion for placement of the tape on
the spectacle lens, Greenwald 11 recommended
that "there be a visible pupillary reflex n both
eyes, just beyond the edge of each tape while the
patent fixates a near and far muscle light" (see Figure
11-1a and 11-1b). Greenwald11 contended that if
the objective angle of deviation is reduced as a
result of wearing the binasal occluders, the prognosis for functional cure s fair to good. However,
if angle H increases, ". . . either eye being 'thrust'
behind the tape (so as to avod simultaneous
awareness) . . .," the prognosis is poor.11
We recommend binasal occlusion in some
cases of esotropa and ARC, especially for chldren younger than 7 years. The purpose of the
method is to promote altrnate monocular fixation while preventng bifoveal stimulation. Ths
approach promotes equal visual acuty and full
abduction of each eye and, possibly, breaks down
ARC. The patient will tend to use the right eye to
326
a.
ChapteMI
RET
Lett Eye
Fixating
forms of occiusion, frequent office visits are recommended to ensure proper application and to
evalate effectiveness.
Graded Occiusion
Method of Revell
c.
Right Eye
Fixating
Chapter11
327
FIGURE 11-2Cutting membrane prism (Fresnel) for appl catin to a spectacle lens. (Courtesy
of Bernell Corp.)
ORTIGAL THERAPY
Prism overcorrection of the deviation and Ludlam's
method are consistent with the sensory adaptation
theory of ARC. These procedures work best with
younger patients and attempt to disrupt ARC localization while stimulating a latent NRC localization
system.
Prism Overcorrection
Several practitioners recommend using prism
overcorrection in the treatment of ARC. 3-14"17
(Figure 11 -2 shows the shaping of a Fresnel membrane prism for appl catin to the back surface of
a spectacle lens.) This approach is most effective
with patients younger than 16 years. The idea s
to disrupt ARC adaptation by inducing diplopia.
In some cases when diplopia occurs, the latent
NRC localization manifests itself. The great
advantage of this method, if it is successful, is
that little of the doctor's time and limited patient
effort are required. The major disadvantage is
cosmetic acceptance. To an observer, the strabismus appears to be a larger deviation than was
apparent before prism application. Also, some
patients cannot tolrate diplopia during the initial
stage of therapy.
Ludlam's Method
Ludlam18 suggested a randomized approach for disruption of ARC by optical means, sometimes called
the rockum sockum method. He stated that a stable,
full correction of hyperopia is not advisable n cases
of esotropa with ARC, as this may allow ARC to
become more embedded. With undercorrection of
hyperopia, the angle of deviation would necessarily
be more variable because of the accommodative
convergence. Whether the full refractive correction
is worn, Ludlam18 contended that various combinations of lenses or prisms should be worn during the
ntervals between office training visits. For instance,
one day the patient might wear a 20 A base-out
prism over the left eye, the next day a 20A base-in
prism, then a 20A base-up prism, and so on. Fresnel
prisms are ideal for this purpose. Also, various
lenses may be used (e.g., a minus-lens add over one
eye one day and over the other eye on the following
day). The same sort of randomized wearing of pluslens adds can be applied.
MAJOR AMBLYOSCOPE
According to the sensory adaptation theory, there
s less chance of ARC responses when testing is
conducted n a reduced (i.e., less natural) environment as opposed to the open (i.e., more natural)
environment. This observation offers support for
beginning ARC training in closed-space Instruments. Although many nstruments and devices
can be used, the major amblyoscope is the best
single instrument for this purpose. Normal binocular localizaron s trained first in a controlled visual
environment using a variety of techniques, and
then the learned visual skills are transferred into
open space.
The amblyoscope was originally designed a century ago by Claud Worth, primarily for the orthoptic
treatment of strabismus.19 Amblyoscopic techniques
for attacking ARC and promoting NRC that have
evolved over the years have come to be known as
the classic method of ARC treatment Classic techniques attempt to elicit bifoveal NRC localizaron
by stimulating the latent NRC system. Amblyoscopic targets are directed to the fovea of each eye
and are flashed to stimulate NRC. The length of time
that a patient has had strabismus of early onset s a
key element in the depth of ARC adaptation. Likewise, a key element in rehabilitating NRC is the
amount of time involved in bifoveal stimulation.
Most of the amblyoscopic techniques represent variations on the theme of intensive bifoveal stimulation. When the patient is not being treated with the
amblyoscope, one eye is constantly patched or the
patient wears prisms or lenses designed to disrupt
ARC. Classic methods are also applcable for the
constant exotrope with ARC.
There are numerous combinations of techniques
involving real images, Haidinger brushes (HBs), and
Chapter11
Ais. Synoptophores (see Appendix J for manufacturer nformation for products given n this chapter),
as well as other modern major amblyoscopes, are
equipped with attachments to make tnese auxiliary
techniques possible. Table 11-1 lists amblyoscopic
techniques discussed later n this chapter. We have
no rigid sequence of training when dealing with
ARC; however, it s best to begin with conditions in
which an NRC response can be elicited. Some techniques are limited by the patient's immaturity, poor
cooperation, or lack of perceptual awareness. The
doctor may, therefore, be limited to using the simpler methods and must begin training with these.
329
classic techniques on an amblyoscope, it s common for ARC therapy to take between 3 and 6
months of concentrated effort by doctor and patient.
Chapter11
330
-O
IT^"
^^~~~~- point a
1
1
1
HARC
_J
NRC
Percepts:
1.
2.
3.
<.
4.
FIGURE 11 -3Flashing targets at the objective angles (TU .1). The duality of correspondence is shown in stages of visin training. (ARC = anomalous retinal correspondence; f = fovea; HARC = harmonious anomalous
retinal correspondence; NRC = normal retinal correspondence.)
Chapter11
331
332
Chapter11
EntopticTags(T11.5)
Consistent with the adaptation theory of ARC is the
observation that NRC is present if there are no contours in the visual field, as NRC is innate. This phenomenon can provide a starting point in treatment
of ARC in the open environment, which is filled
with complex contours. Most major amblyoscopes
come supplied with slides and flash units that can
genrate Ais. Slides S3, a horizontal streak, and S4,
a vertical streak, are used in the Synoptophore.
Each has a central red fixation mark. As with the
Hering-Bielschowsky test (see Chapter 5), it is customary to flash the dominant eye first with the horizontal streak and then to flash the nondominant
eye with the vertical streak. With the older instruments, the opal diffusing screen should be
removed from the optical pathway when each eye
is flashed, providing a much stronger Al than
would otherwise be generated. Most new instruments have an Al mode with intensified illumination, so that removal of the diffusing screen is
unnecessary. The background illumination in the
Synoptophore is kept low enough so that the Ais
are not washed out. The Ais are sustained by an
automatic background flashing feature of the
instrument. The timing of light and dark phases and
the speed of flashing can be adjusted conveniently
as des i red.
Positive Ais are considered less natural than negative; therefore, NRC is more likely to be elicited
when positive Ais are seen. To see these, long dark
phases should be emphasized initially. If the patient
can see a perfect cross with the positive Ais, the dark
phase can be shortened, and the negative Al can be
made visible more of the time. It is not unusual for
the patient to report seeing a cross (NRC) in the dark
phase but a noncross (ARC) in the light phase. In
such a case, various adjustments of the automatic
flashing unit may help in developing a cross response
with negative Ais. The goal is for the patient to
achieve a perfect cross while both eyes are being
flashed simultaneously, indicating NRC.
Once NRC with Ais can be achieved, real
images may be incorporated into the training. The
traditional slides used initially in this technique are
a ring and a dot. The amblyoscope arms are adj usted
to the angle of deviation, al I targets are removed,
and the Ais are properly applied. The patient must
see a perfect cross of the Ais. In the case of left
esotropa, a dot is presented to the left eye as the
patient tries to continu seeing a perfect cross,
which would indcate that NRC is maintained. If
Chapter 11
CURE 11-4Esotropa of the left eye with anomalous retinal corre(ARC) with the amblyoscope set at angle H. a. Noncross i
horizontal afterimage seen by the right eye and the vertical
after-by the left eye. b. A normal retinal correspondence
(NRC) may occur because of the relative unnaturalness of
the after-s. c. Real targets (dot and ring) are seen
separated, indicating ~or more natural targets but NRC for
less natural targets (afterim-i. d. Goal n training is superimposition
of real targets and afterim-L Caution n interpretation is
required f the setting of the cope is at angle 5 rather than
angle H.
333
attempts to superimpose the HB and the Al. Flashing the nstrument lights, either manually or by
various settings of the automatic unit, may help the
patient to achieve superimposition. When this s
accomplished, a real target (dot, circle, square, or
any suitable line drawing on a clear sude) is placed
n the tube, and the nondominant eye fixates on t.
If superimposition of this combination can be
maintained, another real target is presented to the
dominant eye. Ideally, superimposition of the two
real images should occur, in conjunction with the
superimposed HB and the vertical Al. (This technique requires central fixation in each eye.) These
foveal tags are excellent monitors of the state of
correspondence. Many different combinations are
possible. It is good to try a number of combinations on each patient, because some might be very
effective n helping the patient to break ARC,
whereas others may be much less effective.
334
Chapter11
patients. When the eyes are in the strabismic position, ARC exists, but when the patient makes a
fusional vergence eye movement and straightens the
eyes, covariation resulte in NRC. The essence of the
divergence technique with the amblyoscope for
small-angle esotropes is to establish ARC fusin at the
subjective angle and then slowly to diverge the eyes
through the angle of deviation, using fusional divergence demands, until the eyes are physically straight.
The patient then is taken out of the instrument while
concentrating on holding the eyes straight in the
ortho position. It is hoped that the patient will covary
to NRC in open space as the eyes are straight. If he or
she does covary, the patient temporarily becomes
nonstrabismic, shows NRC localization, and experiences a dramatic awareness of stereopsis in the open
environment. One of the virtues of the divergence
technique is that if it is going to work with a patient, it
works relatively quickly. The training program takes
only a few weeks instead of the months necessary for
classic methods.
Only certain esotropic patients qualify for the
divergence technique. Table 11-3 lists the qualification criteria we recommend. Besides having
comitant deviations, good acuity, and HARC,
patients should be older (teenagers or adults)
because the technique requires much concentrated effort and usually is associated with visual
O O
FIGURE 11-5Flom swing technique (T11.7). a. Esotropa of the left
eye with anomalous retinal correspondence (ARC) in the major
amblyoscope. The instrument s set for angle 5. b. Sufficient base-in
demand s introduced to crate sufficient divergence so that angle S
becomes exo and angle H becomes zero. ARC remains, because
superimposition s with points a and f(fovea). c. Ratient views objects
n the open environment, attempting normal retinal correspondence
while the eyes are held in the ortho position. (NRC = normal retinal
correspondence.)
discomfort, Patients should have an angle of deviation of 20A or less. We have found this magnitude
to be the approximate training limit for divergence.
Patients who match this clinical profile have the
best chance for functional cure of strabismus.
The divergence technique proceeds as follows
(Figure 11 -5): After the patient's angles H and 5 have
Chapter11
-------------------- >^0~"
Q-a'A
ctes&qrcjW'rTp -~-
335
336
Chapter11
TRAINING IN THE
OPEN ENVIRONMENT
Although ARC training in cases of esotropa can be
performed in the open environment, we believe it
is generally a good rule to break ARC using the
major amblyoscope before free-space techniques
are introduced. Some practitioners prefer that
Chapter11
According to this technique, the patient tries to
maintain binocular luster (indicating NRC) while
targets are introduced at the edge of the peripheral
visual field. Placing targets initially n a superior
quadrant seems to work best. If a split-field
response results, the object is removed from the
patient's view, and he or she is instructed to perceive luster in the formless field as previously. The
process of slowly introducing an object into the
periphery is repeated until the patient is able to
maintain luster as the object approaches the centration point. When objects are placed in the central visual field, there is a strong tendency to elicit
a split-field response. At first, it may be necessary
to "overplus" the patient in relation to the fixation
distance of the screen. A blurred image may promote luster better than clear, distinct contours. This
training process is repeated until the patient is able
to maintain the perception of luster when a small
target (such as a black dot) and, later, complex targets are centrally fixated.
With the appropriate addition lenses in place,
fusin training can proceed at the centration
point. Theoretically, the patient has sensory orthophoria in relation to the fixated target; normal
color fusin is indicated if the patient continually
notices luster. There is no assurance, however,
that central fusin is actually being developed. It
may well be that only peripheral fusin exists at
this stage of treatment. Consequently, the luster
method can be refined by projecting small red
and green targets on the screen to monitor for
central suppression.
Motor fusin training can be started once normal central sensory fusin is demonstrated. Only
small amounts of vergence demand are introduced
at first, because the patient's ability to maintain
NRC is very tenuous; an ARC response is likely to
recur with any change n sensory or motor fusin
stimulation. The best way to induce vergence eye
movements is to have the patient move slowly
back and forth (only a few centimeters at first) from
the screen while attempting to maintain fusin of
the target. Peripheral fusin targets (e.g., large
Brock red and green rings) may be required initially but, eventually, the patient should be able to
fuse small targets while he or she is moving back
and forth. Sensory and motor fusin training contines until the patient has developed the maximal
range of motor fusin under these conditions.
In combination with the binocular luster technique, Ludlam18 recommended using the rockum
337
Afterimages at the
Centration Point (T11.9)
The technique of using Ais at the centration point
is similar to the open-space luster technique
(T11.8). The Hering-Bielschowsky test is the recommended procedure for generating Ais (see Figures 5-40 through 5-44). First, positive Al training
is provided in dim room illumination, and then the
patient is trained with negative Ais in normal lighting conditions. This s similar to training in the Synoptophore, except that the patient views the Ais n
open space. The first goal is to have the patient
perceive a perfect cross for both the positive Al and
the negative Al. With a centration-point add n
place, the esotropic patient initially views a blank
field at the centration point while trying to hold a
perfect Al cross (NRC) n perception. If NRC occurs
under blank field conditions, then targets and real
objects are moved toward the centration point as
the patient attempts to maintain NRC localizaron.
The final goal with this technique is for the patient
to hold a perfect Al cross while bifixating a variety
of targets at the centration point.
Hugonnier et al.23 recommended a free-space
training technique called direct attack at the objective angle in space (Figure 11-7). A target such as a
pencil point is placed at the centration point, and the
patient attempts to see a Hering-Bielschowsky cross
superimposed on the tip of the pencil. This picture is
an ndication of NRC, but the unilateral cover test
should be performed, because the Al might be seen
with NRC while the pencil tip is seen with ARC. A
movement of the uncovered eye on the unilateral
cover test would indcate ARC. In this eventuality, a
higher plus add and a closer training distance should
be attempted. Bagolini lenses can be used for further
training (see Figure 11 -7c and 11 -7d).
Other Combinations
Many combinations of techniques can be used in
cases of ARC. Real images may be provided by targets such as black dots, anaglyphs, vectographic
targets, and a penlight. These may be used together
with entoptic phenomena or Ais. Only a few repre-
338
Chapter 11
O.S.
O.D.
. PENCIL
Chapter 11
point a
339
point a
FIGURE 11 -8Bagolini striated lenses and prisms for treatment of anomalous retinal correspondence (ARC). a. Harmonious ARC response. b. ARC
response with compensating prism. c. Only one light seen because of foveal suppression of the left eye. d. Normal retinal correspondence response
after ARC has been eliminated and angle of strabismus has been fully compensated by prism. (f = fovea.)
ARC (see Figure 11 -7). Because most cases of strabismus with ARC show HARC on the Bagolini
lenses, the patient sees, as though orthophoric,
response with the light centered in the X (angle 5 =
0) (Figure 11-8a). If the full compensating base-out
prism is worn, the image of the light is now on the
340
Chapter11
Theoretical Considerations
Exotropia is generally much easier to cure, regardless of the state of correspondence. The prognosis
is better because the age of onset tends to be later
for exotropia than for esotropa, and thus the re-education of fusin s easier. Normal fusin had the
opportunity to develop early in many of these patients,
before the onset of strabismus. More mportantly, most
exotropias are intermittent (as compared with
esotropa, which tends to be constant); ARC is also
intermittent because of covariaton. When the eyes
are straght, the patent s fusing with NRC. Covariation is consistent with Morgan's motor theory of
ARC and seems to be independent of the magnitude of exotropia. Training to elimnate ARC in
exotropia is, therefore, a form of motor fusin
training. Consequently, sensory training specifically for eliminating ARC can usually be bypassed
in exotropes, with the exception of some cases of
constant exotropia.
Chapter11
should be sensitizad to changes in convergence
using accommodative convergence. Several sessions of training may be necessary for this sensitization phase, to allow development of the patient's
awareness of convergence eye movements, an
important source of feedback.
The next step s to apply Hering-Bielschowsky
Ais to provide visual feedback when covariation is
occurring. The Ais will appear uncrossed or displaced (ARC) when the eyes are in the exotropic
position. When fusional convergence is stimulated
during the next step in the technique, the patient
will see the Ais joining together to become a perfect cross (NRC) as the eyes move toward bifoveal
alignment on a nearpoint target. This visual feedback is a strong incentive for the patient to continu exerting fusional convergence.
The final phase in this technique s to stimulate
accommodative convergence sufficiently n the
attempt to trigger a fusional (disparity) convergence
response. Merely stimulating accommodative convergence with minus adds cannot be expected to
result in a shift of correspondence, 7 but it may
recruit a fusional vergence eye movement that is
associated with covariation. For example, assume
that a 12-year-old boy has a comitant, constant,
alternating exotropia of 40 A at far and near with
HARC. With visin training, the patient is aware of
eye movements, particularly accommodative convergence, but he cannot yet fuse intermittently at
near. Hering-Bielschowsky Ais are applied and
appear uncrossed (ARC). A -2.00-D add is placed
before the patient's glasses (using Halberg clips) to
reduce the angle of deviation and provide a stimulus to accommodation. With the minus add n
place, the resultant deviation is 30A exotropia. The
patient s asked to look far away and cise his eyes.
A small, detailed, colorful target (e.g., a sticker on a
stick) s held just beyond the patient's nearpoint of
accommodation. He s asked to open his eyes,
focus rapidly on the target, and to try to "pul the
eyes together." This s done while sensing the crossng of the eyes (kinesthetic feedback) and joining
the Ais (visual feedback). Similar to a personal exercise trainer, the therapist gives strong verbal encouragement and feedback about performance, whether
or not there is alignment of the eyes.
On the first few attempts, convergence may be
inadequate. The goal is for the patient to increase
convergence until the Ais join. As the training proceeds, different nearpoint targets are used for the
sake of variety. The technique is practiced at home
342
Chapter11
CASE MANAGEMENT
When considering treatment of constant strabismus associated with ARC, the question must be
raised: "What is the price and the chance of successfully training normal binocular visin?" Clinicians and patients valu this goal differently, and
there is nothing approaching a consensus of opinin. In their extensive review of the literature, Wick
and Cook 22 estimated that approximately 50% of
esotropic patients having ARC can be expected to
achieve normal binocular visin, provided that
sufficient time (up to 12 months) is devoted to reeducation. On the basis of our experience, we do
not prescribe visin therapy when we believe that
we cannot achieve cure (using all therapeutic
approaches including surgery) within a year in a
strabismic patient with ARC. We often accept
patients, however, for 10 training sessions, to verify
the prognosis and assess the patient's responses to
active therapy. This is called diagnostic therapy.
If possible, we prefer to treat ARC by stimulating
covariation. The fusional vergence mechanism of
shifting ARC to NRC often is applicable in exotropia up to 50A and esotropa of 20A or less. For
exotropia, the gross convergence technique n
open space (T11.13) and the Flom swing technique (T11.7) in an amblyoscope can both be
used. In cases of exotropia, the Flom swing technique is applied to genrate convergent eye movements rather than divergence. For small-angle
esotropes who qualify for this method, Flom's
divergence technique offers a fair chance for success within a reasonable period. Once the patient
has learned to covary and use this mechanism
when straightening the eyes, the diverging ability
seems to be permanent. Surgery, however, is sometimes necessary to reduce the magnitude of the
deviation. Regression is prevented by assigning
retainer vergence exercises on a regular schedule.
(Refer to Chapters 13 and 14.)
Besides access to a major amblyoscope, the successful application of classic techniques requires
that the practitioner have considerable ski 11 in managing children over a period of several months. The
techniques are not inherently entertaining. Regular
amblyoscopic training, three to five sessions per
week, is time-intensive and, therefore, expensive.
Because we see similar or better rates of success in
normalizing correspondence by simply prescribing
prism overcorrection, this is our preferred initial
approach with preschool and elementary school
children. Often the prism spectacles are not acceptable for full-time wear, particularly at school, so the
patient is given constant occlusion during school
hours and is instructed to wear the prism spectacles
Chapter11
CASE EXAMPLES
343
worn for 10 minutes and resulted n an eso movement on the altrnate cover test: Prism adaptation
had occurred. The procedure was repeated with a
total of 50A base-out prism with the same result as
before. When a total of 60 A was worn for 30 minutes, there was no eso movement on the cover test.
The patient then was instructed to wear the overcorrecting prism spectacles for 30 minutes per day
while performing active visual tasks. At all other
waking hours, the patient wore a patch on an alternating daily schedule.
After 2 weeks, the patient again showed an eso
movement with the altrnate cover test. A total of
80A base-out prism was prescribed for daily wear
of 30 minutes each day along with patch i ng. After
1 month, there was an exo movement on the cover
test. The Fresnel base-out prism power was
reduced to 70A, and the same rgimen as was used
previously was carried out. After 2 months, NRC
was found with the major amblyoscope (angles H
and Sapproximately 40A).
At this juncture, the second phase of the therapy
was initiated. Overcorrecting prism of 60A was prescribed for 30 minutes per day, with constant
patching at all other times. In-office training techniques began with peripheral first-degree and second-degree targets on an amblyoscope and
sensory and motor fusin training at the centration
point. Home training included monocular pencil
saccades and accommodative facility training with
Hart Charts. With training, the fusional vergence
amplitudes increased to 30 A base-out and 15A
base-in from the objective angle, but the patient
was unable to appreciate stereopsis, although she
did report SILO ("small-in" with base-out prisms
and "large-out" with base-in prisms). Fusional vergence training around the objective angle continued n the open environment usingVectograms.
After a total of 36 office visits, the diagnosis was
comitant, constant, alternating esotropa of 30A at
6 m and 40 cm; there was NRC and a large
fusional divergence range. At this point, the patient
was referred to an ophthalmologist for extraocular
muscle surgery. The operation conssted of a 5.5mm bimedial rectus recession. Postoperatively, a
monofixaton pattern of the right eye was ndicated
by the unilateral cover test and the 4A base-out test
at far. A small right eso flick was seen on the unilateral cover test, with the paradoxical finding of 10 A
base-in on the altrnate cover test (i.e., presence of
an exo deviation during dissociation). Suppression
of the right eye was ndicated with the 4A base-out
344
Chapter11
test. However, 2A of esophoria was found at the 40cm fixation distance. Amb/yoscope testing indicated NRC, but stereopsis was not found with
either the Reindeer or Randot tests.
Ten weekly office training visits followed the
postoperative evaluation. Vision training was done
with Vectograms and stereoscopes to attempt to
break central suppression and increase fusiona! vergence ranges. Although vergences were strengthened with training, there was still no stereopsis; the
4A base-out prism test revealed a small central suppression zone of the right eye. Subsequently, the
exo deviation on altrnate cover test decreased and
the esophoria at near ncreased to 8A. Plus adds
were prescribed in the form of bifocal lenses:
presson on the red-green televisin trainer. Extraocular muscle surgery reduced the deviation to 20A, after
which the patient became exophoric. Postoperative
visin therapy consisted of base-out training with the
televisin trainer, single Aperture-Rule Trainer, and
various chiastopic fusin techniques (see Chapters
12, 14, and 18). The patient had no symptoms, and
all visual functions normalized.
The mportant point of this case s that although
ARC may be present when exotropia is manifest,
NRC may be found when the eyes are in the ortho
position.
O D :+ 0. 5 0- 1 . 0 0 x 17 0
OS: +0.50 -1.25 x 010 with +2.50 adds
Case 2: Stimulating
Covariation in Constant Exotropia
Wick35 presented a detailed case report of a 13year-old patient with constant, alternating exotropia
of 45A and HARC on all tests. Constant occlusion
was prescribed between training sessions (both
in-office and home). He used a variation of the
gross convergence technique (T11.13) to stimulate
fusin at near and covariation to NRC. Minus
2.00-D adds were worn to induce convergence at
far. Ais were used so that correspondence could be
monitored during forced convergence at near. The
minus additions were not used at near. The PolaMirror (see Chapter 12) was included so that suppression could be monitored during convergence
while the patient maintained a perfect Al cross. The
patient was able to achieve this goal after 2 weeks
of visin therapy.
Red-green televisin antisuppression training then
was perforrned in conjunction with Ais at far, using
the -2.00-D addition lenses. After 3 weeks, the
patient was able to achieve an Al cross without sup-
Chapter11
345
REFERENCES
1. Bielschowsky A. Lectures on Motor Anomalies. Hanover,
N.H.: Dartmouth College Publications, 1943:72.
346
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Chapter11
Flom MC. The empirical longitudinal horopter in anomalous correspondence. Doctoral thesis, University of Cali
fornia, Berkeley, 1953.
Caloroso EE, Rouse MW. Clin cal Management o Strabismus. Stoneham, Mass.: Butterworth-Heinemann; 1993:
117-118,162-163,209,213.
von Noorden GK. Binocular Vision and Ocular Motility.
Theory and Management of Strabsmus, 5th ed. St. Louis:
Mosby; 1996:255.
Wong AM, Lueder GT, Burkhalter A, Tychsen L. Anomalous retinal correspondence: neuroanatomic mechanism
in strabismic monkeys and clinical findings in strabismic
children. J AAPOS. 2000;4:168-1 74.
Morgan MW. Anomalous correspondence interpreted as
a motor phenomenon. Am J Optom. 1961;38:131-148.
Kerr KE. Instability of anomalous retinal correspondence.
Am Optom Assoc. 1968;39:1107-1108.
Cook D. Considering the ocular motor system in the treatment of anomalous ret nal correspondence. J Am Optom
Assoc. 1984;55:109-117.
Kerr KE. Anomalous correspondencethe cause or consequence of strabismus? Optom Vis Sci. 1998;75:17-22.
Folk ER. Treatment of Strabismus. Springfield, lll.: Charles
C.Thomas; 1965:72.
Greenwald I. Re-evaluation of binasal occlusion. Optom
Weekly. 1974;65:21-22.
Revell MJ. Anomalous retinal correspondence: a refractive treatment. Ophthalmic Optician. 1971 ;2:110-112.
Bagolini B. Sensorial anomalies in strabismus (suppression, anomalous correspondence, amblyopia). Doc Ophthalmol. 1976;41:1-22.
Berard PV. The Use of Prisms in the Pre- and Post-Operative
Treatment of Deviation in Comitant Squint. In: Proceedings
of the First Congress of the International Strabismological
Association, Acapulco, Mxico. Fells P, ed. St. Louis: Mosby;
1971:227-234.
Fleming A, Pigassou R, Garipuy J. Adaptation of a method
of prismatic overcorrection for testing strabismus in chil
dren one and two years od. J Pediatr Ophthalmol. 1973;
10:154-159.
Amigo G. Present trends in orthoptics and pleoptics in
Giessen. Am] Optom. 1970;47:713.
Arruga A. The Use of Space Diagnostic Methods and of
Prismotherapy in the Treatment of Sensory Alterations of
Convergent Squint. In: The First International Congress
of Orthoptists. St. Louis: Mosby; 1968:62-76.
Ludlam WM. Lecture at San Jos Vision Training Seminar,
San Jos, Calif., 1970.
Revell, MJ. Strabismus: A History of Orthoptic Techniques. London: Barrie & Jenkins; 1971:30-36.
Wick B. Visual therapy for small angle esotropa. Am ]
Optom Physiol Opt. 1974;51:490-496.
Counting 358
Coloring and Drawing 358
Point-to-Point Chasing 358
Tracing 358
Modified Remy Separator (T12.6) 359
Brock String and Beads (T12.7) 359
Televisin Trainers (T12.8) 361 PolaMirror (T12.9) 362 ReadingBars (T12.10)
362 Management Considerations 363 Case
Example 364 Problem 364 Clinical Data
364 Management 364 Results 365
348
Chapter12
OCCLUSION ANTISUPPRESSION
THERAPY
There are two antidiplopia mechanisms in strabismus: anomalous retinal correspondence (ARC) and
suppression. Just as in ARC, patching an eye prevents suppression because it does not occur under
monocular viewing conditions. Therefore, occlusion can be thought of as a passive form of visin
therapy to prevent and break suppression. Suppression is an active process that tends to deepen
with abnormal visual experience. Occlusion helps
to break through suppression by preventing its
reinforcement.
The typical occiusion rgimen in cases of deep
suppression associated with constant strabismus is
.constant patching at all times during which visin
training is not being performed. Occlusion allows
for maintenanceduring daily activity at school,
work, or playof the gains made during antisuppression training (active therapy). .In cases of mod-
GENERAL APPROACH TO
ANTISUPPRESSION TRAINING
There are hundreds of antisuppression training
Instruments, targets, and techniques. Many training
methods are variations of tests used to detect suppression, such as those involving stereoscopes and
colored filters. Although only a few antisuppression techniques are presented, the concepts we
discuss can be applied to most innovative methods
that a therapist originates.
Chapter12
349
Antisuppression Variables
When active antisuppression training is assigned, a
number of mportant variables must be considered
in designing an appropriate training method. Factors that should be considered n training are usted
inTable 12-1.
Attention
The attention factor is a very important consideration n the treatment of suppression. When the
therapist presents a new target or device, each eye
should be occluded in turn, and all suppression
controls should be pointed out to the patient. The
therapist should continually remind the patient to
make a conscious effort to hold the suppression
controls n perception. This mental concentration
can momentarily stop the suppression. Antisuppression training s, therefore, an active process,
and the patient is expected to exert mental effort to
hold the suppression controls n perception.
Although attention s necessary, t alone s not
always sufficient to break through a suppression
response.
Because attention s such an mportant variable,
the therapist should select targets that are of interest
to the patient, particularly n the case of children.
Polarized or anaglyphic televisin trainers or reading bars are antisuppression nstruments that are
popular with most patients. Cheiroscopic training
can also pique the interest of children who enjoy
drawing and tracing. For older children and adults,
we have found the Bernell 500 series of Tranaglyphs
(see Appendix J for manufacturer information for
products Usted n this chapter) depicting sports figures to be well designed for antisuppression training
while holding a patient's nterest.
Brightness
The target before the suppressing eye should be
brighter than the target before the nonsuppressing
eye. This difference in the level of brightness must
be large if suppression is very intense (deep). Even
patients who have deep suppression are unlikely to
suppress when the dominant eye has a dim image
and the nondominant eye has a bright one. Differential brightness of the targets for each eye may be
created either by raising and lowering the lumi nance of the targets or by using graded (attenuating)
filters before the eyes. Instruments such as the Synoptophore have rheostats for this purpose. Home
training and simple office devices can accomplish
* Attention to target
* Brightness of target
Contrast of target
Color of target
Slzeof target
FtasMng of target
Movement of target
TactHe ana kinesthetc effects on suppression
Auditory effects on suppression
Color
Generally, colored targets hold a patient's attention
better than do black and white targets. Targets usually are colored for both eyes, but t may be helpful
to use a black and white target for the nonsuppressing eye and one that s colored for the sup-
350
Chapter12
o.s.
O.D.
O.S.
O.D.
o.s.
O.D.
FIGURE 12-1Example of the use of target brightness to break suppression of the left eye. a. Actual target. b. Patient's perception. c. Target of the left eye lluminated with a penlight. d. Patient's perception
where suppression s broken. Note that room illumination should be
lowered so that the dominan! eye sees a target with low luminance.
(O.D. = oculus dexter; O.S. = oculus sinister.)
pressing eye. This s particularly applicable to firstdegree targets such as are shown n Figure 12-2:
The circle can be brightiy colored, and the X might
be black.
Target Size
Target size and the size of suppression controls
should be tailored to the size of a given patient's
suppression zone in a particular instrument. (Refer
to Table 5-1 for zone classification and dimensions.) The choice of appropriate target size usually
proceeds on a trial-and-error basis. Also, the distance of a target from the patient determines its
size according to the inverse square relationship. A
target size or distance s chosen so that the patient
can hold the suppression controls n perception
most (approximately 80%) of the time, not al I the
time. If the patient s successful all the time, the
Chapter12
lus.2'3 Suppression of a flashing stimulus s difficult. Jampolsky4 suggested that a latency period s
needed for suppression and that a flashing pattern
interferes with this period. One of the most powerful methods of introducing intermittent stimuii is
flashing one or both targets using the automatic
flashing unit on a major amblyoscope. Some
deeply suppressing strabismic patients require this
level of intervention. Clinicians may prefer unilateral flashing of the suppressed target to elicit its
perception. Others prefer altrnate flashing to
forc the suppressing eye to see the controls when
the dominant eye is occluded. Both types of flashing should be tried to discover which s more
effective in a particular case. We often use rapid
automatic flashing in the amblyoscope, which
seems to work well in most cases. At home, n case
of deep strabismic suppression, a circuit breaker
can be put in the socket of a desk lamp, transforming it nto an automatic flashing unit. The iight
from the flashing desk lamp can then be directed
onto the suppressed field in a Bernell Mirror Stereoscope, set up with fusin targets at the patient's
objective angle of deviation. The patient s asked to
make a conscious effort to hold al I the suppression
controls n perception once they are seen.
Flashing can be easily accomplished n free
space (the open environment) n several ways. The
therapist or patient can quickly cover and uncover
an eye with a paddle occluder. This popular technique for breaking suppression can be applied to
many training nstruments if there are suppression
controls n the field. Another method is simply asking the patient to blink one or both eyes when suppression occurs. This also helps to enliven a
suppressed image, but it must not be carried on for
a long time as it results n visual fatigue. A penlight-flashing technique that can be applied with
free-space instruments is illustrated in Figure 12-1 c.
These techniques are the most frequently used
methods for breaking suppression and establishing
sensory fusin both n the office and at home.
Target Movement
Movement of the suppressing eye's target s effective for several reasons. First, noncorresponding
points are being stimulated by the oscillation of the
target. These points are less likely to be suppressed
than are corresponding points. Movement of the
target before one eye stimulates new retinal reas,
and the visual system generally responds to
change. Also, a moving target s apt to draw the
351
352
Chapter12
FIGURE 12-3a. Example of a cheiroscope being used for tracing while the tactile and kinesthetic senses aid antisuppression therapy. b. A
commercially available instrument suitable for home training is the Bernell Single Oblique Stereoscope. c. Example of an accurate cheiroscopic
drawing in a patient without suppression. d. Example of a cheiroscopic drawing in a patient with suppression.
Chapter12
Four-Step Approach to
Antisuppression Training
The following four-step method represents a general
approach to antisuppression training that can be
applied using any specific nstrument (Table 12-2).
Step One
The first step s to design the appropriate training
environment for the patient's level of suppression.
The antisuppression variables listed in Table 12-1
are used for this purpose. If suppression is deep,
the initial training environment should be relatively unnatural (e.g., use of an alpha rhythm
flasher [Translid Binocular Interaction Trainer],
major amblyoscope, red-green televisin trainer).
If the suppression is shallow, a relatively natural
training environment s appropriate (e.g., using
Vectograms, Brock string and beads, Pola-Mirror).
In working with a specific nstrument, the therapist
should select stimulus and target parameters that
allow the patient to succeed at the antisuppression
task approximately 70-80% of the time. The
appropriate variables are found empirically by trial
and error. The training task should neither be too
easy or too difficult for the patient to accomplish.
Step Two
The second step s designed to stimulate perception of the suppressed image. When suppression
does occur, an antisuppression stimulus is applied
to break down the suppression response and
enliven the suppressed image or control. Flashing
a target or an eye (intermittent light stimulation) s
the most commonly used stimulus. Other important antisuppression stimuli are blinking, movement of a target, and pointing or touching. The
type and strength of the stimulus must be appropriate for the depth and extent of suppression. Simultaneous perception of al I targets or suppression
controls in the binocular visual field is the goal.
Step Three
353
354
Chapter12
TI 2,1
T12.2
T12.3
T12.4
T12.5
T12.6
T12.7
T12.8
T12.9
T12.10
SPECIFIC ANTISUPPRESSION
TECHNIQUES
Most visin therapy instruments and targets contain
suppression controls, because suppression is an
omnipresent consideration in binocular visin
remediation. For purposes of this discussion, we
have selected only those techniques that we have
found to be the most effective and practica! in a
direct assault on pathologic suppression. A list of ten
specific antisuppression techniques is presented in
Table 12-3. These techniques are loosely organized
from those appropriate for deep peripheral suppression to those for shallow foveal suppression. This
sequence is based on our experience with patients.
Extreme unnatural visual conditions are necessary when attempting to break deep suppression.
The suppressing eye must be bombarded with relatively bright, large, flash i ng, and moving targets or
controls to break the suppression response. As suppression is broken, the clinician must be vigilantto
ensure that sensory fusin occurs or is possible and
that unresolvable diplopia is not generated. The
clinician should ensure that normal retinal correspondence is present and that normal sensory
fusin is possible before these techniques can be
effectively applied. If, during the course of therapy,
Chapter12
355
/<T*T>
TT
Chasing
tination Gradient and Flashing
cases of deep, extensive suppression, large tarand suppression controls are selected. A bug
356
Chapter12
Chapter12
357
Hand-Mirror Superimposition
CT12.4)
Hand-mirror superimposition, an excellent openenvironment mirror training technique described
by Getz, 5 is particularly appropriate for deep,
ttensive suppression. All the antisuppression variables Usted in Table 12-1 can be applied, and t is
practical for use as a home training technique.
Assume a patient has deep suppression of a left
strabismic eye. A hand-held mirror can be aligned
before the left eye at the bridge of the nose to view
a bright desk lamp. The right eye observes another
stimulating target (e.g., a televisin) (Figure 12-5).
The patient can consciously attend to the televisin program during this training, which makes
tfiis a popular technique. The training task is to
hold the lamp and televisin n simultaneous perception and superimposition as long as possible.
The mirror can be angled so that the image of the
lamp is seen in the same direction as s the televisin to promote bifoveal stimulation. Retinal
valry may be seen f the different contours of the
targets overlap, which is to be expected when differing images are superimposed. The mages can
be made brighter by rnoving closer and reducing
me background llumination. When suppression
occurs, the patient blinks and moves the mirror
slightly to stimulate perception. Conditions can be
ahered to make the task more difficult as progress s
made; for example, the background llumination
and target distances can be increased and less stimulating targets (e.g., vases and doorknobs) can be
selected. This technique effectively stimulates superimposition (first-degree fusin) but, once that s
achieved, t s mportant to move on quickly to
other techniques that build higher degrees of sensory fusin.
358
Chapter12
Chapter12
359
method works well with patients who have intermittent strabismus, anisometropic amblyopia, or
heterophoria. The patient holds one end of a 3-m
string to the tip of his or her nose while the other
end is held by the therapist or tied to a distant
object such as a doorknob (Figure 12-7). Directing visual attention, the patient should be able to
see two strings apparently intersecting wherever
the horizontal components of the visual axes
meet (Figure 12-8a). Seeing only one string or a
portion of one string indicates pathologic suppression (see Figure 12-8b). Three brightly colored beads on the string usually serve as fixation
targets. When one bead s fixated and seen as single, the other two beads should be diplopic. A
double image of the string should also appear to
intersect at the fixated bead. This represents the
proper physiologic diplopic percept. Patients with
binocular anomalies, of course, may not see this
correct image. Suppression is indicated when
only one image of the nonfixated beads or only
360
Chapter12
Chapter12
361
The televisin trainer is attached to the televisin screen vertical ly with suction cups. The
appropriate filters are worn by the patient over
spectacle or contact lenses, f recommended. The
therapist or patient should alternately occlude
each eye to make sure each filter mutual ly
excludes part of the televisin screen. The patient
moves as cise to the televisin screen as s necessary to a position at which the images can be seen
without suppression. The patient should then
slowly step back from the screen until a viewing
distance is found at which there s either unilateral
or altrnate suppression approximately 20-30% of
the time. That position s the correct training distance for the patient. If the patient suppresses more
than 30% of the time, the viewing distance may be
too far or the trainer unit too small.
Once the proper training distance is established,
the task is for the patient to watch a 30-mmute program while breaking suppression every time it
occurs. Suppression s indicated when one portion
of the trainer darkens to obscure that part of the
362
Chapter12
Pola-Mirror(T12.9)
The Pola-Mirror10'11 can be used for visin training in
heterophoric patients with central suppression.
Wearing polarized filters, the patient fixates an
image of his or her face in a mirror. Each eye can see
only an image of its eye. Both eyes are visible under
binocular viewing conditions if there is no foveal
suppression. The filter before a suppressing eye
appears darkened, obscuring the image of that eye.
The technique is for the patient to get cise enough
Reading Bars(T12.10)
Reading bars were a popular antisuppression
method even in the time of Javal.1 The patient can
concntrate on any reading material that he or she
chooses while working to break central suppression. This home training technique does require
sufficient motor fusin at reading distance before it
can be used effectively. Reading bars, placed
directly on the printed page, are available in polarized and red-green filter materials. Strips of filter
material are interspaced on transparent plstic and
alternately clued to the eyes (see Figure 10-20).
The patient wears the appropriate filters over any
needed refractive correction. Suppression will be
recognized by the patient when a filter strip
appears dark, decreasing the visibility of print
Chapter 12
363
MANAGEMENT
CONSIDERATIONS
Antisuppression training also has the effect of
building sensory and motor fusin. As suppression
Aninishes, stereopsis and motor fusional ranges
usually ncrease. Antisuppression training naturally
ewolves into sensory and motor fusin training.
When the emphasis changes to the training of
fusional vergence ranges, motor training is temporarily stopped f endpoint suppression is found; the
suppression should be broken before continuing.
Therefore, antisuppression, sensory fusin, and
motor fusin training consist of a reciprocally interwoven process. Antisuppression training builds sensory and motor fusin; conversely, establishing
good sensory and motor fusin prevents the recurrence of suppression.
Suppression s deepest n cases of strabismus
with normal retinal correspondence, as it s the
only antidiplopic mechanism available. Because
the strength of the antisuppression stimulus must
match or exceed the depth and extent of the suppression zone, in-office techniques that are unnatural, such as the TBI (T12.1) and amblyoscope
training (T12.2), are appropriate and necessary
during the first phase of visin training. Effective
home training techniques include red filters
(T12.3) and hand-mirror superimposition (T12.4).
Progression of targets is from peripheral to macular
to foveal sizes with each technique. At some point
in the training, many patients begin to altrnate
suppression, particularly with "fovea-sized" targets. Central suppression controls in each eye's
field of view are necessary.
364
Chapter12
eye. This usually breaks the suppression response, and vergence training can proceed (see
Figure 12-6).
CASE EXAMPLE
Problem
Trish, a 1 5-year-old straight-A student, presented
for an eye examination without symptoms or a
chief complaint.13 She had worn the following
spectacle lenses for the previous 4 years: oculus
dexter(OD), +2.50 -0.50 axis 010 (20/25~); oculus sinister (OS), +0.50 DS (20/20). The examination revealed that she had 3 diopters of
additional uncorrected axial anisometropia,
intermittent central suppression, and reduced
stereopsis.
Clmical Data
The pertinent clinical findings are summarized as
follows:
Keratometry
OD: 42.75 @ 180, 44.00 @ 90
Management
Although Trish was symptom-free, we expla'med to
her that her visual performance might increase if
she could adapt to the full anisometropic prescription and break the central suppression. Although
we thoroughly discussed the expected adaptive
symptoms when correcting 5 diopters of aniso-
Chapter12
365
1 TABLE 12-5. Resulte of Treatment n Trish: Full Anisometropia Spectades and Antsuppression Training
feual acuity
IF
1
Hereopsis (Fly) test
H&Konds of are)
Bbppression
Intial Examination
1 Mo
2 Mos
8 Mos
20/2520/20
200
20/25+
20/15140
20/20
20/15
40
20/1520/15
50
Intermittent parafoveal
Intermittent foveal
None
None
HplK All data were collected wth the patient wearng the full anisometropk spectacle lenses.
REFERENCES
1.
2.
3.
4.
Results
During the initial 3 days of wearing the prescribed
lenses, Trish experienced minor headaches, occasional double visin, some spatial disorientation,
and misjudgment of distances. Within a week, al I
adaptation symptoms disappeared, and the patient
icported clearer visin and an ncreased sense of
depth when viewing near objects. No suppression
was found at the 2-month progress check (Table
12-5). Stereopsis had ncreased to 40 seconds of
are, and good results persisted in later examinations. It was noted that the stereopsis mproved as
the suppression was eliminated. Eikonometer measurements indicated no aniseikonia. Trish rarely
noticed diplopia, in spite of the induced prismatic
diference between the lenses when viewing was
cf the optical centers. Trish was very pleased with
her increased depth perception and visual skills.
We believe that the antisuppression training was
an important addition to the optical correction n
diminating the obstacles to normal sensory fusin
5.
6.
7.
8.
9.
10.
11.
12.
13.
Additions 369
Centration-Point Training 369 Sensory and
Motor Fusin Training 370 Changing
Vewing Distance 371 Surgical
Management 372 Follow-Up Care 373
Vision Therapy Sequence for Esophoria 373
Speciflc Training Techniques 373
Amblyoscopic Divergence Technique
(TI 3.1) 374 Bernell Mirror
StereoscopeBase-ln
Training (T13.2) 374 Brewster
StereoscopeBase-ln Training
375
Isometric and Step Vergences
(T13.3) 377
Stereoscope Tromboning (T13.4) 377
Anaglyphic Fusin Carnes (TI 3.5) 379
Brock String and BeadsBase-ln Training
(T13.6) 380
Peripheral Fusin RingsBase-ln Training at
Far(T13.7) 380
368
Chapter13
DIAGNOSTIC CONSIDERATIONS
Eso deviations, whether tropic or phoric, are generally classified into three categories: (1) divergence
insufficiency (DI), having a low accommodativeconvergence/accommodation (AC/A) ratio; (2) basic
eso (BE), having a normal AC/A ratio; and (3) convergence excess (CE), having a high AC/A ratio.
(See Chapters 3 and 7 for discussions of these classifications.) In this scheme, however, not all nine
diagnostic variables of a deviation are taken into
account; only the near and far magnitudes are considered. (The AC/A ratio can be calculated from the
far and near deviations.) The use of a limited number of variables, however, is convenient for classification of dignoses, to avoid the hundreds of
possible permutations arising when nine variables
are considered. Nonetheless, it should be remembered that a complete strabismus diagnosis and
prognosis should include a description of all nine
variables: constancy, comitancy, laterality, direction, magnitude, AC/A ratio, variability, dominancy,
and cosmesis (see Chapter 4). Diagnosis of heterophoria would exclude constancy, laterality and,
possibly, variability and cosmesis.
Elimination of Major
Sensory Anomalies
This discussion of visin therapy approaches in
esotropa assumes that major sensory anomalies
Chapter13
Centration-Point Training
As part of esotropa management, Vodnoy6 highlighted the importance of findng a fixation ds-
370
Chapter13
Chapter13
ting on the nstrument scale actually reads 10 A
0O.) Other instruments, such as the Dual Polachrome Illuminated Trainer (see Appendix J for
rformation on each trade product cited n this
diapter), may also be used in this manner. Divergence training s repeated until the patient's
fusin range, with clear visin, increases beyond
the ortho demand setting on the instrument scale.
This goal, however, is not always achievable at
this early time in visin therapy.
Accommodative changes will blur the fused
image; blur ndicates that pur fusional vergences
are not in play. When the target (e.g., Vectogram)
becomes blurred, the patient s relying on accommodative vergence changes (decreasing accommodative response, in an eso case) to maintain
single visin. The goal at this point n therapy s to
achieve clear visin with mximum fusional
ranges, free of foveal suppression, around the
angle of deviation.
Most patients with esotropa are ready to leave
instrument training and begin open environment
training when the motor fusin range at the angle
of deviation s 10A in either direction. However,
if preventable, the patient should not be allowed
to lapse into strabismus. The patient should be
kept fusing most of the time by means of compensating prisms or plus-lens additions. During
visin training, whether in- or out-of-office, vergence demands are introduced n the open environment (free space). Numerous methods are
available for changing vergence demand, some
of which are listed inTable 13-2.
Sliding vergences can be introduced with convenient and available mirror stereoscopes, split
Vectograms, Tranaglyphs, and the like. Such techniques simlate the smoothness of movement
afforded by a major amblyoscope. Sliding vergence ranges are trained initially because they are
generally easier to achieve than are step vergence
responses. Step vergences are introduced later,
beginning with small prismatic demands and
allowing ampie time for the patient's responses.
Rapid step changes in vergence demand are conveniently accomplished with the use of a prism
bar. Wick7 described a bar made with Fresnel
Press-On prisms that has the advantage of less
weight and bulkiness than conventional prism bars
made of glass or plstic. Flipper prisms are also
good for step vergence training. BO prism may
nave to be used exclusively at first, until the patient
can learn to fuse when Bl prism is flipped into
371
A, Prisms
-1." Rlsley prisms
2. Lose prisms
3. Prsrn bar
a. Conventional gtass or plstic
b, Wck's Fresnel bar
1. Use of septums {septa}
1, Brewster stereoscope (h0mofogous point separa
tion increased for ir and dcreased for 8O
demands}
2, Wheatstone stereoscope (mirror angle changed
for il or BO demands}
3, Remy Separator (Bl demand increased with tar
get separation inerease)
C Vectographk and coiored filters (separation varied
ior prismatic demands)
D. Plus and minus spherkal lenses
1. BO demand witlt plus
372
Chapter13
or
A bilateral medial rectus recession operation,
weakening both medial rectus muscles
backwarcl
while
maintainmg
Surgical Management
Extraocular muscle surgery is necessary in cases
of esotropa in which the magnitude of the deviation is too large for compensating prisms to be
worn with acceptance by the patient. As regards
prognosis for functional cure, an esotropa is
considered large if the magnitude exceeds 20 A
(see Chapter 4). A common surgical procedure is
bilateral medial rectus recession (Table 13-3),
which not only reduces the magnitude of the
angle of esotropa but also tends to lower the
AC/A ratio. A lowered AC/A is particularly helpu\ \n cases o CE. The symmetric operation
(medial rectus of each eye) helps in maintainine
cornitancy, in contrast to recession and resection
ot the muscle of one eye only. In cases of DI surgeons often prefer a bilateral lateral rectus resection, as this symmetric operation tends to preserve
comitancy and increase the AC/A ratio. Two
types of operations are popular with strabismus
surgeons for basic esotropa: bilateral medial rectus recession or unilateral recession-resection
(Strengthening and weakening approaches n surgery are dscussed n Chapter 6, as are other
aspects of surgical management.)
At the beginning of a visin therapy program for
esotropa, the doctor should introduce the patient
to the possibility that extraocular muscle surgery
wil be necessary. If the deviation remains cosmetically obvious after full correction of the refractive
error, discussing this possiblity s essential for
good management. If the residual eso deviation at
near and, particularly, at far measures 20A or more an
operation often s necessary for the sake of long-term
comfortable and efficient binocular visin In our
experience, fusonal divergence can be effec-tively
trained, butthere are realstic limite
Chapter13
373
Follow-Up Care
If a postoperative patient has used compensating
prisms or plus-additon lenses to establish fusin
before the operation, it s important that new prescription lenses be given to the patient immediately after surgery. It is hoped that the prisms and
lens additions will no longer be necessary. Fresnel
Press-On prisms can be applied to new spectacle
lenses as needed to resolve any significant diplopia
in the primary position or at the reading distante,
but patching usually is not recommended.
Vision training can be started again approximately 2 weeks after an operation. Immediately
postoperatively, the eye(s) are sensitive to irritation and bright lights, so a little time off from
training s appropriate. If preoperative visin
training and the operation have been successful,
the patient quickly establishes fusin in the open
environment, and the angle of deviation rapidly
stabilizes during the healing process. Vision
training s directed toward identifying and breaking any suppression that may occur. Motor fusin
ranges and vergence facility are again maximally
ncreased. If there is any restriction of ocular
motility in some fields of gaze, training might
help to reduce the restrictions. In all cases,
whether postsurgical or not, when vergence skills
are maximally ncreased, retainer exercises are
given to the patient and a regular recall schedule
is established on the basis of quality of results.
374
Chapter13
Amblyoscopic Divergence
Technique(T13.1)
The amblyoscopic divergence technique discussed
here s similar to that presented in Chapter 11 for
esotropa with ARC (T11.7). However, the emphasis
here s on improvement of the fusional divergence
range n the nstrument, the assumption being that
NRC s present. This technique usually is applied n
cases of esotropa but can also be used for esophoria when lttle or no progress has been made usng
other techniques. Large stereoscopic targets with
suppression controls are used (e.g., the swing si des;
see Figure 11-5). Rapid altrnate flashing intensifies
the perception of stereopsis and breaks suppression
that may be present. With the targets initially set at
the subjective angle, the amblyoscope arms are
diverged slowly until the images become diplopic
or suppression occurs. The divergence demand then
s reduced just enough for the patient to re-establish
fusin. This vergence demand s held stationary for
1 or 2 minutes as an isometric exercise. The
amblyoscope arms then are diverged slowly again,
and the technique s repeated until mximum divergence has been achieved within a 20-minute
period.
The emphasis in this training technique s to
expand the divergence range within the nstrument
and then to have the patient view distant objects n
the open environment while he or she tries to
maintain the achieved divergence. In cases of
esotropa, partial prism compensation usually is
necessary to help the patient maintain binocular
algnment n the open environment. Besides seeing
diplopically for feedback when motor fusin is
lost, the patient also uses the sensation of eyestrain
to provide subjective feedback that free-space
motor fusin is occurring. At some point, the doc-
Chapter 13
TARGET
MIRRORS O.S.
O.D. TARGET
//'
375
a.
b.
b.
Brewster Stereoscope
Base-ln Training
376
Chapter13
O.C.
TEIEBINOCULAR MEAD
O.C.
FIGURE
13-3Schematic
top
view
SEPTUM
f
+5.00 D
SPHERE
0-S. S = 95 mm
STEREOGRAM IN
ADJUSTABLE
CARO HOLDER
AUXItlARY
LENS-HOLDER/OCCLUDER
SLIDES
FIGURE 13-4KeystoneTelebinocular.
SPHEROPRISM EYEPIECES IN
Chapter13
separation of 87 mm represents 4A BO and s the
practical distance that compnsales an eso postural shift caused by the proximal convergence. For
this reason, stereograms designed for an ortho
demand have homologous point separations of
approximately 87 mm.
Note that standard Brewster stereoscopes have
an optical-center separation distance of 95 mm,
and the 87-mm homologous point separation
applies. (Some small stereoscopes vary in this standard, so the doctor should measure the opticalcenter separation if in doubt.)
When nearpoint training (closer than optical
nfinity) is performed in a Brewster stereoscope,
new target separation vales represent the ortho
demand setting of this instrument. A nearpoint
accommodative stimulus of 2.50 D s represented
by a distance of 0.133 m (13.3 cm) within the collapsed optical space of the stereoscope. The 0.133m distance has a dioptric valu of 7.50 and,
because the 0.2-m distance has a dioptric valu of
5.00 D, the total demand on accommodation is
7.50 - 5.00 = 2.50 D. The h valu s calculated for
nearpoint as follows:
h = 95x0.133x5 = 63 mm
This means that f the homologous points are separated by a distance of 63 mm, the vergence
demand at this nearpoint distance of 0.133 m is
ortho. At this particular distance of 0.133 m (1.33
decimeters), it takes 1.33 mm of lateral displacement on a stereogram to equal 1A. For example, if
the circle and star are 59 mm apart, the BO
demand s 3A (4/1.33). At the farpoint (2 decimeters), every 2 mm on the stereogram equals 1A, and
every 1.33 mm equals 1A at the nearpoint (traditionally at 2.50-D demand with a fixation distance
of 1.33 decimeters). Any prismatic demand can be
determined by applying this "decimeter rule" when
stereograms are used in a Brewster stereoscope.
Isometric and Step Vergences (T13.3)
One of the most widely used Brewster stereoscopes s the Keystone Telebinocular (see Figure
13-4). The Biopter and the BernelI-O-Scope are
two of the many examples of small Brewster stereoscopes for home training purposes. Many training techniques can be performed with such
nstruments.
The first phase of training involves having the
patient fuse a stereogram and appreciate stereop-
377
sis while suppression s being monitored. Initially, the homologous points may need to be
relatively cise together to crate a BO compensation for the esotropic or esophoric patient. For
example, the separation of the targets could be
77 mm to help the patient fuse, by providing a 5 A
BO compensation ([87-77]/2 = 5) for the eso
deviation. The patient can maintain fusin on a
target with a divergence demand for a designated
time (e.g., 1-2 minutes) as an isometric exercise.
When there s good fusin, the target separation
can be increased to, say, 87 mm for an ortho
demand. Over time, the patient should attempt to
fuse the targets when the separation becomes
wider, thus creating Bl demands to stimulate
fusional divergence.
The next phase of training with the stereoscope
is to introduce vergence steps. Figure 13-5 depicts
a typical stereogram providing step vergence
demands. The top pair of targets has a relatively
more Bl demand than does the bottom pair. Later
in training, as the patient's fusional divergence
ability improves, BO demands are placed on the
bottom and relatively large Bl demands are positioned on the top of the stereogram. This s training
vergence facility, also known as vergence rock. It is
phasic (fast) vergence training, as opposed to the
initially easier technique for steady isometric vergence training. (See Chapter 2 for goals for fusional
vergence ranges and facility.)
If there is suppression, an external light source
can be directed toward the suppressed image; also,
bimanual pointing can be added to break the suppression response (see Figure 12-6). Corporations,
such as Keystone View, Bernell, and other suppliers, provide a large variety of stereograms designed
for most levis of sensory and motor ski 11 and different interests of patients. Examples of stereograms designed specifically for young children are
the Dvorine Cards (Figure 13-6). Stereograms
appropriate for older children and adults include
the Biopter Bl and BO Cards (Figure 13-7). In addition, the Bl range of the Brewster stereoscope
exceeds its BO range, making it an ideal instrument for building divergence abilities. This point is
made explicit in the following discussion of the
tromboning technique.
Stereoscope Trombonng (T13.4)
Although some stereograms are split to allow for
sliding vergence training with Brewster stereoscopes, stereogram sliding s more easily accom-
378
Chapter13
ChapteMB
379
FIGURE 13-7Example of a
Biopter stereogram (Stereo Optical
Co.).
380
Chapter13
Chapter13
(Figure 13-9). In this farpoint technique, the redfiltered eye sees only the red rings and the
green-filtered eye sees only the green rings.
(Both colored rings are printed on a black background.) The patient is instructed to fixate the
center configuration while wearing red-green
spectacles (red on right eye and green on left
eye). The outer complementary-colored rings are
laterally disparate, creating a stereoscopic effect.
The outer rings should appear to float forward n
relation to the central fixation rea. Even in
cases of strabismus, if the farpoint angle is
smaller than 10A, many patients can appreciate
the floating of the rings. For some patients, esophoric and esotropic, several minutes of intense
target viewing is required before the full stereopsis effect s perceived. Even many orthophoric
individuis with good binocular visin may
require a minute or more to perceive the mximum stereoscopic effect. The latency period of
perception, however, tends to decrease with
repeated training sessions.
A DI or BE deviation should be neutralized
with BO prism. The patient stands approximately
2 m from the target and is nstructed to maintain
the floating effect while he or she slowly walks
away, as far as possible, while maintaining fusin
of the target. As fixation distance s ncreased, the
rings should appear to be floating closer. They
may appear to be 1 or 2 m closer than the wall on
which the target is attached. This is so for the
outer rings that have the largest lateral disparity.
The smaller rings also have a dramatic floating
effect but not to the same extent as the larger
ones. Fusional divergence ranges are built up by
gradually reducing the BO compensation and,
eventually, by introducing Bl prism of progressively greater power. Later, flipper prisms are used
to ncrease vergence facility at far.
Other similar anaglyphic targets for the peripheral fusin ring technique (T13.7) are the Bernell
500 and 900 series (e.g., ring target shown mounted
in the lower portion of the Dual Polachrome Illuminated Trainer n Figure 13-10). Stereo targets with
suppression controls are transparent and can be
attached to a televisin screen. An isometric technique would be to ncrease the Bl prism demand to
mximum acceptance while the patient watches
televisin for an extended period (e.g., 30 minutes).
A Bl Fresnel or lose prism can be attached to the
spectacles to crate the appropriate divergence
demand for the patient.
381
382
ChapteMB
e.
a.
No. 2 Variable
h.
No. 10 Variable
b.
No. 9 Non-Variable
i.
No. 5 Variable
No.3 Non-Variable
C.
No. 11 Variable
No. 6 Variable
No.4 Non-Variable
No. 12 Variable
No. 7 Variable
FIGURE 13-11Ten Vectograms for the Bernell Dual Polachrome llluminatedTrainer (previously named the Polachrome Orthopter). a. Quoits, no.
2. b. Spirangle, no. 5. c. Clown, no. 6. d. Chicago Skyline, no. 7. e. Mother Goose, no. 10. f. Figure 8, no. 3. g. Compass Points, no. 4. h. Acuity
Suppression, no. 9. i. StereoTest, no. 11. j. Basic Fusin, no. 12. Note that there are no targets 1 or 8. Vectograms 3, 4, and 9 are not split, butthe
others are, so that varying base-in and base-out demands can be nduced with the latter. (Courtesy of Bernell Corp.)
Chapter13
383
384
Chapter13
P^Wr
\^55^
Chapter 13
385
Vectogram
\
\
40 cm \
\
80 cm
3ABI
160cm
386
Chapter13
face for projection other than a blank wall. The Berneli 500 or 600Tranaglyph Kits are good choices for
this technique. These split tranaglyphic techniques
are carried out in the same manner as are those in
which split Vectograms are used.
Binocular Accommodative
Rock (T13.11)
Monocular accommodative skills should be
ensured before binocular accommodative training
is given (see Chapter 16). Binocular accommodative rock can be used to increase accommodative
and vergence skills, particularly in esophoric
patients (see discussion in Chapter 2). Patients with
basic esophoria or CE generally have difficulty
clearing the target when looking through minus
lenses. Binocular facility is poor due to a limited
range of fusional divergence (i.e., the eso deviation
increases with the accommodative stimulus, and
the patient must rely on fusional divergence to
maintain single and clear binocular visin).
The therapist should start this technique with
small amounts of minus lens power (i.e., -0.50 D
to -1.00 D). The amount is determined empirically
by working with the patient. Equal plus and minus
flipper lens powers are commercially available, or
the therapist can prepare unequal powers as
needed using a clip demonstrator lens holder and
trial-case lenses. The nearpoint target should have
suppression controls appropriate for the patient's
level of sensory fusin. Various targets can be used
for this purpose (e.g., strip reading bars, Minivectograms, and Minitranaglyphs; see Figure 16-6).
The technique requires the patient to flip the
lenses (keeping them horizontally aligned with the
eyes), fuse and clear the target, note the suppression controls, and build the speed of alternation.
The lenses are not flipped until the target is perfectly clear and the suppression controls are
present. The patient or therapist records the number of cycles within a prescribed time interval (12 minutes) or the amount of time required for a
patient to complete an assigned number of cycles.
These numbers are logged to chart progress. With
short rest periods of approximately 30 seconds
between sets, the patient contines this exercise
for a 10-minute period each day until proficiency
is achieved. For nonpresbyopic adults, the binocular flipper rate should eventually be 20 cycles per
minute using +1.50-D flippers. Using +2.00-D
flippers, children aged 8 years and older should
Chapter13
Ortho
Point
387
391
CASE MANAGEMENT
AND EXAMPLES
Convergence Excess Esotropa
Management Principies
CE esotropa and esophoria are characterized by
a near deviation that is substantially larger than at
far. If the patient s phoric or ntermittently strabismic at near, visual symptoms when reading
may be reported (e.g., intermittent blur, diplopia,
and asthenopia). Many CE patients have considerable suppression at near; therefore, symptoms
such as diplopia do not always result. 10 CE usually
is caused by an abnormally high AC/A ratio with
inadequate fusional divergence. However, a
392
Chapter13
rnargin of the pupil and, for older patients, the segment height would be at the lower eyelid margin.
These investigators also advocated progressive
addition lenses for the sake of cosmesis and for
promoting fusin at intermedate distances. The
top of the progressive addition lens segment
should be placed 4 mm above the center of the
pupil for children younger than 8 years and 2 mm
above for older patients.
In cases of accommodative esotropa, especially CE cases, there s usually the need for active
visin therapy to break suppression and build vergence ranges and facility. Bifocals correct only the
nearpoint deviation in CE at one particular viewing distance, whereas patients habitually use
many near and intermedate distances in real-life
situations. The deviation, therefore, can easily
decompensate f sensory and motor fusin are
weak. von Noorden et al.13 reportad that the best
long-term results were achieved by those patients
who underwent fusional vergence training n
addition to bifocal management. We believe that
the most effective management of accommodative esotropa ncludes a relatively short program
of visin training to maximize sensory and motor
fusin, followed by the prescription of retainer
exercises and regular progress visits, once or
twice yearly, to ensure successful long-term
results.
The emphasis of visin training s to break the
deep suppression often found at near even with a
bifocal add and to extend the motor fusin ranges
to compnsate for an eso deviation at all viewing
distances. Specific training techniques, used in
combination with a bifocal lens, that we have
found particularly effective with CE patients
include Brock string and beads (T13.6), Vectograms and Tranaglyphs (T13.8), binocular accommodative rock with minus lenses (T13.11), and
vergence rock techniques (T13.12). Push-up training should be stressed with all these techniques to
extend the range of sensory and motor fusin to
very near distances, within 10 cm.
Successful management of CE patients with a
very high AC/A ratio can be difficult with adds,
even when visin training is ncluded, because
such CE patients tend to redevelop suppression at
near and regress quickly. 10 In those cases n
which the AC/A ratio exceeds 12A/1 D, the potential for needed strabismus surgery (a bilateral
medial recession) as part of a visin therapy program significantly increases (see Chapter 7).
Chapter13
Basic Esotropa
Management Principies
Most cases of basic esotropa (normal AC/A ratio)
have an assocated accommodative component
that requires full optical correction. Sometimes
esotropa is caused solely by uncorrected hyperopa. Once the patient adapts to wearing the cycloplegic spectacle or contact lens correction, a
strabismus may not be found. Esotropc patients
should be encouraged to wear ther spectacles full-
393
394
Chapter13
Divergence Insufficiency
Esotropa
DI is a relatively infrequent vergence anomaly n
which the eso deviation at far s greater than the
eso deviation at near, a low-AC/A case. (The characteristics of DI esophoria are discussed n Chapter
3.) The same principies apply to DI esotropa,
except that more ntensve and extensive visin
therapy is required for the strabismic condition,
particularly if the magnitude of deviation at far is
large. Differential diagnosis s important in cases of
DI (as discussed in Chapter 7); a divergence paralysis originating from a midbrain lesin can sometimes imtate DI esotropa.
Many patients wth DI have NRC; therefore, BO
prisms can be benefical. A major probiem with
prsm compensaron for the farpoint eso devation,
however, is that the nearpoint devation may consequently be increased in an exo drection n many
of these patients. Some patients, therefore, wear
the prism spectacles only for dedicated far vewing
and switch to another pair of glasses without prism
for reading. Others may find t dsturbing and dffcult to adapt to constantly changing spectacles.
A temporary soluton might be to attach an
appropriate-power Fresnel BO prism to only the
top half of the lenses.
BO prsm for the whole lens may be prescribed,
wth caution, for some patients not needing more
than 10A of BO compensaron at far. Convergence
training sometmes is necessary for the induced
nearpont exo deviation but, more mportant,
fusional dvergence trainng to help control any
remaining eso deviation at the farpoint s most defntely required n such cases.
Increasing the fusional divergence range at far
wth visin training s not easy. Progress s often
slow; asthenopic symptoms frequently intensify.
If the eso devaton at far exceeds 20A, strabismus surgery (most likely a bilateral resection)
often s necessary for a satisfactory outcome.
396
Chapter13
Mkroesotropia
Management Principies
Microtropic patients generally have a stable binocular condition and do not report visual symptoms. ARC and reduced stereopsis are expected;
many also have amblyopia. If the amblyopia in
these cases is worse than 20/30, we often recommend a short-term patching program to improve
it. The goal is to ensure that the patient has good
visual acuity in each eye even though there is no
central fusin. Other than treating amblyopia
(see Chapter 10), we rarely try to cure the
microtropia unless the patient has asthenopic
symptoms. We have found that in cases of symptomatic microtropia, symptoms often abate with
standard sensory and motor fusin training.
Prisms usually do not help because of prism
adaptation, but a plus-addition lens may help if
an accommodative deficiency exists. Suppression
may be partially broken with a televisin trainer
(T12.8) and Brock string and beads (T13.6). Vergence ranges are increased with sliding Vectograms (T13.8), the Mirror Stereoscope (T13.2),
and the major amblyoscope (T13.1), if necessary.
However, in most cases, although symptoms are
resolved, the microtropia as measured by unilateral cover test persists. Patients usually consider
this to be a satisfactory result, and we accept
their judgment. These patients have enhanced
peripheral sensory and motor fusin and resolution of their visual symptoms.
There are some cases, however, in which the
microesotropia is not associated with ARC. In
these cases, patients often experience intermittent diplopia and asthenopia. This type of
microtropia represents an intermedate condition between esophoria with fixation disparity
and a manifest esotropa. Such patients with
microesotropia often respond well to prism compensation, plus adds, and antisuppression and
divergence training, as the following case example demonstrates.
Case Example
20/15(6/4.5)
20/15(6/4.5)
Chapter13
this optical combination, the patient had 60 seconds of are on the Stereo Fly test. Motor fusin
ranges, however, were not measured because of
suppression.
These binocular findings are unusual because
the microesotropia was not associated with
eccentric fixation or ARC at far; n addition, there
was a manifest deviation of 22 A at near. The
patient demonstrated peripheral fusin at far but
not at near. (Refer to the discussion of microtropia n Chapter 7.) It is likely that the potential for
sensory fusin was always good because the
patient would habitually read without his spectacles, as though having an add for fusing at his
centration point.
The visin training plan included prescribing
CAMP spectacle lenses to solve his probiem of
blurred visin at far, which was the patient's only
complaint. The plan also included prescribing BO
prism and an add at near n the form of bifocals, to
promote fusin at far and near. The patient was
reluctant, however, and wanted contact lenses for
cosmetic reasons. The patient made a compromise
and agreed to accept the following: soft contact
lenses for social occasions and, for study and critical viewing occasions, plano spectacles having 4A
BO overall (for fusin at far) and a bifocal add of
+3.00 (for fusin at near) to be worn with the contact lenses.
Vision training with weekly office visits and
daily home training was conducted for 3 months.
The techniques and sequence generally followed
the program for basic esotropa discussed previously. Emphasis, however, was on the use of
physiologic diplopia with Brock string and beads,
a televisin trainer and prism rock, and the Spirangle Vectogram. At the conclusin of visin
therapy, there was no movement on the unilateral
cover test at far or near, although there was a
latent eso deviation of 20A at far and 2A at near
(testing done with contact lens-spectacle combination). Motor fusin ranges with the Spirangle
Vectogram were 15A Bl and 20A BO, and the
patient was free of suppression. Stereopsis was 40
seconds of are (Stereo Fly test).
The patient had not shown any regression in
binocular skills after 2 months. His vergence
ranges had not diminished but had actually
increased. The patient had no symptoms and was
happy with the contact lens-bifocal combination.
He was nstructed to continu home visin training for 10 minutes once monthly to monitor
397
Esophoria
Management Principies
Our preference n treating symptomatic esophoriaall three typesis to correct fully any significant refractive error, then prescribe fusional
divergence training to determine whether symptomatic and performance problems can be abated.
If not, we prescribe prisms, plus-addition lenses, or
some combination of these. As regards the prescription of prism, we usually apply at least one of
three clinical criteria:
1. Clnica! wisdom recommends completely
compensating for the eso deviaton f the
devation measures 10A or smaller. Larger
amounts are given partially compensating
prisms.
2. Sheard's criterion should be met.
3. Associated phoria (as measured by the
Mallett, Bernell, Saladin, or other vectographic or anaglyphic tests) with a central
fusin target should be neutralized.
Sensory and motor fusin training proceeds
much n the same pattern as s recommended for
the corresponding types of esotropa. (Refer to the
earlier section, Vision Therapy Sequence for Esophoria, and Table 13-4.) Initally, we suggest an
emphasis on training ocular motility, ncluding
accommodation, f a dysfunction exists. When
vergence skills are introduced, t is prudent to
include convergence ranges as well as divergence
ranges. This is because convergence ranges
expand quickly, which is an encouraging result
for the patient. Divergence ranges expand slowly,
but divergence facility may ncrease rapidly with
training. We, therefore, stress phasic (i.e., step
and jump) over tonic (i.e., sliding and tromboning) exercises when training divergence. Isometric
exercises also seem to be an efficient approach in
the treatment of esophoria. The patient can be
instructed to read while wearing a Bl prism or a
minus-lens add for a predefined period. This training of divergence by optical means may cause
some eyestrain, and so frequent breaks may be
needed.
398
Chapter13
REFERENCES
1.
2.
3.
4.
5.
Case Example
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Exo deviations are more prevalent than eso deviations. The ratio regarding strabismus is approximately 3 to 2, which transales nto approximately 5
million people having some form of exotropia (XT)
in the United States.1 Approximately 80% of exotropes have fusin at some distance at least part-
400
Chapter14
DIAGNOSTIC CONSIDERATIONS
TABLE14-1. Vision Therapy Sequence for
Comitant Exotropia
Chapter14
Elimination of Major
Sensory Anomalies
Amblyopia is not usually associated with XT,
because most of these deviations are not constant.
In those XT cases in which amblyopia exists, however, t s important to improve visual acuity to
approximately 20/60 (6/18) before proceeding
with binocular therapy. It is also necessary for the
patient to have good ocular motility at this point in
the sequence (i.e., good fixation, pursuits, saccades, and accommodation). If these skills are
deficient, they should be the immediate concern n
visin training (see Chapters 10 and 16).
Anomaious retinal correspondence (ARC) usually
is not a significantly unfavorable factor n cases of
XT and s no problem at all in XP (see Chapter 11).
401
Because most exotropes fuse at some distance, usually at near, they covary from ARC to normal retinal
correspondence (NRC) when fusional vergence
movements align the eyes. When the exo deviation
s manifest, however, they covary back to ARC. Even
in cases of constant XT, ARC often is not an overriding consideraron f the patient can learn gross convergence (T11.13). On the other hand, ARC does
become a serious obstacle to progress in constant
XT when gross convergence techniques fail to align
the eyes at near, with covariation to NRC. If classic
amblyoscopic techniques for eliminating ARC are
necessary n cases of constant XT, the same problems and restrictions limit success as in cases of
constant esotropa (see Chapter 11). Wick18 demonstrated that success is possible, even n the case of
an adult with constant XT. We believe success s
possible n many such cases. However, there are
considerations that can make treatment impractical
for the patient: Vision training may be time-consuming, difficult, and expensive.
Deep suppression, if present, can also be a significant obstacle to establishing sensory and motor
fusin. As with ARC, t s best to stimulate gross
convergence (T11.13); it is hoped that the patient
can attain peripheral fusin at some near distance.
Antisuppression training can begin at this position
in the open environment.
402
Chapter14
Chapter14
Sensory and
Motor Fusin Training
General Considerations
It bears repeating that during a visin training program for strabismus, the patient should never be
allowed to reinforce the strabismus. If the strabismus is constant, then occlusion to treat or prevent
suppression or other sensory adaptations must also
be constant. For example, if after a good effort with
gross convergence training n a Cl exotropic case,
fusin at near has not been achieved, except during active training, the patient must still wear a
spectacle half-patch (lower portion of the lens) for
nearpoint viewing. However, if this patient fuses
60% of the time and loses fusin n the afternoon
and evening, the patch need be worn only during
the latter part of the day. Patching alone may result
in a cure of intermittent XT. In a clinical series
reported by Cooper and Leyman,10 4 of 11 cases
(36%) reverted to an exophoric condition when
occlusion was used as the sol treatment modality.
Suppression must be addressed first. (Refer to
Chapter 12 for antisuppression therapy.) Eliminating suppression at far s not always easy. The best
approach is to have the patient achieve alignment,
even if temporary, by use of minus-lens overcorrection and mental effort (voluntary convergence).
When the eyes are aligned, the ARC is eliminated
403
404
Chapter14
Surgical Management
TABLE14-2. Common Surgical Procedures
for Exotropia
the stimulus target (e.g., a Vectogram or Tranaglyph) while attempting to hold fusin. The goal s
to extend sensory and motor fusin to al I distances
and positions of gaze in the open environment.
Efficacy ofTreatment
Vision training, as a sol intervention, has been
used extensively and with good results in the treatment of intermittent XT. In one clinical series of 31
exotropes, most having constant deviations, Sanfilppo and Clahane24 reported a success rate of 64%
and a failure rate of only 3%, with little regression
after 4.5 years. Success was defined as no strabismus at far or near and good fusional vergence
ranges. These authors concluded that the size of
the deviation and age of the patient were not
mportant factors in achieving successful results
but that patient motivation was.
Goldrich 25 presented a series of 29 intermittent
exotropes of the DE type, this type of XT being the
most difficult to treat solely with visi n training.
He reported a success rate of 82% and defined
success as the presence of a phoric condition after
treatment, no symptoms, and normal fusional
ranges. Only one patient made no progress. The
average number of in-office training sessions was
29, with a standard deviation of 14.
Other equally impressive clinical series have
been reported n the literature. 26' 27 In their literature review involving 740 cases of ntermittent XT,
Coffey et al. 23 reported a functional cure, by their
strict criterion, of 59% when visin training was
used as the sol therapeutic option.
General Considerations
Cenerally speaking, f a patient has an intermittent
XT greater than 25 A at far or near or a constant XT
greater than 20A, the possibility of strabismus surgery needs to be discussed with the patient or parents, whichever is appropriate. The larger the
angle, the more likely t s that an operation will be
required for successful long-term management. It
s important to remember that intermittent exotropic patients should undergo a prolonged cover test
to determine the full angle of deviation and
unmask any latent deviation. The degree of
fusional control and the severity of the patient's
symptoms, if any, are also important factors n
assessing the appropriateness of surgery.
The general guidelines for surgical procedures
vary according to the type of XT and are summarized n Table 14-2. In cases of true DE, the preferred operation is bilateral lateral rectus recession.
This type of operation has the effect of reducing
the AC/A ratio while decreasing the magnitude of
the XT. The generally preferred operation in Cl
cases is bilateral medial rectus resection, which
has the effect of increasing the AC/A ratio. In cases
of BX, the surgeon may elect to perform a recession of the lateral rectus and a resection of the
medial rectus muscle of the same eye, usually the
strabismic eye. This recession-resection (R-and-R)
operation tends to have little effect on AC/A magnitude. According to Helveston, 28 when the angle of
deviation s larger than 50 A, the surgeon often
operates on three muscles (e.g., an R-and-R on the
strabismic eye combined with a lateral rectus
recession of the dominant eye). Deviations larger
than 75A often require a four-muscle operation, a
bilateral R-and-R. Although there are differences of
opinin, most surgeons try to achieve an immediate postoperative result of no more than 10 A eso, a
siight overcorrection. 29 The healing process often
results in a shift back n the exo direction. Henee,
leaving a postoperative residual exo deviation
increases the risk that the patient will revert to an
XT at a later time.29 For this reason, some surgeons
use adjustable sutures on one muscle so that postoperative refinement of the deviation s possible. 30
Chapter14
mltiple operations for a successful outcome. Frequently, surgery is unsuccessful or only partially successful. Intermittent XT s probably one of the most
difficult problems faced by strabismus surgeons. Flax
and Selenow31 reviewed 22 journal articles dealing
with surgical success in XT. They reported only a
34% success rate using as a definition of functional
cure a phoric condition at al I distances, sensory
fusin, and demonstrable vergence ranges. The failure rate, as defined by the authors, was 22%, al I
other cases falling in between. In a later review by
Coffey et al.,23 surgical success for intermittent XT
had apparently improved and was reported as 46%
on the basis of an accumulated total of 2,530 cases.
A particularly revealing study that compared
results of different treatment modalities was that
of Cooper and Leyman. 10 In this retrospective
study of 673 cases, orthoptics alone had the highest success rate (59%) and lowest failure rate
(5%), as compared with the three other therapeutic approaches: (1) occlusion only; (2) surgery
only; and (3) orthoptics and surgery (Table 14-3).
The authors pointed out, however, that the
smaller deviations tended to be found n the
orthoptics-only group and the larger angles of
strabismus n the two surgical groups. For this reason, these data are not exactly comparable.
Nonetheless, when surgery and orthoptics are
combined, success tends to ncrease and failure
rates diminish.
On the basis of the many studies of therapeutic
efficacy for XT, despite their scientific nadequacies, we believe that the following treatment recommendations can be made with assurance:
1. In cases of intermittent XT of 25 A or less (far
or near or both), visin training is the preferred treatment option and may be com
bined with occlusion, prism compensation,
and minus adds, as each case demands.23-32
2. In cases of XT greater than 25A at far or near
or both, surgery becomes increasingly necessary to effect a cure as the angle of deviation increases. The amount of fusional
control of the deviation s an mportant fac
tor. Constant XT is far more likely to require
an operation than is intermittent XT.
3. In cases of XT (constant or intermittent)
requiring surgery, visin training and optical
compensation used n conjunction increase
the likelihood of a successful outcome (see
Table 14-3).10-33
405
No. of
Cases
Occlusion only Surgery
only Surgery and
training Training only
11
264
216
182
Good
{%)
36
42
52
59
Fair
28
41
38
36
Poor
36
17
10
5
Follow-Up Care
Compensating prisms (Fresnel) and minus-add
lenses should be given to the postoperative patient
as soon as possible to aid the development and
maintenance of sensory and motor fusin. Patching
an eye s not recommended unless there are surgical complications such as an infection. Vision
training can usually be started approximately 2
weeks after the operation without excessive discomfort. If fusional skills exist at near, we usually
recommend home training exercises (e.g., Minivectogram [T14.9], chiastopic fusin [T14.14],
binocular accommodative rock [T14.15], and vergence rock techniques [T14.16 and T14.17]). Any
of these techniques can also be used as a retainer
exercise for the patient, to monitor regressions and
to give periodic booster training as needed, per haps once monthly. Regular progress evaluations
are scheduled consistent with fusional results of
therapy.
406
Chapter14
Chapter14
407
Once the patient with XT learns gross convergence or voluntary convergence, he or she should
attempt isometric exercises to hold the eyes n full
convergence posture for a reasonable period, at
least 1 minute. This exercise requires great effort
and a high level of convergence control and stamina; consequently, t often causes significant eyestrain. The patient should be given frequent rest
breaks between training intervals.
Amblyoscopic Convergence
Technique (T14.2)
In cases of constant XT when suppression is deep and
fusin cannot be established with voluntary convergence, amblyoscopic convergence training can be
used to achieve sensory fusin. Ratients are, ideally,
scheduled for hourly sessions, two or three times
weekly. Constant occlusion is required when the
patient s not actively training, to help break any
existing suppression. The first sudes introduced n the
amblyoscope are usually first- or second-degree
peripheral targets, n an attempt to establish rudimentary fusin at the objective angle of strabismus. Suppression is broken with autornatic, rapid, altrnate
flashing and by dimming the image of the nonsuppressing eye. Initially, the patient's task s to use mental effort to hold in view the suppression controls for
each eye simultaneously for a required time nterval
(e.g., 1 minute). When this goal is achieved, the stimulus characteristics of the targets are changed to challenge the patient further, and the process s repeated.
Once suppression s consistently broken on a
second-degree target set at the patient's angle of deviation, motor fusin demands can be ntroduced. The
amblyoscope s designed to build sliding vergence
ranges in horizontal, vertical, and cyclotorsional
directions. In cases of XT, expanding convergence
ranges are, of course, the primary concern, but building motor fusin skills in the other directions is ideal
for the sake of generalization and reinforcement of
learned skills. A reasonable goal for fusional convergence in the major amblyoscope is at least 20A from
the angle of deviation without suppression. When
this level of skill s achieved, and perhaps even a
lesser level when the XT s of small or modrate magnitude, the patient can then learn to apply voluntary
vergence movements to achieve and maintain fusin
in the open environment. For the sake of efficiency
and effectiveness of training, every effort should be
made to transfer the patient out of the instrument and
into the open environment as soon as possible.
408
Chapter14
Bernell Mirror
Stereoscope (T14.4)
The Bernell Mirror Stereoscope (see Figure 13-1)
can be set for an angle of deviation of 40 A Bl. This
Chapter14
409
fusional recoveries is recorded at each training session, to chart progress and to enhance motivation.
Physiologic Diplopia
Brock Strng and Beads (T14.5)
Chapter14
410
PIN
POHTION
REMOVED
PATIENT
quick jump vergence responses without suppression are achieved. When suppression is noticed,
the patient blinks his or her eyes and wiggles the
card slightly to re-establish perception of physiologic diplopia. Near-far jump vergence can also be
trained by having the patient altrnate fixation
between a distant object and the three-dot card.
The goal of these jump exercises is to improve vergence facility as well as the NPC. The therapist can
make these exercises easier for the patient by using
minus adds or Bl prism; in contrast, the level of difficulty can be raised with plus adds or BO prism.
This jump vergence training is effective but very
demanding; patients will need to rest after each 2minute training interval.
Brewster Stereoscope
The optics of the Brewster Stereoscope were discussed in Chapter 13, as was its application to
visin training in cases of esotropa and esophoria.
The same principies apply for exo deviations
except that the emphasis in these cases is on
fusional convergence training with BO demands.
The Brewster Stereoscope s an mportant training
instrument for farpoint exo deviations, because the
stereograms can be placed at optical infinity. For
this reason, this instrument s used in cases of DE
and BX but infrequently in Cl cases.
Vectograms and Tranaglyphs are open environment training materials, described in Chapter 13
(T13.8-T13.10), that can be used in the office or at
home and are distinguished by the variety of welldesigned and interesting targets with stereopsis
and suppression clues. In XT and XP, the emphasis
is on developing and expanding suppression-free,
fusional convergence ranges and step convergence
Chapter14
reflexes that are fast and accurate. Fusional convergence can be increased with sliding, step,
jump, trombonmg, and sometric training using
Vectograms and Tranaglyphs. There are countless
variations and embellishments of these familiar
themes that result in many more effective training
techniques than can be published in any book.
Innovation n visin training is limited only by the
creativity of the therapist.
Converge/ice Training at Near (T4.9)
The majority of patients with XT have the ability to
fuse at near at least some of the time. In such cases,
the target demand of a Vectogram or Tranaglyph s
set at the ortho position, and fusiona! convergence
training can begin with the gradual ntroduction of
BO prism demand. The Mother Goose Vectogram
(see Figure 13-11 e) is a good initial target, because
it has large suppression controls for al I three figures.
As the patient makes the very small step vergences
when fixating from one figure to the next, the sudes
are separated slowly n the BO direction (numbers
showing in the mask ruler). The patient uses voluntary convergence in attempting to maintain fusin
with clearness and without any suppression (e.g.,
Little Bo Peep losing her sheep). The initial emphasis
s on the BO range, but eventually Bl demands are
intermittently introduced so that fusional vergence
can be strong n both directions.
When diplopia (break) occurs, the BO demand is
reduced sufficiently to allow for recovery of fusin.
The patient contines to bifixate each target on the
Vectogram for at least 1 minute before an ncreased
BO demand s given. Smoothness of disparation
requires the therapist to move each sude laterally
and simultaneously at an appropriately slow speed
for the patient. Later in training, the patient can learn
to move the si des properly and at a faster rate commensurate with his or her ability to maintain fusin
during the disparation. The patient should learn to
perceive blur (f possible) and record this valu along
with breakpoint and recovery point. Each training
period should last approximately 10 minutes. Various split Vectograms and Tranaglyphs can be used
for nterest and for the special features offered on
some (e.g., the Spirangle, with its subtle stereopsis
and suppression clues; see Figure 13-11b).
As progress is made, two pairs of split Vectograms or Tranaglyphs can be used on a Dual
Polachrome Illuminated Trainer for vergence facilty training. The top target can be a divergence
demand and the bottom, convergence. The goal for
411
the patient s to reach the mximum limit of vergence in either direction and to recover fusin on
each pair as quickly and accurately as possible.
The clinician prescribes as many sets as the patient
can complete within a 10-minute training session;
this training also benefits stamina.
In relatively rare cases of XT in which the patient
cannot achieve any fusin at near, split Vectograms
or Tranaglyphs can be placed at the patient's
objective angle of deviation in an attempt to obtain
sensory fusin. Fusional convergence training proceeds n a fashion similar to that just described,
except that the starting point may be with Bl compensation rather than at the ortho demand point
As progress s made, the Bl demand s reduced
gradual ly and, eventual ly, a normal BO range is
achieved. This technique works well if there s
NRC but not f there is ARC when the exo deviation is manifest. (Refer to Chapter 11 for a discussion of treatment of XT with ARC.)
Convergence Walk-Aways (T14.10)
Split Vectograms and Tranaglyphs are particularly
helpful for DE and BX patients, who often lose
fusin as the fixation distance s increased. A good
pair of targets is the Spirangle Vectogram, which is
large and has an appreciable stereopsis effect at far
distances (see Figure 13-11 b). The BO demand
should be increased maximally at near while the
patient maintains fusin. When a good BO range is
established, the patient s instructed to walk away
from the target slowly while maintaining fusin with
clearness. The spiral figure should appear more indepth as fixation distance increases. Furthermore,
the vergence demand decreases (theoretically),
which should make fusin easier for the patient. For
example, 12A at 40 cm transales to only 6A at 80
cm and only 3A at 160 cm. Exotropic patients who
previously could not bifixate at far are delighted to
realize that they can fuse at far: The visual feedback
of stereopsis and monitoring of suppression tells
them so. This newly discovered skill builds confidence and motivation to continu to achieve in
visin therapy. Once the patient can master fusing
at far with a small BO demand, the split targets are
separated further (sliding vergence) to train for an
ncreased fusional convergence range.
Projected Base-Out Sudes (T14.11)
412
Chapter14
FIGURE 14-3Patient performing convergence training with the ApertureRule Trainer with a single aperture.
Aperture-Rule Trainer
(Single Aperture) (T14.12)
The Aperture-Rule Trainer can be used as an noffice and home training instrument in cases of Cl
and basic XP. The design of the nstrument was discussed in Chapter 13 (T13.13). A single aperture s
used to crate BO demands (Figure 14-3). The
patient looks at and fuses the pair of targets at the
distance of 40 cm through the single aperture (.e.,
chiastopic fusin). If there s difficulty fusing the
first few cards, the patient s instructed to look at a
pointer stick placed in the center of the aperture.
Fixation on the pointer helps to converge the eyes
so the patient can nitially fuse the pair of targets
even though they may appear blurred. With fusin,
the pointer s quickly withdrawn and the patient s
encouraged to maintain fusin. Blinking sometimes helps to relax accommodation to the plae
of the fusin targets.
The goal is for the patient to progress to cards
having higher step prism demands, up to card 12,
while perceiving all suppression clues. The therapist or patient must remember to move the aperture slider appropriately with each change of target
so that the slider does not block the view of either
eye. Using lose BO prisms, a prism bar, or flipper
prisms or lenses can extend the range on the
instrument if desired.
An effective jump vergence technique involves
having the patient diverge the eyes and focus on a
far target over the top of the Aperture-Rule Trainer
and then converge to the targets seen through the
aperture (Figure 14-4). The back-and-forth fixations
should be as rapid as possible. The patient records
the number of cycles achieved within 2 minutes
and s given instructions to repeat this routine at
least five times daily. Suppression should be monitored and broken, if it occurs, before the patient
contines with this jump technique.
Chapter14
413
414
Chapter14
Chapter14
415
FIGURE 14-6Chiastopic fusin training with the use of Keystone Colored Circles (Lifesaver card). a. Use of pencil to
aid convergence and teach patient to
cross-fuse. b. Chiastopic fusin without
the use of pencil as aid to convergence.
416
Chapter 14
Binocular Accommodative
Rock (T14.15)
As in eso deviations (T13.11), binocular accommodative rock can be used to increase accommodative
and convergence skills of exotropic and exophoric
patients. The clinician should ensure good monocular accommodative skills before proceeding to bin-
Chapter14
417
418
Chapter 14
Bar reading (T12.10) with BO prism rock is especially helpful in Cl cases, because training is done at
near (see Figure 10-20). However, the technique can
be used effectively for any type of exo deviation as
long as there is nearpoint fusin. It is a demanding
exercise that is often given in the final stages of training and as a retainer exercise. Step vergence training
is conducted by having the patient alternately
change the prism from Bl to BO at the end of each
line. If suppression occurs, the patient can blink his
or her eyes, increase illumination, and move closer
to the page. Reading in this manner is continued for
a 10-minute period. With practice, patients can
learn to read passages for meaning without thinking
about sensory or motor fusin. The prism amount
can be increased each week as needed.
Effective isometric training is performed when
the patient wears the mximum amount of BO
prism power for periods of at least 10 minutes. The
goal is clear, single, comfortable binocular visin
without suppression.
Framing and Prisms (TI 4.18)
Pola-Mirror Vergence
Techniques(T14.19)
Training with the Pola-Mirror was discussed in Chapter 12 as an antisuppression technique (TI 2.9) and is
shown in Figure 12-10. Because this type of training
monitors foveal suppression, vergence training can
be done while bifixation is being ensured. In Cl
cases, the technique involves push-ups with the
Pola-Mirror to train fusional convergence. The
patient is instructed to hold the mirror at arm's length
and to.move it slowly closer to approximately 5 cm.
The patient is to see both eyes simultaneously. If one
eye darkens, indicating suppression, the patient is to
blink that eye and pay attention to it using mental
effort to break the suppression. The intermedate goal
is to be able to see both eyes at all times from a
range of 75 cm (note doubling of image distance by
mirror [.e., 1.5-m image distance]) to approximately
10 cm. A final goal in Cl cases can be to master this
technique while wearing 20A BO prisms over the
polarizing filters during tromboning of the mirror.
In cases of BX and DE, the patient performs the
described technique but emphasis is on pushaways, because the fusional convergence demand
is greater at far. Training can begin at a near distance, and the mirror then is slowly moved farther
away (or the patient walks away), to at least 75 cm
(i.e., 1.5-m image distance). By adding BO prism,
the fusional convergence demand is increased even
more. The patient should practice this technique for
5-minute periods at least twice daily. The goal for
the BX or DE patient is to achieve fusin continuously without suppression during push-aways.
Computerizad Convergence
Training (T14.20)
Computerized visin therapy programs for exo
deviations are founded on the same principies as
Chapter 14
419
xr
^r>>
are those for eso deviations (T13.16). Such programs provide excellent training techniques for
step and sliding vergences. Vergence ranges often
are improved quickly in children as well as adults,
because al I patients seem to appreciate the game
features of computerized programs. We recommend such programs because of patient interest
and the motivation they stimulate. Particularly fascinating s Computer Orthoptics by Dr. Cooper,
which incorporates high-speed liquid crystal filters
for mutual cancellation of targets for the right and
left eye (see Appendix J and discussion in Chapter
16). Most of the training techniques for patients
with XT and XP can be accomplished with com-
puterized programs for improving fusional convergence ranges, facility, and stamina.
CASE MANAGEMENT
AND EXAMPLES
Divergente Excess Exotropia
Management Principies
True DE XT and XP are characterized by a farpoint
deviation that is substantially larger than at near.
These patients present with farpoint problems (e.g.,
asthenopia, diplopia, a cosmetic deviation) and
often show normal fusional skills at near. DE usu-
420
Chapter14
Chapter14
her right eye. The patient's and the family's eye and
health histories were unremarkable. There was no
history of eye surgery, and the patient was doing well
in school.
Pertinent clinical findings were as follows:
Habitual lenses (2 years od)
+
OD:+0.25-2.75x180 20/30
OS: +1.00-2.50x140 20/30
Refraction
+3
OD:+0.25- 2.25x015 20/30
+2
OS: +1.00-2.50x155 20/30
Cycloplegic and manifest refractions were not significantly different.
The binocular visin evaluation indicated a comitant, ntermittent, alternating, XT of 20A at far and
10A XP at near. The Worth four-dot test showed good
fusin at near but i ntermittent suppression OS at far.
Fusional vergences measured as follows: Bl A78/2,
BO A/10/4 at far and, at near, B110/12/10, BO A/10/
4. The monocular accommodative amplitudes were
reduced for the patient's age (OD, 9.00; OS, 9.00),
as was the relative accommodation (negative
[NRA], +1.00; positive [PRA], -1.00). The NPC was
normal (8 cm), but stereopsis appeared slightly
reduced (70 seconds of are on Randot). Eye health
examination proved unremarkable.
The diagnosis was modrate astigmatism with possible slight meridional amblyopia oculus uniter (OU),
DE XT, normal correspondence, suppression at far,
slightly reduced stereopsis, and slight accommodative nsufficiency.
Vision therapy n the office and at home during
the first four weekly visits emphasized accommodative training with minus lenses and a Hart Chart,
vergence training with pencil push-ups and pushaways, Brock string and beads, and the three-dot
card. Accommodative skills had improved. By the
fifth visit, after Vectograms, the Aperture-Rule
Trainer, the Lifesaver card, and Tranaglyphs had
been ntroduced, the patient was able to appreciate SILO and converge 18A BO and recover 9A BO
at nearpoint. Accommodative skills had also
improved. By the seventh visit, she was able to
perform chiastopic fusin walk-aways with large
eccentric circles and projected Vectograms.
The training results after week 7 indicated significant mprovement in most binocular findings. No
strabismus was found at near or far. Fusional vergences had increased: Bl A/14/12; BO 8/10/8 at
far, and Bl 14/16/8, BO 18/30/18 at near. The relative accommodation was normal (NRA, +2.25;
421
20/25
20/25
Basic Exotropia
Management Principies
Patients with basic XT (the normal AC/A type) tend
to have the largest angles of deviation and the highest prevalence of constant deviations, although the
majority are i ntermittent. Most BX patients have an
ntermittent strabismus at near and a constant strabismus at far, as in DE cases. Exotropes, n general,
have a better prognosis for a functional cure than do
esotropes but, as in esotropa, constancy of the deviation s a major consideraron (a 30% factor) in predicting successful outcome.7
Our approach to therapy n cases of constant XT,
whether associated with NRC or ARC, is to attempt
to convert the constant deviation into an intermittent deviation at near distances as soon as possible.38 This step assumes that amblyopia is not
present or has been successfully treated. As discussed previously, we train for fusin at near using
gross convergence (T11.13) and voluntary conver-
422
Chapter14
Chapter14
NRC was found on all tests. The patient had suppression at far on the Worth dot test but good
fusin at near. Stereopsis at near on a contoured
test was 140 seconds of are. Fusional vergence
ranges were limited, being only 4 A diverging and
5A converging around angle S in the major
amblyoscope. The NPC was 15 cm to breakpoint
and 20 cm to recovery. Monocular accommodation was normal, but binocular accommodative
facility could not be tested because of suppression
when plus lenses were introduced.
These findings were discussed with the child's
parents, and recommendations for visin training
were made. The possibility of surgery was discussed but not recommended owing to the good
prognosis for cure with visin training. The estimated treatment time was 20 to 25 office visits
along with home training.
The first 8 weeks of visin therapy consisted of
gross convergence training (pencil push-ups, Brock
string and beads, and three-dot card), accommodative training (various techniques using a Hart
Chart), and a variety of saccadic and pursuit training techniques. The next phase involved the following training techniques:
1. Sliding vergence techniques, including
Vectograms emphasizing BO demands and
perception of SILO, Bernell Mirror Stereoscope, and major amblyoscope
2. Step vergences, including Vectograms, Ber
nell Mirror Stereoscope, major amblyo
scope, and televisin trainer (with -2.00-D
overcorrection to faciltate fusin at far)
3. Chiastopic fusin with Lifesaver cards and
Keystone Eccentric Circles (near and far)
with -2.00-D overcorrection at far when
needed
4. Accommodative rock, monocular and bin
ocular
5. Fusional high-level vergence techniques
(e.g., Delta Series Biopter Cards for far BO
recoveries, projected vectographic slides,
and accommodative rock combined with
vectographic Bl and BO demands)
After 15 weeks of office visits and home training, the patient was cured of XT. There were normal vergence ranges, and oculomotor deficiencies
were abated, as were accommodative infacility,
suppression, and poor stereopsis. At the time of
dismissal, the patient was prescribed a home
maintenance therapy program including eccentric
423
Convergence
Insufficiency Exophoria
Management Principies
Cl exo deviation refers to a prevalent condition
characterized by a low AC/A ratio, a larger exo
deviation at near than atfar, deficient fusiona! convergence and, often, a reduced NPC (beyond 8
cm). Frequently, there exists an associated accommodative deficiency. Exophoric Cl is far more
prevalent than s exotropic Cl, but the management principies are essentially the same. Between
3% and 5% of the young adult population was
reported for a prevalence of Cl.40 Patients usually
present with a slight XP at far and a larger XP and,
occasionally, XT at 40 cm. Visual symptoms
include headaches, occasional diplopia, ntermittent blurring, eyestrain, tired eyes, loss of concentration, and sleepiness, among others. Cl has also
been found to be more prevalent among students
with reading problems. 8 Differential diagnosis
requires distinguishing etiologies other than a low
AC/A ratio and deficient fusional convergence,
which account for the gross Cl, as indicated by a
reduced NPC. These other neuromuscular conditions include accommodative insufficiency resulting in pseudo-Cl and convergence weakness due
to neurologic paresis or paralysis. (Another possible cause of a remote NPC is convergence excess
esotropa; at near distance, the esophoria increases
beyond the limits of fusiona! divergence, resulting
in a "break.")
Vision training has been the traditional therapy
for Cl. In most cases, it can be considered to be an
effective and practical approach, and training time
is brief. Grisham8 evaluated the results of training
in Cl cases reported between 1940 and 1984. With
a datbase of 1,931 cases, the cure rate was 72%,
the improvement rate 19%, and the failure rate
9%. Daum 41 analyzed the results in 110 Cl
patients and presented the clinical factors that correlated with success. Most of the training in this
patient series was completed at home. The average
training time was 4.2 weeks. The average age of
the patients was 20 years, ranging from 2 to 46
years. Adult patients were mildly associated with
shorter periods of treatmen, presumably due to
424
Chapter14
Chapter14
425
Chapter14
426
2.5
I Relief from Symptoms
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WEEKS
The following case of XP with Cl also was contributed by Dr. Garth N. Christenson, an optometric
practitioner, of Hudson, Wisconsin. A 16-year-old
female patient presented with reports of frontal headaches after reading for approximately an hour, blurring of words, great difficulty concentrating during
reading, and problems focusing from far to near. Her
health history was unremarkable. The refraction indicated only a slight amount of hyperopic astigmatism
that was considered to be clinically insignificant. The
uncorrected visual acuities were 20/15 OD, OS, and
OU. Pursuits and saccades were full and normal with
comitancy. Cover testing indicated orthophoria at 6
m and 7A XP at 40 cm. NPC was 5 cm to breakpoint,
and recovery was 7 cm; however, the breakpoint was
8 cm and recovery 10 cm after five attempts (indicating a possible problem with vergence stamina). There
was good fusin on the Worth four-dot test. The Randot Stereo test at near and the Vectographic Slide at
IO
WEEKS
Chapter14
REFERENCES
1. National Center for Health Statistics. Refractiva Status and
Motility Defects of Persons 4-74 Years. National Health
Survey 206, 1971-1972. United States Vital and Health
Statistics, Series 11. Hyattsville, Md.: DHEW Publications,
1978.
2. Schlossman A, Boruchoff SA. Correlation between physiologic and clinical aspects of XT. Am J Ophthalmol. 1955;
40:53-64.
3. Simons HD, Grisham JD. Binocular anomalies and read
ing problems. J Am Optom Assoc. 1987;58:578-587.
4. Simons HD, Gassler PA. Vision anomalies and reading
skills: a meta-analysis of the literature. AmJ Optom PhysiolOpt. 1988;65:893-904.
427
428
Chapter14
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
429
430
430
Occlusion
430
Prism Compensation 432
Ocular Calisthenics 433
Sensory and Motor Fusin Training 433
Fusin Field Expansin (T15.1) 434
Double Maddox Torsin Training (T15.2)
434
Surgery and Follow-Up Management 434
Intractable Diplopia 435
Diagnosis 435
Occlusion Strategies 436
Prism Displacement 437
Hypnotherapy 437
Congenitai Nystagmus 438
INFANTILE NONCOMITANT
DEVIATIONS
Diagnosis
Management
When an nfant s found to have a noncomitant deviation from birth or within the first year of life, the clini-
430
Chapter 15
ACQUIRED NONCOMITANT
DEVIATIONS
Diagnosis
When a patient of any age presents with an acquired
noncomitant strabismus, often accompanied with
reports of diplopia, an active neurologic condition
must seriously be considered and ruled out. Often, a
referral to a neurologist or neuro-ophthalmologist is
Occiusion
Diplopia s the most pressing problem facing
patients with recent onset of extraocular muscle
paresis. This annoyance can easily be eliminated
by prescribing an occluder to be worn over the
affected eye. Although this has been the traditional
method in paretic cases, generally it s better to
recommend altrnate occiusion rather than confining the patch to the paretic eye. Occluding the
sound eye may provide beneficial stimulation to
the paretic eye that can lead to eye movernents
into the field of action of the paretic muscle. Patching the unaffected eye may reduce the risk of secondary contracture of the homolateral antagonist
of the affected eye. For example, if the right lateral
rectus muscle (RLR) is paretic, patching the left eye
might encourage the patient occasionally to
abduct the right eye to view objects in right gaze.
This should occur unless the patient has become a
head turner. When the patient abducts the ri ght
eye, the right medial rectus (RMR; the homolateral
antagonist) relaxes and, consequently, may help to
prevent contracture of that muscle.
Continuous patching of the nonparetic eye can
lead to trouble, because contracture may develop
in the contralateral synergist. In this example of a
paretic RLR, the yoke muscle s the left medial rectus (LMR), which will overact (risking contracture
because of Hering's law) when abduction is
attempted with the right eye. Therefore, altrnate
occiusion is preferable because of the possibility of
contracture of either the homolateral antagonist
(e.g., RMR), when the affected eye is occluded, or
the contralateral synergist (e.g., LMR), when the
sound eye is patched (Figure 15-1).
Chapter15
431
CONTRACTURE
OF RMH LIKELY
RELAXATION
OFRMR
STI M U L AT I O
N
EXCESSIVE
INNERVATION
TO LMR WITH
CONTRACTURE
LIKELY
RELAXATION
OFLMR
FIGURE 15-2Partial occlusion for relief of diplopia in cases of noncomitancy. a. Occluder on temporal portion of spectacle lens in case
of right lateral rectus paresis, b. Base-out Fresnel prism when fusin
can be obtained on dextroversion in case of mild paresis.
Binasal occlusion can also be applied to prevent diplopia and contractures n cases of sixth
nerve palsy. Binasal strips of opaque tape are
positioned on spectacle lenses to promote alternation of fixation (see Chapter 11). The right eye
is used for fixation in the right field of gaze, and
the left eye is used for left gaze. In this way,
abduction of each eye is continuously encouraged and thereby prevents contracture of the
medial recti. The procedure works well with
cooperative adults who understand the importance of alternately abducting each eye as much
as possible. Young children, however, are less apt
to cooperate fully and tend to become head turners, using only one eye for fixation. Total unilateral occlusion, alternated on a daily basis, s
recommended in such nstances.
Partial occlusion can be used to prevent diplopia n some cases of mild paresis. If the patient has
a mild RLR paresis, for example, with diplopia
only in right gaze, the temporal portion of the right
spectacle lens can be occiuded (Figure 15-2a). This
type of occlusion allows the patient to maintain
fusin n the primary position and in left gaze,
which s therapeutically desirable, possibly with a
slight right head turn. Diplopia s prevented with a
versin eye movement to the right field. A Fresnel
prism may also be tried (see Figure 15-2b). Partial
patching does not prevent contracture; fortunately,
contracture is usually not of serious consequence
in cases of mild paresis.
432
Chapter15
\/
Prism Compensation
If possible in cases of recent diplopia, fusin
should be maintained with Fresnel prisms without
resorting to occlusion. This ideal seems achievable
only when the extraocular muscle paresis proves
to be mild. von Noorden reported, "When a deviation is less than 10 prism diopters we have found
prismatic correction to be most effective in deleting diplopia." 1 We recommend trying Fresnel
prism compensation even in cases of modrate
paresis in which a deviation exists in the primary
field of gaze at far or near (or both). Fresnel prisms
can easily be changed to keep up with changes in
the angle of deviation during the healing period. In
cases of modrate paresis, prisms can be prescribed for a specific distance and for specific
Chapter15
power at the particular axis is recorded for a strabismic eye. For example, for a deviation of 8 A
base-up and 18A BO of the left eye, the measurement and prescription would be approximately
20A at 23 degrees oculus sinister (OS) (Figure 15-4).
This information is given to the optical laboratory
for fabrication of either a ground-in prism or a single Fresnel prism.
For training at home, we have found the Marsden ball technique (T16.14) to be effective. An
afterimage placed on the fovea of the paretic eye
can provide visual feedback to the patient as to
the accuracy of the pursuit eye movement as the
patient attempts to keep the afterimage on the
swinging ball (T10.17). There are also severa!
appropriate saccadic training techniques (TI 6.1T16.12) for therapy in the affected field of gaze,
described in the next chapter. Playing various eyehand coordination games, such as Ping-Pong or
computer games (T16.12), is effective and popular
with patients.
Ocular Calisthenics
Physical therapy is recommended for paretic
extraocular muscles. Exercises designed to forc
the paretic eye to move, particularly toward the
field of action of the affected muscle, may help in
restoring function and preventing contracture.
Many pursuit and saccadic techniques discussed
in Chapters 10 and 16 are appropriate here. Initially, the unaffected eye is occluded for monocular pursuit training of the affected eye. (Refer to
Tables 16-5 and 16-6 for specific techniques.)
Sensory and
Motor Fusin Training
The patient should be fusing as much of the time as
possible after an acquired extraocular muscle paresis. The majority of patients have a history of good
binocular visin prior to the onset of noncomitancy.
1 2
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434
Chapter15
Chapter15
After the waiting period, when the residual deviation n the primary position exceeds 15A esotropa,
20A exotropia, or 12A vertical strabismus and
remains significantly noncomitant, extraocular muscle surgery should be considered as a treatment
option.5 Lesser degrees of deviation can often be
successfully managed with a combination of compensating prisms and visin training.
These patients often need cise follow-up care,
regardless of whether an operation is required.
There is usually some residual deviation that may
present a fusin problem to the patient. Six-month
progress checks are realistic for many patients, but
each must be judged by resultant clinical features
of the deviation.
INTRACTABLE DPLOPIA
Diagnosis
When a patient presents with double visin, the
clinician must discover the cause, because some
etiologies are life-threatening (e.g., a brain tumor).
Several history questions should be asked: Is the
diplopia monocular or binocular? Does t occur
with or without spectacles? Is t constant or ntermittent? Under what circumstances is it present?
Describe the time and type of onsetrapid or
gradual. What is the separation distance and direction? Are there associated general health, neurologic problems, and ocular health signs and
symptoms? The diagnosis often requires an accurate refraction and visual acuity assessment, a
complete ocular motor evaluation, and thorough
visin and general health examination.
Successful management of intractable diplopia
presents a challenge to the clinician. This condition
occurs when there s some insurmountable obstacle to sensory and motor fusin and a lack of suppression to prevent diplopia. Fusin may not be
established by conventional therapeutic methods:
refractive error correction, prism compensation,
visin training, or surgery. These methods for reestablishing single, clear, and comfortable binocular visin should be tried or at least considered
before other means are attempted to elimnate one
of the diplopic images. Intractable diplopia can
occur from severa! causes, such as (1) a change in
Ihe angle of devation in a developmental strabismus associated with ARC; (2) nonfusible metamorphopsia; (3) bilateral superior oblique palsy; and
(4) sensory fusin disruption syndrome. These cases
435
are somewhat rare, but most clinicians will eventual ly be called on to manage or refer a case for
defintive treatment. Each etiology s discussed,
along with its therapeutic mplicatons.
In some individuis having a constant strabismus in early childhood, ARC becomes adapted
permanently to a particular angle of deviation.
Unlike most patients with ARC n whom this sensory adaptation shows considerable variability
(e.g., covariation), a few patients show little or no
variation in their angle of anomaly when the angle
of deviation changes for some reason later in life.
The strabismic angle may change during life for
any number of reasons, and intractable diplopia
may occur due to cosmetic strabismus surgery, 6
injury, disease, visin training (particularly inappropriate antisuppression training), growth, and
idiopathic causes. Suppression is not deep n these
cases, so the change in the angle of deviation may
be accompanied by diplopia. We have seen cases
in which the diplopia s present oniy when the
patient's attention is directed toward the second
image or under certain testing conditions; otherwise, the second image s usually suspended from
perception. In one case, testing revealed central
horror fusionis; the images could not be fused n
real space or n a major amblyoscope. The patient
was reassured that the diplopia represented only a
potential problem requiring no treatment at that
time. The patient was counseled to continu to
ignore the double image and not to look intentionally for it.
Some patients with early-onset strabismus experience "fixation switch diplopia." 7'8 When these
patients fixate with the preferred eye, they have no
diplopia, due to suppression or ARC. When fixating with the nonpreferred strabismic eye, however,
they notice diplopia. Fixation switch seems to
occur primarily in patients with good visual acuity
in the nonpreferred eye and in patients in whom
patching of the dominant eye has occurred for an
extended time, as in the treatment of amblyopia. If
there s spontaneous altrnate fixation and the
resulting diplopia is bothersome, the patient needs
reassurance and treatment. Such patients can be
taught to elimnate the diplopia by blinkng the
nonpreferred eye to switch fixation back to the preferred eye. If this simple measure is not sufficent,
the visin of the strabismic eye can be optically
blurred to discourage fixation.9 A careful diagnosis
is necessary before treating such patents on a
symptomatic basis. It s possible that when patients
436
Chapter15
Occlusion Strategies
Some patients who experience intractable diplopia
can tolrate the condition under certain circumstances. They occlude their nondominant eye only
when critica! viewing s needed (e.g., when driving
or reading). Other patients find diplopia intolerable
at all times and prefer constant occlusion. In these
latter cases, one acceptable solution may be wearing
Chapter15
Prism Displacement
Most patients with i ntractable diplopia do not
respond well to compensatory prisms. In cases of
horror fusionis and sensory fusin disruption syndrome,12 n which the images are closely aligned or
overlapped with prisms but fusin does not occur,
patients may find the diplopia more annoying than
f the images are separated by a large distance.
437
Occlusion strategies:
Hypnotherapy
We have recommended hypnosis as a last-ditch
therapy for cases of ntractable diplopia in which
nothing else has worked. These unhappy patients
are referred to a clinical psychologist skilled n
hypnotherapy. The psychologist evalales and
438
Chapter15
counsels the patients regarding their emotions surrounding the condition and sets specific goals for
hypnotherapy. If such patients are good hypnosis
candidates (and not everyone is), they are given a
posthypnotic suggestion to ignore the double
image and to experience less anxiety about the
problem. Several sessions may be required, but
some patients benefit greatly from this approach.
CONGENITAL NYSTAGMUS
Diagnosis
Nystagmus, affecting approximately 0.4% of the
population, 18 is considered to be a "red flag" for a
neurologa disorder. Most cases, however, are congenital, static, and of long duration. The cause of
congenital afferent nystagmus may be easily identified (e.g., optic atrophy, ocular albinism, congenital
cataracts). Determining the etiology can be subtle in
congenital efferent nystagmus, owing to obscure
lesions in the brainstem. An effort should be made
to determine the cause and characteristics in every
Optical Management
In treating binocular anomalies, we have consistently emphasized the importance of fully correcting
any significant refractive error; in the case of congenital nystagmus, this principie is even more applicable. Refracting, however, is not easy in nystagmus
cases, for obvious reasons. The prescription needs to
be refined frequently through repetition. Binocular
visual acuity may be improved, and nystagmic eye
movements may be lessened, with the wearing of an
appropriate spectacle or contact lens correction in
both afferent and efferent types of nystagmus.
In cases of significant refractive error, a trial fit
with rigid gas-permeable contact lenses should be
evaluated and seriously considered as a treatment
option. In some patients, contact lenses have
resulted in immediate improvements of nystagmus
and visual acuity, whereas other patients improve
over time. Many patients, however, show no
improvement, but this cannot be accuratel y predicted before a trial fit. The improvements, f they
occur, may be attributed to previously undetected
and uncorrected astigmatism that is often associated with congenital nystagmus. Another possible
explanation is that the lenses cause subtle eyelid
sensations of the nystagmic eye movements; the
patient may learn some degree of nystagmus control using this form of sensory feedback.
A prism can be used in some cases of congenital
nystagmus to diminish the oscillations. One com-
Chapter15
mon observation is that the frequency and magnitude of nystagmus decreases with convergence. 20
If, for example, the patient has an exophoria, the
clinician should evalate the effect of BO prisms
or plus-add lenses on the control of nystagmus.
Metzger21 reported a case of a 10-year-old highly
myopic boy who was given prisms of 6A BO; his
binocular visual acuity improved from 10/100 to
10/40, and reading became comfortable.
If the binocular status can be improved in cases
of esotropa, there often s an improvement in the
characteristics of nystagmus (see the section Case
5: Congenital Nystagmus). The amount of prism
necessary to reduce the nystagmus by placing the
eyes n a fused, converged position vares, dependng on the specifics of each case; the total amount
generally ranges between 6A and 20A BO. Fresnel
prisms may be necessary for the higher prescriptions. Metzger21 described an albino girl with congenital nystagmus, high myopia and astigmatism, a
hearing impairment, latent nystagmus, and an
alternating esotropa. Prisms of 15A BO were prescrbed and gave immediate improvement of the
nystagmic oscillations and visual acuity.
Minus-add lenses have also been used to attempt
to reduce the nystagmus, but this approach may be
undesirable n some cases.20 The primary problem
with minus-add lenses is that an esophoria at near
may be produced, rendering reading or other sustained close-viewing activities uncomfortable.
Yoked prisms may be used as a means of treating an abnormal head posture associated with
congenital nystagmus. As an example, consider
the patient with a left head turn and a quiet zone
in right gaze. A BO prism over the left eye and an
equal base-in (Bl) prism over the right eye will
shift both eyes and the nuil point to the right,
partially relieving the head turn (Figure 15-5).
Small to modrate amounts of head turn (to
approximately 15 degrees) can be managed n
this way. The prisms required for larger amounts
are often unacceptable to the patient, owing to
distortion and cosmesis. Through the prisms, the
eyes appear deviated to an observer, and one
cosmetic problem s merely substituted for
another. It seems that yoked prisms have a role to
play but only n borderline cases of abnormal
head posture. For example, f a patient has a 15degree head turn to the left, 10 A yoked prism
bases-left would reduce the head turn by some 5
degrees, rendering the remaining head turn cosmetically acceptable. This amount of prism can
439
FIGURE 15-5Example of yoked prisms to dampen nystagmus. a. Nystagmus on left gaze or n primary position. b. Minimal nystagmus on
right gaze or with left head turn. c. Patient looking straight at target,
but eyes are in right gaze position because of yoked, base-left prisms.
be ground into spectacle lenses with an acceptable edge thickness, if the eye size and lens
power are limited.
Vision Training
Several visin training techniques may be
attempted to help to lessen or elimnate nystagmus
in congenital cases. A consistent clnical observation regardng nystagmus intensty is that t
decreases as binocular visin is enhanced. If a
patient has insuffcient sensory or motor fusin, the
nystagmus seems to have larger amplitude and
higher frequency. Because of these observations,
various methods have been attempted to improve
sensory and motor fusin.22 Antisuppression and
fusional vergence training can be administered
using most of the different instruments and techniques discussed in other chapters. This form of
therapy seems to have a beneficial effect in heterophoric cases n which there is already some normal peripheral sensory fusin, but t has rarely
been attempted in nystagmus cases complicated
by esotropa. Three training methods that have
been particularly effectve n the management of
congental nystagmus are afterimage tag techniques, intermttent photic stmulation, and auditory biofeedback.
Afterimage Tag Techniques (T15.3)
The use of afterimages s a practical training technique for improving steadiness of fixation and
Chapter15
440
X
x x *x* x
x * x x
X
x
X X X
XX
XX
Y*
00o0
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OOoO O
O 0 00 _
O O O
o o
O
A
^ A A
V A
A
A
0 0
A A
A A A
reducing a compensatory head turn. The afterimage gives the patient visual feedback regarding the
intensity of nystagmic oscillations. A binocular
afterimage is applied using a strobe flash generator
(see Figure 5-40a) from a distance of approximately 50 cm while the patient holds fixation as
steady as possible at the nuil point, if present. The
patient observes the movement of the afterimage
as a blank screen is viewed with a blinking light in
the background to intensify its perception. As
threshold size targets are gradually introduced into
the visual field, the patient attempts consciously to
reduce the intensity of the afterimage movements
and to resolve the detail of the targets. The goal o
this technique is to develop patients' conscious
control of the nystagmic eye movements so that
they can dampen the oscillations at will, under
social circumstances, orwhen maximal visual acuity is required.
Expanding the nuil regin to the primary position
also can be attempted by having patients first adjust
the head posture to reduce the oscillations (the nuil
position) and then slowly moving the head toward
the primary field of gaze while attempting to maintain the dampened oscillations.23
Intermittent Photic Stimulation (T15.4)
Mallett24 adaptad an amblyopic training technique
Chapter 15
441
Surgical Management
One of the cosmetic consequences in many
cases of congenital nystagmus s a disfiguring
head posture. The patient naturally prefers a
peripheral field of gaze in which the nystagmus
oscillations lessen and visual acuity improves.
Kestenbaum 31 ntroduced a surgical procedure
designed to move the nuil point to the primary
position, obviating the need for a head turn. All
horizontal rectus muscles were operated on to
rotate both eyes away from the eccentric nuil
point. Resection and recession procedures were
recommended for yoke muscles in each eye,
with an dentical amount of adjustment administered to each. For example, to move the nuil
point from left gaze, resections of the RLR and
442
Chapter15
6[ 'f^^^^i^^
5 sec
Chapter15
443
mproves.39 In these cases, the possibility of convert ng manifest to latent nystagmus by strabismus
surgery is a reasonable goal.
ACQUIRED NYSTAGMUS
Diagnosis
When a patient presents with acquired nystagmus,
the presumption s that the cause is a disease process of some type affecting oculomotor neurology.
A differential diagnosis must be established so that
the underlying cause can be treated. When the
cause is successfully treated, the nystagmus usually
disappears. (SeeTables 8-15 and 8-16 for a description of several acquired and, fortunately, rare types
of nystagmus.) When the cause s not readily apparent, computed tomography and magnetic resonance imaging studies are often indicated. If the
etiology of nystagmus s attributable to an infectious process, a vascular disorder, or a metabolic or
toxic imbalance, appropriate medications are an
indispensable part of the medical management of
the underlying condition. (Description of the many
possible alternatives s beyond the scope of this
text.)
Management
A few medications have been effective in the symptomatic relief of oscillopsia and vrtigo associated
with vestibular nystagmus, down-beat nystagmus
and, on rare occasions, congenital nystagmus. The
illusory sensation of movement of an object or the
environment s a particularly distressing and debilitating symptom. When this symptom occurs, t is
nearly impossible to read comfortably or sustain
any demanding visual activity. Symptomatic relief
from an oscillating world, even for a short time, is a
desired goal of all afflicted patients.
Currie and Matsuo40 reported a series of 10
patients whose vertical oscillopsia associated with
down-beat jerk nystagmus was successfully reduced
or eliminated with the administration of a 1- to 2mg dose of clonazepam. The nystagmus n these
cases had various etiologies: Arnold-Chiari malformation, cerebellar hemangioblastoma, cerebellar
infarction, and mltiple sclerosis. The nystagmus
and oscillopsia were lessened or eliminated for 2-6
hours per dose, and one patient experienced relief
for 72 hours per dose. In 7 of the 10 cases, visual
acuity mproved during the treatment period. The
444
Chapter 15
CASE EXAMPLES
Case 1: Duane
Retraction Syndrome
Griffin and Carlson44 reported successful results
with visin therapy n a 10-year-old boy with
Duane retraction syndrome (DRS) (see Chapter
8). DRS of this patient was first diagnosed at age
3 by a pediatric ophthalmologist. On presentation, the patient reported discomfort, fatigue, and
pain when reading. He also was aware of occasional diplopia in secondary and tertiary positions of gaze and relied on head turning for
compensation.
Clinical findings were as follows. Refraction and
acuities were
OD: plano 20/20 (6/6)
O S :+ 0. 2 5 - 0 . 2 5 x 1 0 5
20/20 (6/6)
Chapter15
445
FIGURE 15-8Example of Duane retraction syndrome (type III). a. Patient fusing in the primary position of gaze. b. Esotropa on dextroversion due
to restriction of abduction of the right eye. There s narrowingof the left palpebral fissure that is made moreobvious by the vertical strabismus in this
position of gaze. The appearance is that of a left hypertropia, but the left eye was the fixating eye; therefore, the right eye was hypotropic as well as
esotropic in this position of gaze. c. Exotropia on levoversion due to restriction of adduction of the right eye. There is narrowing of the right palpebral fissure that s made more obvious by the right hypertropia n this position of gaze.
446
Chapter15
Case 2: Noncomitant
Intermittent Hypertropia
Bergin et al.46 reported a case of hyperphoria of
large magnitude with mild noncomitancy. The
patient was a 27-year-old man who presented with
no symptoms other than noticing momentary
diplopia when tired and having a dislike for reading, especially when fatigued with prolonged read-
20/15 (6/4.5)
20/15 (6/4.5)
Altrnate cover testing showed a small exophoria, approximately 10A at far and near, with a hyper
deviation of the left eye on continuous testing. A
base-down prism before the left eye was gradually
introduced in increasing amounts as the vertical
deviation increased, ultimately stopping with 50 A
base-down.
The left eye was patched, and the patient was
allowed to rest for 30 minutes. When the patch
was removed, the left hyper deviation was 26A. As
greater power of the base-down prism was given
while the patient maintained fusin, the deviation
stabilized with 52A base-down after 10 minutes,
presumably through prism adaptation (Figure 15-9a).
When the vertical prism was removed, the patient
quickly regained fusin; this was objectively
observable, and the patient reported the merging
of the momentarily seen diplopic images (see
Figure 15-9b). Other testing indicated that the right
eye was the dominant eye and that there was intermittent central suppression of the left eye. The
Hess-Lancaster test suggested a mild paresis of the
left inferior rectus and, possibly, of the right inferior oblique muscle. It can be speculated, however, that left superior oblique muscle paresis
occurred early in the patient's life and that there
was an eventual spread of comitancy. Pursuit
movements were normal, but the patient showed
frequent regressions on reading tasks. Nearpoint of
convergence was normal. Stereoacuity was 30 seconds of are, and Bl and BO motor fusin ranges
Chapter15
Case 3: Acquired
Third Nerve Palsy
A 53-year-old woman reported constant vertical
diplopia n the primary position and the necessity
of using extreme chin elevation to achieve binocular fusin. Two years previously, she had experienced a basilar artery aneurysm resulting in a
bilateral third nerve paresis, left facial palsy, and
balance problems. Neurovascular surgery at the
time saved her life. With healing, she regained
some of the lost functions; her balance improved
as did the facial palsy, but she presented with a stable bilateral restriction of up-gaze (-3), a constant,
noncomitant, unilateral, left 11 A hypertropia
decreasing in down-gaze, and horizontal jerk nys-
447
448
Chapter15
Fusiona! evaluation on the major amblyoscope indicated second-degree fusin at the subjective angle
but very limited fusional vergence ranges in Bl and
BO directions, due primarily to the variable hyper
and cyclo deviation.
Prism compensation was attempted at both far
and near without success; superimposition of the
images was possible, but sensory fusin did not
occur or was unstable. Vision training was considered as a treatment option but was rejected due to
the noncomitant cyclo nature of the deviation and
the impracticability of an in-office-based training
program in this case. Vertical and horizontal prism
displacement was tried to determine whether suppression would be easier for the patient; it was not.
The patient's main problem was visual confusin. Because the patient had good visual acuity in
each eye, a monovision spectacle correction was
evaluated using a trial frame. The patient's farpoint
correction was placed before the right eye and the
nearpoint correction before the left, as that eye was
hypotropic already in down-gaze. The patient's initial response was the report of diplopia, but now
there was one clear and one blurred image. With a
little practice, the patient was able to altrnate fixation easily between far and near. The following prescription was given for a trial period of wear:
OD: -1.25 -0.50 x 095 20/20 (at 6 m)
OS: +1.00 -0.25 x 088 .4M (at 40 cm)
The patient was instructed to wear the monovision correction for as much time as she could during a trial period of 2 weeks. At the progress check,
she reported that the monovision correction seemed
to be a major improvement. She had learned to
ignore the blurred image even during critical viewing, such as televisin and reading. Diplopia was
noted less frequently as she gained experience with
monovision spectacles. At a 6-month progress
check, the deviation had not changed significantly,
but she was essentially symptom-free, except for
high-contrast situations, such as viewing streetlights
at night.
Chapter15
449
30LET
5LET
50LET
40LET
(20/50), and there was less nystagmus than previously in the left field of gaze. Strabismus surgery
was performed at age 18 monthsa recessionresection operation of the left eyeresulting in an
intermittent 12A left esotropa and improved horizontal comitancy. The head turn reduced to
approximately 10 degrees left. Spectacle lenses
with BO prisms then were prescribed (OD: 3 A
BO; OS: 6 A BO). These prisms improved the
child's fusin n the primary position, further
reduced the head turn, and dampened the nystagmus. Although initially resistant to wearing the
prism spectacies, the child eventuaily accepted
them over a 2-month period; the binocular acuity
mproved to 20/30.
The patient was scheduled for progress checks
every 6 months and was released. The parents
were pleased with these results: minimal nystagmus; adequate acuity n each eye, no strabismus in
the primary position, and no apparent head turn.
This case Ilstrales that binocular therapy can help
to reduce congenital nystagmus.
REFERENCES
1. von Noorden GK. Binocular Vision and Ocular Motility:
Theory and Management of Strabismus, 5th ed. St. Louis:
Mosby; 1996:419.
2. Erickson GB, Caloroso EE. Vertical diplopia onset with
first-time bifocal. Optom Vis Sci. 1992;69:645-651.
3. Wick B. Vision therapy for cyclovertical heterophoria.
Probl Optom. 1992;4:652-666.
4. Iwasaki Y, Wanaka Y, Ikeda N, et al. Treatment and prog
nosis of diplopia. Nipn Canka Gakkai Zasshi Acta Soc
Ophthalmol Jap. 1993;97:815-850.
5. Rutstein RP. Evaluation and treatment of ncomitant deviations in children. Probl Optom. 1990;2:528-561.
6. Eskridge JB. Persisten! diplopia associated with strabismus
surgery. Optom Vis Sci. 1993;70:849-853.
7. Boyd TAS, Karas Y, Budd GE, et al. Fixation switch diplo
pia. Can J Ophthalmol. 1974;9:310-315.
8. Karas Y, Budd GE, Boyd TAS. Late onset diplopia in childhood onset strabismus. J Pediatr Ophthalmol. 1974;11:
135-136.
450
Chapter15
452
Chapter16
VISUAL COMFORT
AND PERFORMANCE
Vision efficiency s a modern concept. This concept, however, contines to be rrelevant to the
majority of people subsisting in a third-world agrarian culture. The level of visual requirements for the
farmer guiding a water buffalo is not as high as that
of a technical worker who is expected to succeed
in 12-20 years of formal education, which is
merely a precursor to an eventual occupation.
Vision efficiency refers to ocular comfort with high
performance over time. Many workers who must
look at a computer display for 7 or 8 hours daily
experience severe symptoms of ocular discomfort.
The causes of these disturbing symptoms may be
binocular anomalies, such as poor vergence or
accommodative skills, which are intensified if there
is a mismatch between that individuaos particular
oculomotor physiology and psychological disposition and the job's visin requirements. This chapter
is based on the premise that inefficient visual skills
can be remedied when it is in a patient's interest to
do so. Over the years, we have seen an ncreasing
number of office workers, computer operators,
machinists, lawyers, athletes, and others seeking
improvement in visual comfort and performance.
Unless world culture takes an unexpected turn in
its evolution, this trend toward the necessity for
higher visin efficiency will continu to accelerate.
The rise in world literacy s a fundamental part of
cultural and economic development. The print-ng
press, invented approximately 400 years ago,
rendered possible the distribution of books to the
public at large. Now we find that there are many
ocular conditions that compromise reading comfort and performance. Clinical experience and
studies have shown a higher prevalence of certain
visual problems among poor readers as compared
with skilled readers. Uncorrected hyperopia and
anisometropia, excessive exophoria and fusional
vergence deficiency, hyperphoria, and accommodative infacility have all been implicated by association.1 The computer age has burgeoned into mass
markets during the last few decades, and this genie
will not be put back into the bottle. A large number
of computer operators show deficiencies in vergence and accommodation over time. 2 Many
symptomatic individuis respond to increasing
visual requirements in inefficient ways. Some lose
interest and avoid the noxious stimulus altogether,
whereas many individuis tolrate the discomfort
ANISEIKONIA
Aniseikonia is an often overlooked condition that
is a barrier to efficient binocular visin. Unexplained binocular symptoms may be due to
aniseikonia. This condition s one in which the
ocular image size of one eye s different from that
of the other. This problem is often produced by
anisometropic corrective lenses f the power difference between the two eyes is significantly large.
Contact lenses may be a remedy in cettain cases,
particularly if the anisometropia s refractive,
meaning that the corneal curvatures of each eye
are greatly different. If, however, the anisometropia
is due to differences in eyeball length (axial anisometropia), a spectacle lens correction may be preferable to contact lenses. There are exceptions,
however, that show inconsistencies in Knapp's
law.3 This may be due to the fact that aniseikonia
can result from a difference in distribution of the
retinal elements and from a difference n the size
of the dioptric images formed on the retinas. Clinicians must, therefore, evalate each patient and
not always adhere strictly to Knapp's law. In some
cases of axial anisometropia, contact lenses may
be the preferred prescription. When the difference
in ocular image size is very small (e.g., less than
1%), symptoms usually are not produced. As the
size difference becomes greater, symptoms may
result. If the aniseikonia is greater than 5%, this
obstacle to fusin may render it impossible for
affected individuis to have central fusin.
Many of the symptoms reported by patients
with aniseikonia do not differ significantly from
symptoms of ametropia, heterophoria, and intermittent strabismus (e.g., headaches, asthenopia,
reading difficulties, and diplopia). 4 Other symp-
Chapter16
toms associated with aniseikonia are photophobia, nausea, nervousness, dizziness, vrtigo, and
general fatigue. When ametropia and binocular
anomalies are eliminated, the persistence of such
symptoms may indcate aniseikonia, providing
ihat such patents are in sound physical and mental health. Anseikonic symptoms are generally
long-standing and are not relieved by conventional prescription lenses or visin training.
However, the American Optical Space Eikonome-r is
no longer avalable for the precise measurement | o
the magnitude of anisekonia. Other methods
mam for nvolved clinicians. Clinicians can estithe magntude of aniseikonia from the refractive tion
of anisometropia. Ogle 5 suggested that ?konia of
1.5-2.0% is induced by every dopter i of
ansometropa that s corrected wth spectacle s.
Others have disagreed with Ogle's estmate
indcate that 1% per diopter s a more realistic ?.6'7
Most clnicans use 1 % per diopter as a cln-gudelne
(a so-called rule of thumb). Lubkn et L* reported the
lmitatons of such estimatons. The other method s
direct comparison of the images. There are
several ways in which can be dissociated for
drect comparison: cal prism dssociaton,
stereograms, and vec-jhic methods. We
recommend using a Mad-rod and two penlghts
(Figure 16-1 a). The are held by the cl inican,
one above the (separation of 15-20 cm), and the
patient fix-,the lghts from a distance of
approxmately 2 .The Maddox rod s orented with
ts axis at 90 s, so the patent should see two
horizontal ; with that eye. The other eye does not
have a jx r od b e fo re t b ut lo o ks dire ctly a t th e
If there s no aniseikonia, the patient should :the
streaks going through the lights (see Fig-16-1 b). If
there s a significan! degree of skonia, the
distance between the streaks will fferent from the
distance between the lights gure 16-1c). Iseikonicsized lenses are intro-before each eye n an
attempt to equalize fsize of ocular images n the
vertical meridian. (test other meridians, the
orientation of lights the Maddox rod are
rotated by the same it to axes of 180, 45, and
135 degrees. Any ital or vertical phoria or
tropia, however, be neutral ized with a prism
before the konic measurement can be made. 1 New
Aniseikonia Test (NAT) of Awaya (Han-rTokyo) is
composed of sets of red and green :les that are
anaglyphically viewed for size
453
MADDOX ROD
FILTER
OS.
OD
Chapter16
454
Back
Surface
0
-5.00
Thickness
(mm)
Front
Surface
(D)
+5,00
2
3
4
5
7
9
11
+11.25
+12.00
+12.00
+12.00
+16.50
+20,75
+25.00
-11.50
-12.37
-12.50
-12.62
-17.62
-22.62
-27.75
2.7
3.7
4.9
6.1
6.1
6.1
6.1
Magnifkation
(%)
Front
2,2
Magnification
<%>.
1
2.
3
4
5
j
9
11
Surface
(D>
Back
Surface
(0)
Thickness
(mm)
+5.00
-5.00
2.2
+7.50
+9,00
+10,00
+12.50
+16.3?
+20.62
+24.75
-7.62
-9.25
-10,37
-13.12
-17.50
-22.50
-27.50
3.9
4.9
5.8
5.7
6.0
6.0
6.0
[1 -.013(5)]A[1 -.003/1.530(11)]
Chapter16
We recommend direct measurement of image size
difference between the eyes and manipulation of
the shape factor in ophthalmic lens design to
reduce aniseikonia to within tolerable limits.
MONOVISION
Some presbyopic patients, particularly successful
contact lens wearers, prefer a monovision contact
lens prescription rather than the traditional solution of spectacle bifocals. Because these patients
usually have normal binocular visin, they choose
to disrupt their binocularity by wearing a contact
lens correcting the farpoint ametropia on the domnant eye and a contact lens add for nearpoint
viewing on the nondominant eye. The primary
advantage of monovision contact lenses is selfevident: There is no need for spectacles. In addition, monovision can provide far and near visin
independent of field of gaze. Unlike bifocals,
monovision contact lenses do not often present
visin problems while affected individuis are
descending or ascending stairs. However, monovision is accurately described as optically induced
anisometropia. When a monovision patient is carefully tested, foveal suppression will often be found.
In monovision patients, stereopsis measures on
average 60-90 seconds of are.10'11 This represents a
small reduction, but monovision contact lens
wear does affect accuracy in some occupational
tasks.12 Monovision also compromises visual resolution under low-contrast viewing conditions,
especially for adds of more than 1.50 D. 13 This
means that contrast sensitivity for night driving, for
example, can be significantly reduced.
Whether monovision contact lens wear is in a
patient's best interest is a decisin that must be
carefully made by the patient in consultation with
the doctor. What must be seriously considered is
the patient's need for binocular visin efficiency
and the chances of producing symptoms. We generally do not recommend monovision contact
lenses to presbyopic patients who have high visin
requirements (e.g., commercial drivers, pilots, surgeons, lawyers, or computer operators). These
patients often are not successful in making the
adaptation. Drivers can experience an annoying
glare at night 14; depth perception and resolution
can be reduced for critical nearpoint work 12; and
degraded binocularity can result in asthenopia
with prolonged reading demands.15
455
On the basis of our experience, we do not recommend the monovision approach to patients
whose binocular status is frage or poor. Lebow
and Goldberg16 reported that 20% of their monovision patients were unable to achieve seconddegree fusin. For example, we consider intermittent
exotropes to be poor candidates for a monovision
prescription. If such patients insist on wearing
monovision contact lenses, the doctor should, in
response, recommend visin training to improve
fusional skills. This training could possibly counteract the adverse effects of monovision contact
lens wear. Conversely, we do use a monovision
approach in some cases of binocular anomalies
(e.g., amblyopic patients who are managed with
optical penalizaron; see Chapter 10) and in some
cases of intractable diplopia.
Stepl
The first step in visin training for good saccadic
eye movements is to ensure good fixation ability of
456
Chapter16
Step 2
In step 2, the patient practices accuracy of saccades, progressing from large to small eye movements. The large saccades are mostly voluntary
and can general ly be improved with concentrated
effort by the patient. Fine saccades, as used in
reading, tend to be reflexive; they are more difficult to train initially. Training techniques would go,
for example, from the patient practicing wall fixations (gross saccades) to working with Ann Arbor
(Michigan) Tracking materials (fine saccades; see
T10.7 in Chapter 10). Table 16-4 lists some specific
training techniques that are arranged in a progres-
Chapter16
457
T16.1
T16.2
TI 6.3
T16.4
T1 S.5
T16.6
T16.7
T16.8
T16.9
T16.10
T16.11
T16.12
Fixatng and picklng up objectson a tabletop{e.g., toys, raisins, peanuts, cookie sprinkles, Iridian
beads). All 10 principies apply.
Pladng toothpkks in a soda stratvthat s moved from one location to another by the therapist. If the
patient consistently misses, he or she can use the other hand to lcate the straw, giving tactilekinesthetic support. The goals are accuracy and speed of eye-hand coordinaton.
Peg-board type games (e.g,, Lite-Brite, geoboards). The patient s instructed to place the pegs in the appropriate holes as quickly and accurately as possible. (See Figure 16-3, which depicts a Lite-Brite game.)
Wall fixations, The patient fixates randomly placed pictures or objects on a wall on command by the
therapist. All 10 principies apply. Also, a large picture of a baseball diamond can be hung on the wall,
The patient fixates certain bases on command, sirnulating a baseball game.
Fixations with an aftermage, This provides good feedback as to accuracy of eye movements and fixations and can be applied to most other specific training technques.
Continuous motion tasks, Numbers 1-15 (or more later in therapy) are randomly drawn pn a page and
the patient has to f ind and rnark each number in ascendng order on command (Figure 16-4). Also, the
patient can be instructed to draw a Continuous line to connect the numbers, by cirding them, in proper
sequence. Speed is the primary goal with thls technique. The Word Tracking workbook from Ann
Arbor Publishers is particularly useful for continuous motion techniques. The student draws a line under
the words without touching any word and circles the target words as instructed (see Figure 193cinPartThree).
lose pr/sm steps. Prism of various powers can be used, sequenced from large to small. The goal is for
the patient to perceive image dispacement artd make fine saccades as small as 0.5a. This s done
monocularly with the other eye faeing occluded.
Dot-to-dot games. Many games can be purchased in department stores and at newsstands for these
activities. The patient is instructed to connect a series of dots by drawing a continuous line from one
dot to the next, which completes a picture that is eventual ly revealed once the sequence is completed.
The Rosner Test of Visual Analysis Skills (TVAS) and training materials are excellent for many purposes,
including training accuracy and speed of saccades (Figure 16-5).
Filling Os or orier designated letters. The patient is instructed to fill n each letter O on a page of a
newspaper. The emphasis is on accuracy, eye-hand coordination and, eventually, speed.
Sequential fixation sheets (see Figure 2-7). Marks involving very little cognitlon, such as dots, dashes,
and asterisks, are printed on a page, and the patient is instructed to fixate each n a specified
sequence without hand support. The goal is speed and accuracy of saccades.
Symbols demanding cogniton. Letters, numbers, and words are used in a similar manner as in T16.10,
the difference being that quick and accurate saccades are required with relatively complex cogniton.
Computerizedprograms. Many video games involving eye-hand coordination are available and have
training valu (e.g., Nintendo). Smart Eyes is a program for the Macintosh that teaches speed-reading
strategies, with an emphasis on saccadic training, Also, the available visin therapy computerized programs all have tasks dedicated to building ocular motilty.
458
Chapter16
><
FIGURE 16-2Saccadic Fixator. (Courtesy of Wayne Engineering.)
Step9
The development of automated, reflexive saccades
is involved in step 9. Patients should be able to cope
with cognitive demands (commensurate with mental ability) so that they will not be distracted when
making accurate eye movements (see Chapter 2
regarding automated saccades). This is absolutely
essential for good reading ability, good work performance, or effective and enjoyable play. Much of this
type of training can be accomplished at home and,
it is hoped, at school. However, cise supervisin
must be provided to ensure proper saccadic
responses so that visin therapy is successful. Moreover, patients who are unable to achieve step 9 may
be no better off than if no saccadic visin therapy
was undertaken. The mportance of establishing
automated responses cannot be overemphasized.
Step 10
The final step n this sequence is the finishing process in which significant overshoots, undershoots,
or regressions are eliminated. If there are neurologic
soft signs, affected patients may not be completely
able to overeme these inaccurate eye movements.
However, we have been amazed at the progress
Chapter16
459
Specific Techniques
(T16.1-T16.12)
Many types of fixation targets can be used for saccadic training techniques. The 12 exemplary techniques usted in Table 16-4 can be applied to the
general training approaches just described (and
fcted in Table 16-3). Using ordinary objects as in
TI 6.1, the first step is for the patient to fixate the
i object (e.g., a peanut) steadily for several seconds.
| The therapist observes the patient's eye and provides
i feedback, regardless of whether there is steady fixaI Son. The use of an afterimage for the patient's subIjective feedback as to accuracy of fixation can also
| le used. In step 2, peanuts can be widely dispersed
a tabletop for gross saccadic training; with
roved performance, the peanuts can be placed
closely together for fine saccadic training. In 3, the
patient is encouraged to look from one iut to the
next as quickiy as possible. The perfor-ce can be
timed as the therapist closely watches
460
Chapter16
Sfep
Step 2
Step 2 involves proceeding from voluntary to reflexive responses. The concept of mental effort is useful.
Patients' attention must be actively engaged in the
Chapter16
possible to follow the target, whether it be a swinging Marsden ball, a moving hand-held penlight, or
an afterimage on the hubcap of a passing car. Volition (and attention) are important in the remaining
steps, particularly n controlling head movement.
Step 3
In step 3, eye-hand coordinaron is trained. Patients
should practice correctly pointing to the moving target. The act of pointing provides visual-kinesthetic
support for proper eye fixation and tracking. Many
of the techniques for amblyopia therapy presented
n Chapter 10 apply here. In time, after good eyehand coordination is achieved, pointing should be
discontinued so that pursuits can be practiced and
mproved without this support.
Additional eye-hand training may be introduced
for variety. One technique of which most children
are fond is the so-called talking pen (see Figure
10-10). The pen has an infrared light sensor n its tip.
When the tip of the pen is exactly on a dark line, no
sound is emitted; however, when the tip falls off the
dark line onto a bright portion of the paper, the pen
emits a buzzing sound. The sound is louder and
higher in pitch as the tip moves from a darker to
lighter rea. Later, when auditory feedback is not
essential, the tracing pursuits can be strictly visual.
Step 4
Step 4 involves progressing from small to large
excursions, as large as possible. (Note that the progression in saccadic therapy is different; the training
proceeds from gross to fine movements, because
larger saccades are easier to control than are smaller
saccades, such as reading saccades.) Pursuit training
begins within a range where success comes easily,
then ends with large excursions. The range of movement is naturally limited, being smaller for up-gaze
(approximately 30 degrees) as compared with other
directions. The rotation range with a swinging Marsden ball as a target, for example, can be ncreased
by simply having patients move closer to the target.
Step 5
Speed is emphasized in step 5. Fast pursuits are normally more difficult than are slow pursuits. Therefore, it is best to start pursuit training at a slow speed
within patients' ability to perform and progressively
to ncrease the target speed. On a training task, such
as a buzzing pen, patients are encouraged to finish
the task more quickly while mamtaining accuracy.
461
Step 6
Smooth movements can be solicited by giving
patients feedback regarding the accuracy of pursuits. Two types of feedback are available. The
therapist can directly observe patients' pursuit
movements and report inaccuracies as they occur.
Subjectively, patients can observe pursuit inaccuracies with a foveal afterimage tag. Step 6 s one of
the most effective n building accurate pursuits.
Some form of feedback is critical n all stages of
visin therapy.
If jerky pursuits are due to functional causes,
such as attention problems, the prognosis for
achieving smoothness is good. We consider the
prognosis for maturational delays in fine motor
coordination to be fair; training can improve pursuit movements in most of these cases. Nystagmus
and other neurologic disorders, however, present a
formidable obstacle in this regard. Nevertheless,
we have seen some patients with nystagmus
improve their pursuits, particularly after successful
results with accommodation and vergence therapy.
Step 7
In step 7, patients must become aware of unnecessary head movements during pursuits and exert
voluntary control to stop such movements. Positive
feedback to such patients is important. A convenient adjunct n therapy is to have patients "wear a
book" on their head. When it falls off, they know
that head motion was the cause.
Step 8
If monocular training of each eye has been effective
up to this point, the pursuit skill of the right and left
eyes should be approximately the same. If not, further training for the deficient eye is indicated. On
occasion, it is impossible to achieve equality.
Step 9
Binocular pursuits should be trained to the same
level as monocular pursuits. Usually, patients have
no problem n making the transition from ductions
to versions. An exception occurs when there is a
vergence anomaly. For example, intermittent exotropic patients may have difficulty n proceeding
from monocular to binocular pursuit training
because of the voluntary effort required to maintain bifixation on the target. Considerable vergence and binocular pursuit training may be
needed in this step.
462
Chapter16
Step 10
In step 10, cognitive demands are introduced, proceeding from simple to complex. Some adults can
calclate numbers while maintaining fixation on a
moving target. However, such complex tasks
exceed what is normally expected of younger
patients in visin therapy. Cognitive demands for
children must be appropriate to their ability. Children can be asked, for example, to sing a song,
count from 1 to 10, or state the ames of friends
and relatives.
Step 11
Step 11 focuses on integrating pursuit eye movements with general body posture, movements, and
balance. The vestbulo-ocular response (VOR) system nvolves the otolith organs, semicircular cais,
and neck receptors. This system integrales eye and
body movements and is increasingly involved when
individuis change posture requiring dynamic balance, as in skng. This is so when patients are asked
to stand on a balance board or to move forward and
backward on a walking rail while performing accurate pursuit eye movements. At first, there is a stimulus overloading for such patients; they will not be
able to balance and maintain good pursuit eye
movements as well as when in a sitting position. If
there are no neurologic defects in the VOR and pursuit systems, however, most patients can eventual ly
learn to cope with these demands and perform pursuits accurately.
Step 12
A stimulus "overloading" can also be accomplished by bringing in the vergence system, as is
accomplished n step 12. Base-out (BO) lose
prisms can be placed before patients' eyes to crate
a convergence demand while the patients view a
moving target (e.g., a hand-held moving penlight).
Conversely, a divergence demand can be created
by placing base-in (Bl) lose prisms before patients'
eyes. If they can overeme the prismatic demand
and continu to perform pursuits well, patients are
ready to proceed to more stressful demands.
Step 13
Increased stimulus overloading can be accomplished in many ways and is the task performed n
step 13. There are many permutations and variations using the previous 12 steps. For example,
patients may be asked to follow a moving target
Specific Techniques
(T16.13-T16.19)
Most of the foregoing general approaches (usted in
Table 16-5) can be applied to the seven specific
techniques listed in Table 16-6. An automatic rotating device, such as a Bernell Rotator (see Figure 213) can serve as an example. Once steady position
maintenance of a stationary target is estab-lished,
patients are asked to follow a target on the rotating
disk. Such patients may have to resort to voluntary
saccades before reflexive pursuits can be made to
follow the moving target. They can point to the
target for eye-hand support. Next, the size of
excursions can be ncreased by moving patients
closer to the instrument. The speed of the target
can be increased. Accuracy and smoothness of
pursuits are emphasized. It is important to give
patients adequate feedback regarding how well
they are doing in all steps, but particularly when
working on accuracy. Also, they should not make
unnecessary head movements during pursuit training. Each eye is trained ndependently until performance is equal. Binocular pursuits then are trained.
Cognitive demands (e.g., counting numbers aloud
while doing pursuits) are presented. Affected
patients stand up and balance to help intgrate
pursuits with the VOR system. Prismatic demands
for fusional vergences are ntroduced. Higher levis of performance can be achieved by combining
the aforementioned steps in various ways.
ACCOMMODATION
In this section, visin therapy is discussed for
accommodative excess, insufficiency, infacility, lag,
and poor stamina. These dysfunctions and their
diagnoses are discussed in detail in Chapter 2.
Chapter16
463
T16.13
T16.T4
T16.15
T16.16
T16.17
T16,18
T16.19
Automatk rotating dsks (e.g,, lernell Rotator [office]). The speed of the rotation can be changed f rom
slow to fast; the direction can be switched from clockwise to countrelockwis; and the size of excursions can be increased by having the patient move closer to the target.
Swinging bat (e.g., Marsden BaH [office or home}). The ball is suspended from the ceiling and set in a
swinging motion, The patient can look at the target at eye level for horizontal pursuit training or from
below while lying supine for circular pursuits,
Penlight pursuits (office or home). fn the office, the therapist moves the penHght target in various directions while the patient attempts to follow t smoothly and accurately. At home, the helper (e,g., parent, sibling, friend) acts as a therapist to provide the target movements.
Ple-pan pursuits (home). The patient is instructed to place a marbie in a pie pan or similar dish and to
move the pan so that the marbie can be seen rolfing arond at the edge, either in a clockwise or counterclockwise direction.
Flashlight spot chasing (office or home). The therapist or helper shines a spot on the waJI or celi ng from
his or her f lashlight while the patient holds another flashlight. The patent's task Is to follow the therapist's spot and to attempt to superimpose both spots of light, The therapist moves the spot slowly at
frst, but, as training progresses, the speed and extent of the movements are increased.
Minivectograms and Minitranaglyphs (office or home). These can be used for vergenc and pursuit
training (office and home; see Figure 16-6). Sensory fusin can be monitored while base-in and baseout demands are presented. The target can be moved into various felds of gaze for pursuit training
while sensorimotor fusin is monitored and trained.
Computerzedpursuits (office and home). Sophisticated prograrns for pursuits are available for visin
training. Various computer games (e.g., Nintendo) can also be appled to pursuit training for home use.
TABLE 16-7.
Approaches to Accommodative
Training
2.
3.
4.
5.
6.
7.
8.
464
Chapter16
that patients have the fu 11 refractiva correction (corrected ametropia most plus [CAMP] lenses) n place,
particularly myopic patients. The target should be
detailed nearpoint print. Patients alternately clear
the print as quickly as possible with each flip of the
lenses. Training progress can be recorded in two different ways. The time can be recorded for a given
number of lens flips (or cycles) or, conversely, the
number of flips (cycles) can be noted vvithin a certain time limit. Out-of-office flipper training can be
accomplished conveniently because very little
equipment is necessary.
Step 3
Speed rather than amplitude is emphasized in step
3. The ideal goal is to have patients achieve 20
cycles per minute on accommodative rock. Using
accommodative flippers (T16.23), for example,
once adequate speed s achieved with low-power
lenses, higher powers are used until the ideal
range of clear visin (if possible for a particular
patient) of 2.50 D is achieved with a speed of 20
cycles per minute.
Step 4
The stimulatory and inhibitory phases of jump
focus (near-far-near rock) or accommodative flipper (lens rock) training should be equalized.
Patients having trouble in clearing the target
through plus lenses in flipper training, for example,
should work on this problem both n the office and
at home. When equality s achieved for plus and
minus lenses, patients move on to the next step.
StepS
The accommodative skills of each eye should be
approximately equal. Sometimes achieving this
goal s not possible for many reasons (e.g., ocular
pathology or incurable amblyopia). However, most
patients are able to achieve good monocular
accommodative skills in each eye even though one
eye has strong ocular dominance.
Step 6
Bi-ocular rock exercises are another way in which
to train and equalize monocular accommodative
skills. This is a transition phase between monocular
and binocular training. The most practica! way to set
up this training s to introduce a vertical dissociating
prism before one eye. Simply, the occluder that was
used in monocular rock is removed and s replaced
usually is
ue
with a prism (e.g., 10A base-down). This should crate vertical diplopia. A single line of Snellen letters
can be used (e.g., 20/30 acuity demand). If the
base-down prism is placed before the left eye and
that eye views through a minus lens, the image will
be higher and will be an accommodative stimulus.
The right eye views the lower image through a plus
lens, which requires inhibition of accommodation
for clarity. Patients alternately fixate the targets with
increasing speed. The power of the lenses can be
increased as training progresses.
Step 7
Binocular accommodative rock is introduced n
step 7. Training s similar to testing procedures (see
Chapter 2). The same goals of range and speed in
the first six steps also apply to binocular rock.
Training can be near-far-near jumps and lens rock
with flippers. The ideal goal is 20 cycles per
minute using 2.50-D flippers.
Step 8
Introduce Bl or BO demands while the patient s
performing binocular accommodative rock. Fresnel
prisms are good for this purpose.
466
Chapter 16
Other Considerations
We have found that most patients with functional
accommodative deficiency can be trained successfully within 5 or 6 weeks, assuming good compliance. This guideline applies if there is no significant
vergence anomaly. Accommodative excess, however, can vary considerably in the strength of the
spasm, and training time varies accordingly.
Vergence and accommodation are part of a
reciproca! neurologic system. Vergence problems
can have a profound effect on binocular accommodative facility. Take, for example, esophoric
patients. When minus lenses are introduced binocularly, accommodation causes accommodative
convergence to increase. Such patients offset this
VERGENCES
Techniques for improving vergence ranges are extensively discussed earlier in this text (eso deviations in
Chapter 13 and exo deviations in Chapter 14). Finishing concepts of training in cases of esophoria and
exophoria are discussed in this section, as is visin
therapy for hyperphoria and cyclophoria.
Finishing Concepts n
Heterophoria
Fusiona! vergence ranges are expanded through
visin training, which includes five basic methods
of presenting vergence demands: sliding, stepping,
tromboning, jumping, and isometrically bifixating
(see Table 9-4). One convenient home training
instrument for this purpose is the Minitranaglyph
(Figure 16-6). Sliding vergences are performed by
slowing and steadily moving the targets in Bl and
BO directions while sensory fusin is maintained.
Step vergence can be performed in several ways:
(1) abrupt separation of the targets; (2) use of Bl
and BO flipper prisms; or (3) use of alternating
anaglyphic flipper filters (e.g., switching the red filter on the right eye to the red filter on the left eye
while green filters switch position from left to
Chapter16
467
Hyperphoria
Many of the training techniques for eso deviations
(see Chapter 13) and exo deviations (see Chapter
14) can be applied to training n cases of hyperphoria. During chiastopic fusin, for example,
Keystone Eccentric Circles (T13.15 and T14.14)
can be separated vertically by a slight amount to
induce a disparity stimulus for vertical vergence.
Performing these techniques is not easy, and so
they should be introduced toward the end of training. We have, however, seen several patients
ncrease their vertical vergence by as much as 12 A
with these techniques.
468
Chapter16
Cyclophoria
Much of what was said for functional training for
vertical deviations can be said for cyclotorsional
deviations, as the two tend to be associated. Prism
compensation, however, s not feasible for cyclophoria. Vision training is the bestand often the
onlyoption. Many targets can be used in this
manner. For example, Keystone Eccentric Circles
can be rotated during orthopic (T13.15) or chiastopic (T14.14) fusin to stimulate incyclovergence
or excyclovergence. The major amblyoscope s the
most ideal instrument for this type of training. Torsional amplitudes can be increased for some
patients, in our experience, up to 25 degrees.
Besides visin training techniques, surgery is the
only other method for treatment of these problems.
However, it s not advisable in most heterophoric
cases. Cyclophoric problems often are alleviated
after horizontal and vertical vergences become
efficient by means of visin therapy.
Chapter16
Symptomatic Orthophoria
Vergence efficiency therapy is sometimes important
for orthophoric patients. This is particularly true if
the fusional vergence ranges are decreased and
vergence facility and stamina are poor. Clinicians
may wonder why patients who are orthophoric at
far and near have symptoms pathognomonic of vergence anomalies. Testing with the altrnate cover
test in conjunction with pencil push-ups can sometimes answer this enigmatic question. This testing
procedure of Griffin's is called the kinetic cover
test, as opposed to a regular statc cover test.
Orthophoric patients (found with usual testing procedures) are only orthophoric under static viewing
conditions. People, however, live under dynamic
viewing conditions and not in a static world. The
kinetic cover test reveis how orthophoric patients
will momentarily have an exo deviation as fixation
is changed from far to near and have an eso deviation when fixation changes from near to far. Orthophoric patients may have binocular symptoms if
there are inadequate vergence ranges (see Figure 320). All vergence and accommodative ranges,
including facility and stamina, should be expanded
with visin training in these cases of a "tight" zone
of clear, single binocular visin.
STEREOPSIS
Stereopsis represents the highest level of binocular
visin. There is little doubt n the minds of experienced clinicians that stereoacuity can be improved
with visin therapy. Improvement can be due to
the successful results of antisuppression training,
cure of amblyopia, elimination of anomalous retinal correspondence, reduction or elimination of
fixation disparity, and ncreased perceptual awareness of binocular depth. Wittenberg 25 reported a
study conducted with the late Dr. Frederick Brock
and indicated that "stereoscopic acuity had definitely improved n the trained group." Before a
patient s released from a visin therapy program,
stereoacuity should be maximally enhanced f t
remains deficient.
Vectogram Stereo
Enhancement (T16.26)
A number of Vectograms are beautifully designed
for enhancing a patient's sense of stereopsis. The
Spriangle is one of our favorite targets for this pur-
469
470
Chapter16
Computer Stereo
Enhancement (T16.27)
Computer Orthoptics by Dr. Cooper (see AppendixJ)
uses random dot stereograms to genrate stereo
perception in a game format (T13.16). The stereoscopic target can be seen in only one of four random positions on the screen: up, down, left, and
right. The patient indicates the target's position by
rapidly moving a joystick (or directional arrows) in
the appropriate direction. Initially, without Bl or
BO demand, the patient builds speed of stereo perception. The next step is to change fixation distance by walking away, holding the joystick, and
continuing the process. Next, the targets are disparated Bl and BO within the patient's range of
fusional vergence at various speeds. The therapist
programs these parameters into the computer. The
CASE EXAMPLES
Case 1: Eye
Movement Dysfunctions
This 18-year-old woman presented with symptoms
of sharp pain in her left eye and headaches.26 She
had noticed these symptoms for many months.
They were consistent in that they would begin after
approximately 15 minutes of reading. The symptoms subsided, however, in approximately 30 minutes after cessation of reading. She also reported
skipping lines and losing her place while reading.
The patient was a freshman in college and had a
history of being an excellent reader, but recently
her symptoms had affected her reading performance. She mentioned that she was able to read
on a college level when she was n jnior high
school.
At the first visit, further history indicated that the
patient had had an eye examination 1 year previously. Accommodative rock training was recommended at that time but was never carried out. She
reported that her mother has intermittent exotropia. There was no other remarkable eye or health
history n her family.
Subjective refraction was as follows:
Oculus dexter (OD): plano -0.25 x 180
20/15 (6/4.5)
Oculus sinister (OS): plano
20/15 (6/4.5)
The patient had 0.5A exophoria at far and 5A
exophoria at near. Bl to breakpoint at 6 m was 5A
and to recovery was 3A; Bl to blurpoint at 40 cm
was 10A, to breakpoint 16A, and to recovery 4A. BO
Chapter16
471
T
F
R
C
C
N
Z
R
X
C
A
H
F
K
S
Z
o
K
B * X
U
Y
T
H C K B R F T S E A H O N P N F L
L VP
N
B
S
O
A
X
N
Z
H
O
A
T
F
S
P
A
RCURE 16-8Eye movement testing results befare visin therapy.
a. Position maintenance. b. Gross saccades. c. Fine saccades on card
with five dots per row (see Figure 2-3).
472
Chapter16
aches or pain n the eye. She reported "noticing a greatly increased reading speed." O:
Phorometry indicated orthophoria at far and 5A
exophoria at near. Bl was A/5/4 at far and 20/
24/18 at near. BO was 14/24/12 at far and 187
24/18 at near. Accommodative amplitude was
11.00 D OD and 11.00 D OS. On Keystone
Eccentric Circles, 55A BO chiastopic and 37A
Bl orthopic fusin were achieved. The Eye-Trac
showed improvement n fixation and eye
movements with fewer regressions during saccades and better return sweeps (Figure 16-10).
A: All subjective and objective problems were
abated.
P:The patient was dismissed for 6 months and
put on a maintenance program with the following home visin training prescription: pencil push-ups, monocular and binocular, for 5
minutes weekly; binocular pencil saccades
(two pencils) for 5 minutes per week; and Keystone Eccentric Circles for orthopic-chiastopic vergence rock with fixation shifts to a
farpoint Hart Chart for 5 minutes per week.
The patient was advised to have a progress
evaluation in 6 months.
Case 2: Accommodative
Dysfunctions
This patient in this case had accommodative insufficiency and infacility.27 A 30-year-old female college
student presented with frequent headaches and
burning of the eyes after an hour of concentrated
reading. She would sometimes becorne dizzy when
shifting focus abruptly from the chalkboard to her
notebook. Onset of symptoms coincided with
entrance into college 6 months previously. Her history was unremarkable, and the patient had never
worn any spectacle or contact lenses.
There was no significant refractive error and
unaided visual acuities were 20/15 (6/4.5) each eye.
The patient had 1A exophoria at far and 5A exophoria
at near. Fusional convergence at far was slightly
restricted (4/12/10). The NPC was normal (7 cm).
Monocular accommodative amplitude, however,
was markedly reduced for her age (6 D). Also,
accommodative facility using +1.50-D flipper
lenses was only 2 cycles in a period of 90 seconds.
A home visin training program of 20 minutes
per day was initiated to build accommodative facility, working on speed, accuracy, and sustaining
ability. Prescribed visin training included pencil
Chapter16
push-ups, jump vergences, accommodative lens
rock with flippers, Brock string and beads, and
monocular jump focusing. The patient used home
instruction sheets for each of these techniques and
aithfully followed the program for 5 weeks. She
returned once weekly for a progress check. The
patient's accommodative amplitude and facility
improved quickly to almost normal levis after only
2 weeks of training. By week 3, the lens flipper rate
was 25 cycles in 90 seconds. (Figure 16-11 shows
increased speed.) Reduction of symptoms paralleled the increase n skills. Headaches, dizziness,
and asthenopia with reading decreased noticeably
after week 2 of training; these symptoms were completely eliminated by the fifth week.
Ratients with accommodative insufficiency and
infacility often respond quickly and dramatically to
ashort-term visin training program. If they do not,
Ihen other possible causes should be reinvestigated. Prescribing plus-add reading lenses also
often helps to relieve symptoms.
FUTURE DIRECTIONS IN
BINOCULAR VISION THERAPY
Binocular anomalies, particularly heterophoria and
visin efficiency dysfunctions, can cause visual discomfort and inefficiency at school, work, and play.
In the last three decades, we have seen a rising
number of heterophoric and visin efficiency
patients who need and want visin therapy. The
prevalence of strabismus and amblyopia probably
will decline because of early detection n infants
and young children and, consequently, timely and
appropriate ntervention with visin therapy. We
believe, however, that there will be an everincreasing demand for binocular visin therapy
seivices. At least three cultural movements provide
ie mpetus: (1) a movement toward lifelong edueation; (2) the emergence of high-tech industries as
tte basis of modern economies; and (3) a movement toward universal physical fitness with increasng participation in sports.
473
abridged copy of this statement.) In contrast, a position policy statement from the American Academy
of Pediatrics, American Academy of Ophthalmology, and American Association for Pediatric Ophthalmology and Strabismus29 asserted that ". . . the
majority of children and adults with reading difficulties experience a variety of problems with language
that stem from altered brain function and that such
difficulties are not caused by altered visual function." These groups further stated, "No scientific evidence supports claims that the academic abilities of
children with learning disabilities can be improved
with treatments that are based on ... visual training,
including muscle exercises, ocular pursuit, tracking
exercises, or 'training' glasses.. . ,"29
There may be some merit in these assertions: For
example, dyslexia may, n part, be due to "altered
brain function" and not necessarily caused by
"altered visual function." The discussions on visin
and learning, including reading, in this text, however, provide evidence to contradict most of the
assertions made by these professional organizations and highlight a lack of understanding on the
part of the authors of the policy statement. We
believe that the discussions n this text provide evidence that verifies the relation of visin and learning, ncluding reading, as well as the positive
effects of visin therapy.
In their investigaron of this issue, Grisham et al.30
reported that poor readers (defined by standardized
testing) generally experience more visual symptoms
than do good readers. They also found a low, but
significant, correlation between reading achieve-
474
Chapter16
Visagraph Testing of
Reading Eye Movements
The Visagraph II Eye Movement Recording System
s a modified Ober 2 infrared monitor composed of
hardware and software components used primanly
to record and analyze the fine structure of reading
eye movements. The system includes goggles that
emit nfrared light that s reflected off the cornea
and is picked up by two horizontal sensors for each
eye that sample eye positions 60 times per second.
As the eyes move across a page, the amount of light
falling on the sensors vares, and this variation is
analyzed electronically. The goggles are connected
to a junction box that feeds into a PC loaded with
software designed to analyze and dsplay the eye
movements. After the goggles are adjusted properly
and set to the patent's near interpupillary distance,
the patient silently reads the printed text in a freespace environment. Testing is done using reading
material that is grade-level-appropriate for the
patient's sight vocabulary. Test passages are available for eight grade levisgrades 1-6, middle
school, and high school. Ten true-or-false comprehension questions are asked after the recording has
been made to ensure that the passage was basically
understood. The validity criterion requires that at
Chapter16
475
3ft
Fixations/IOOwords
1 23
Right Norms
11 206 lab
r*x
29
33 35
0. Av. Duration
0.
4 5 6 7 8 9 101112131415161718
i i
^^
28
~j
0.29 0.28
^r
Subject information
ame :
Class :
School : Examiner :
Guiiia
Born :
1.5
14%
109
80%
0.973
Anomalies (Fix/Regr/Both)
Grade:
9
10
21
5/4/6
Filename : JOG-28-Q.rec
Sex :
Director/ : C:\VISA\REC
Text information
No of unes :
63 )
9 Noof words:
4.3
3
I
FIGURE 16-12The Visagraph profile of reading eye movements. This third-grade patient read a second-grade-level selection with 80% comprehension, an acceptable performance for analysis. The computer selected the left eye as the best recording of the two eyes and graphed these data
alongside normative data (displayed as Grade Norms). Guilia's number of fixations was 211 per 100 words, comparable to that of an average firstgrade student; however, she showed fewer regressions than most third-grade students. The duration of fixation, on average, was 0.28 seconds,
equivalen! to that of most third-graders. Overall, the reading rate was slow owing to the excessive number of fixations, and the overall grade-level
equivalen! was at the 1.5 level. The cross-correlation was high (0.973), indicating good eye teaming; however, there were 21 saccades on return
sweeps and 15 anomalies, suggesting tracking deficiencies. This was confirmed by a direct inspection of the eye movement recording and simulation. Normal regressions and duration of fixation suggest that these deficiencies, and probably not a single-word decoding dysfunction (dyslexia),
were the cause of this child's reading problem.
476
Chapter16
477
Behaviors: Please rate the child on the following tems. Place a number in the blank to the left of
the tem that describes the child's school or home behavior.
1Always; 2Frequently; 3Occasionally; 4Rarely; 5Never; 6Unknown
___ Hyperactive
____Easily distracted
____Short attention span
____Easily frustrated
____Impulsive
____Easily fatigued
____Poor ability to organize work
____ Indistinct speech
____ Awkward or clumsy
____ Poor peer group relationships
____ Behavior problems
____ Emotional problems
____ Confusin after a series of verbal instructions
____ Variable school performance (from hour to hour or day to day)
____ Reverses letters, words, or numbers in reading
____ Reverses letters, words, or numbers in writing
____ Shows confusin about right, left, or other directional orientations
FIGURE 16-13Questionnaire screener for learning problems. (Modified from Lee S, Grisham JD. Establishing history tems for learning disabled
children. O.D. Thesis, University of California, Berkeley, 1975.)
3. The grade-level equivalent, an overall efficiency ndex, is either within one grade
level of the present school grade or higher.
No general management recommendations
need to be made n these cases.
Inefficient Reader Profile
476
Chapter16
eyes are trackmg in tndem or are out o synchrony. A correlation of 0.950 or higher indicates
good teammg o the eyes. Poor teammg m the eye
movement record can be caused by trackmg, dysunctions, ocusmg prob\ems, and lapses o binocular
fusin when the eyes under- or overconverge.
Saccades n return sweeps are evaluated by
assessing the manner in whch saccades are made.
When the eyes track from the end of one Une to
the beginning of another line, ths return sweep
should be completed in one or two eye movements. If 10 lines were recorded, then up to 20
saccades n return sweeps may be normal. However, to diagnose trackng problems, the eye movement recording needs to be nspected directly to
determine exactly how these movements were
made. Return sweeps are efficent if the patient fixates on the first or second words in the next I me.
However, they are considered inefficient, for
example, f the patient simply drops the eyes
below to the next line and then makes the return
sweep, or if the return fixation lands near the mid-dle
of the next Une.
The anomalies ndex represents the number of
times that the eyes were not n perfect synchrony
n an eye movement reading record (e.g., when
there s a blink of one eye or a lapse in the vergence eye position).
Chapter16
477
Behaviors: Please rate the child on thefollowing tems. Place a number in the blank to the left of
the tem that describes the child's school or home behavior.
____ Hyperactive
____ Easily distracted
____ Short attention span
____ Easily frustrated
____ Impulsivo
____ Easily fatigued
____ Poor ability to organizo work
____ Indistinct speech
____ Awkward or clumsy
____ Poor peer group relationships
____ Behavior problems
____ Emotional problems
____ Confusin after a series of verbal instructions
____ Variable school performance (from hour to hour or day to day)
____ Reverses letters, words, or numbers in reading
____ Reverses letters, words, or numbers in writing
____ Shows confusin about right, left, or other directional orientations
FIGURE 16-13Questionnaire screener for learning problems. (Modifed from Lee S, Grisham JD. Establishing history tems for learning disabled
children. O.D. Thesis, University of California, Berkeley, 1975.)
3. The grade-level equivalent, an overall effciency ndex, is either within one grade
level of the present school grade or higher.
No general management recommendations
need to be made n these cases.
Inefficient Reader Profile
An inefficient reading strategy is ndicated under
the following conditions:
1. The grade-level passage needed for successful testing s more than 1 year below the
school-grade placement. The fluency level s
determined prior to Visagraph testing by having the patient read aloud a grade-level selection. If the patient has decoding difficulties
(e.g., does not know the words), then a lower
478
Chapter16
Chapter16
479
480
Chapter16
Grade Left
Fixations/1 00 words
89
162 139
16
18
31
Recognition (words)
0. Av. Duration 59
0.62 0.72
of Fixation (seo)
0.
0.26 0.27
25
N E
: s^ :::
138
158
0.75
0.93
Equivalen!
Diractional Attack
Rale adj. for Rereading (words/min)
3.1
9%
138
80%
Cross Correlation
0.968
Anomalies (Fix/Regr/Both)
7
7
11
3/2/5
Subject information
ame :
Class :
Guilla
Bom : 10/16/1989
Grade:
Sex :
3
F
School :
Filename : JOG-29-O.rec
Recorded : 11/02/1999 17:53
Directory : C:\WINVISA\REC
Examinar :
Text nformation
Filename :
C:\WINVISA\TEXTS\amer_eng\t-3-29.txt
No of lines :
Tille:
Stamps 3-29
A n s w er s :
YNNYYNYN NN
No of questions :
10
Correct answere
No of words:
Av. word length :
depth perception, are facilitated by normal binocular visin. 40 More than half of the computerrelated symptoms of eye care patients stem from
deficiencies n accommodation and convergence.2
The need for high-quality binocular skills is evident in these visual environments. Nearpoint
lenses for computer use and, often, visin training
usually resolve patients' symptoms.
It appears likely that the joint influences of hightech industries and the drive toward universal
usage of computers will continu to genrate
increasing demands for binocular visin services.
This technologic revolution has inspired the collaboration of visin scientists and optometric practitioners to solve new problems regarding ocular
comfort and visin efficiency. Many optometry
schools and prvate practices offer some form of
video display terminal assessment, and the need
for visin therapy s growing.
Possibly the most important and far-reaching
development n the field of visin therapy in the last
10 years has been the emergence of a number of
computer-based programs to train visual skills. Two
well-developed and readily available software products that can be used for either n-office or home-
7
50
4.2
Chapter16
481
tory of performance can be viewed for each module by choosing the performance review option.
These performance charts can be transferred to a
disk and brought to the doctor's office for review
and progress consultation.
In-office HTS, and other similar programs, can be
easily mplemented by a trained assistant, thereby
allowing the doctor to double-schedule patients or
perform other tasks. Some doctors have set up a
small computer laboratory in a visin therapy room
and ncreased staffing, thereby substantially increasing their patient flow. Internet versions of computerized visin training will soon be available, which
should make this form of visin efficiency training
more widely available to the doctor's office, the
patient's home, and even school classrooms under a
Consulting doctor's supervisin.
Sports Vision
Binocular visin therapy is an integral part of the
emerging specialty of sports visin. Several binocular
visual skills have been reported to be superior n athletes, particularly players of ball games: These
include speed and accuracy of ocular motility,41 farpoint vergence facility,42 static depth perception,43'44
and dynamic stereopsis.45 Studies have shown that all
these skills can be trained to higher levis of performance.46 Most outstanding athletes do not have significant visual dysfunctions but, when an athlete does
have them, doctors render care with the hope that
athletic performance will improve.
Clnica! application in sports visin extends
beyond the classic concept of visin therapy for
remediation. A growing number of optometrists provide enhancement programs in visin therapy. They
train amateur and professional athletes having normal binocular visin and perceptual-motor skills
and help them to attain superior levis with the
ntent that this training will faciltate ncreased onthe-feld sports performance. The glamour aside,
this new direction does indeed have a serious
basisthat of helping individuis to overeme their
limitations and achieve their dreams. One of our
patients, for example, improved her softball batting
average from .250 to .750 as a result of visin
enhancement therapy that included classic visin
therapy approaches along with eye-hand coordination and peripheral awareness training. Controlled
studies of visin training and athletic skills are
needed, however, to confirm the hopes of many
fledgling athletes and of sports visin doctors.
482
Chapter16
FIGURE 16-15Home Therapy System (HTS). a. Training modules, b. Command screen. c. Example for saccadic training showing results of an intial session.
Chapter16
483
484
Chapter16
REFERENCES
1. Grisham D, Simons H. Perspectives on Reading Disabilities. In: Pediatric Optometry. Rosenbloom AA, Morgan
MW, eds. Philadelphia: Lippincott; 1990:518-559.
2. Sheedy JE, Parsons SD, The video display terminal eye
clinic: clinical report. Optom Vis Sc. 1990;67:622-626.
3. Mets M, Pnce RL. Contad lenses in the management of
myopic anisometropic amblyopia. Am J Ophthalmol. 1981;
91:484^t89.
4. Bannon RE. Clinical Manual on Aniseikonia. Buffalo, N.Y.:
American Optical; 1976.
5. Ogle KN. Research n Binocular Vision. Philadelphia:
Saunders; 1950:264.
6. Polasky M. Aniseikonia Cookbook. Columbus, Ohio: The
Ohio State University School of Optometry; 1974.
7. Ryan VI. Predicting aniseikonia in anisometropia. Am ]
Optom. 1975;52:96-105.
8. Lubkin V, Shippman S, Bennett G, et al. Aniseikonia
quantification: error rate of rule of thumb estimation. Binocul Vis Srabismus Q. 1999;14:191-196.
9. Kleinstein RN. Iseikonic trial lenses: an aid to diagnosing
aniseikonia. Optom Monthly. 1978;69:132-137.
10. Koetting RA. Stereopsis and presbyopes fitted with single
visin contact lenses. Am J Optom Arch Am Acad Optom.
1970;47:557-561.
11. Emmes AB. A statistical study of clinical scores obtained
in the Wirt Stereopsis test. Am J Optom Arch Am Acad
Optom. 1961;38:298-400.
12. Sheedy JE, Harris MG, Busby L, et al. Monovision contact
lens wear and occupational task performance. Am J
Optom Physiol Opt. 1988;65:14-18.
13. Josephson JE, Erickson P, BackA, etal. Monovision. J Am
Optom Assoc. 1990;61:820-826.
14. Schor C, Carson M, Peterson G, et al. Effects of interocu
lar blur suppression ability on monovision tasks perfor
mance. ] Am Optom Assoc. 1989;60:188-192.
15. Josephson JE, Caffery BE. Monovision vs. bifocal contact
lenses. A crossover study. J Am Optom Assoc. 1987;58:
652-654.
16. Lebow KA, Goldberg JB. Characteristics of binocular
visin found for presbyopic patients wearing single visin
contact lenses. J Am Optom Assoc. 1975;46:1116-1123.
17. Bahill AT, Adler D, Stark L. Most naturally occurring human
saccades have magnitudes of 15 degrees or less. Invest
Ophthalmol. 1975;14:468^69.
18. Griffin J. Pursuit fixations: an overview of training procedures. Optom Weekly. 1976;67:534-537.
19. Keller JT, Amos JE. Low plus lenses and visual performance:
acritical review. J Am Optom Assoc. 1979;50:1005-1011.
20. Greenspan SB. Behavioral effects of children's nearpoint
lenses. J Am Optom Assoc. 1975;46:1031-1036.
21. Pierce JR. A response to low plus lenses and visual perfor
mance: a critical review. J Am Optom Assoc. 1980;51:453459.
22. Grisham JD, Bowman MC, Owyang LA, Chan CL. Vergence orthoptics: validity and persistence of the training
effect. Optom Vis Sci. 1991;68:441-451.
23. Patano F. Orthoptic treatment of convergence insufficiency:
a two year follow-up report. Am OrthoptJ. 1982;32:73-80.
PART THREE
TECHNIQUES
Introduction
PartThree's ntention s to provide systematic laboratory-like nstruction n binocular training techniques for optometric practitioners, students, and
visin therapists. This part s coordinated with Parts
One and Two, so the clinician wili find it to be a
practical guide to visin training. Theory and
research citations are not included, as they are
amply covered in the previous chapters. Only the
most frequently used visin training techniques are
presented n PartThree, and they are applicable to
therapy for efficient visual skills to achieve maximal performance n school, work, and play.
The first set of techniques (in Chapter 17) is for eso
deviations, the second set (n Chapter 18) s for exo
deviations, and the third set (n Chapter 19) is for
saccades, pursuits, and accommodation. Chapter 20
ncludes recommended sequences for visin training
techniques based on diagnostic categories. Also in
Chapter 20 are comments on practice management
of visin therapy in various clinical settings.
Each visin training technique (designated by a
double number preceded by T) s discussed n the
following format: purposes, equipment, recommended office visin training instructions, and
home visin training instructions. These visin
487
490
ChapteM?
See Chapter 13 for further discussions of the techniques addressed n this chapter and for other
techniques and therapies for eso deviations.
MIRROR STEREOSCOPE
(T13.2,114.4)
Purpose
The main purpose of using the Bernell Mirror Stereoscope s to build fusional vergence ranges
while monitoring suppression. In eso deviations,
the emphasis is on fusional divergence. Stereopsis
may be improved when stereograms are fused
through large ranges of base-in (Bl) and base-out
(BO) demands.
Equipment
This technique requires the use of the Bernell Mirror Stereoscope (see Figure 13-1),
11111111111111111ti111111111
Chapter17
491
Purposes
One purpose of the Dual Polachrome Illuminated
Trainer Vectograms and Tranaglyphs for divergence
training at near is to train sliding fusiona! vergence
(Bl). Additionally, the technique helps to monitor for
suppression during ncreased Bl demands. Through
the training, patients can develop second-degree
and third-degree fusin skills and strengthen step
vergences.
Equipment
Equipment includes the Dual Polachrome Illuminated Trainer, crossed polarizing viewers, and a
selected Vectogram (vecto), listed here n approximate order of difficulty (see Figure 13-11): Quoits
(two-piece); Clown (two-piece); Mother Goose
(two-piece); Spirangle (two-piece); Figure 8 (onepiece); and the Chicago Skyline (two-piece).
492
Chapter17
APERTURE-RULE TRAINER,
DOUBLE APERTURE (T13.13)
Purposes
The purpose of the Aperture-Rule Trainer s to
improve the range and speed of fusional divergence (Bl training). The device can also monitor
suppression during fusional divergence demands.
Chapter17
AA
493
DA
Pointer
with
1&2
and
double
aperture
AP2
Equipment
The Aperture-Rule Trainer with the double aperture
is used (Figures 1 7-3 and 1 7-4; see also Figures
13-13through 13-15).
Nearer Portion
of Rule
8
Farther
Portion
of
Rule
Pointer
with
API
and
double
aperture
10
11
12
Fusin
Target
Here
Tip of Nose Here
O
AP
card
here
FIGURE 17-4Top view of the rule showing where the patient's nose
s placed on the proximal end, where the target cards are placed
toward the middle, and where pointers can be inserted on the distal
portion of the rule. The Aperture-Rule Trainer is for base-in demand
training when the double aperture slide is used.
494
Chapter 17
Equipment
The equipment used for orthopic fusin training
ncludes the Keystone Eccentric Circles, Lifesaver
Card, or similarly designed targets on transparent
actate cards (see Figure 13-18).
Chapter17
495
496
Chapter17
Equipment
Equipment for the Remy Separator ncludes Keystone Colored Cirels (Lifesavers, both opaque and
transparent) and a manila file folder (see Figures
13-16 and 13-17).
Chapter17
497
Purposes
Pencil push-aways with Bl prism are designed to
ncrease fusional divergence ranges and to maintain bifixation with ncreasing Bl demand as viewing distance is ncreased.
Equipment
An ordinary pointer stick or a penlight target can
be used. Lose prisms are introduced in the Bl
orientation.
498
Chapter17
Purposes
The Brock string and beads with Bl prism is ntended
to monitor bifixation at various distances, to check
for suppression, to improve fusional vergence ranges,
and to develop vergence facility.
Equipment
The equipment for the Brock string with Bl prism s
a long string with three colored beads, and red and
Chapter17
4. "Now open both eyes and look at the middle bead. You should be able to see two
strings that meet at the middle bead and
form an X pattern. Put on the red-green
glasses to make this more noticeable, espe
cial ly if you tend to suppress one of the
string images."
5. "Next, look at the nearest bead and repeat
the previous techniques."
6. "Try to look from one bead to another and
keep the string images meeting at exactly
where you are looking. In other words, the
string images should cross exactly at the
bead at which you are looking. Your goal is
to be able to do this quickly and easily and
as the beads are moved farther away, perhaps to halfway across the room."
7. "Eventually you should be able to perform
the technique while wearing Bl prisms and
without the need to wear red-green filters."
BREWSTER STEREOSCOPE
(T13.3,T13.4)
Purposes
The purposes of the Brewster stereoscope are to
develop good sensory fusin at far (optical infinity), to mprove fusional divergence at far, and to
develop vergence facility at far.
Equipment
The Keystone Telebinocular (see Figures 13-3 and
13-4) s a standard nstrument for visin therapy.
However, many other Brewster stereoscopes are
available, such as the Biopter and the Bernell-OScope, and the many types of hand-held Brewster
499
87 mm
0 <D
FIGURE 17-8Stereogram for a Brewster
stereoscope n which the relative vergence demand s zero (ortho
demand).
stereoscopes that are suitable for home visin training. To help the patient with an eso deviation to
fuse targets in the stereoscope, the homologous
points should be fairly cise together, which creates
a BO prismatic relief. The separation would be less
than 87 mm when the stereogram is placed at the
farpoint position. The patient is eventually given Bl
demands at which the separation exceeds 87 mm;
this allows for fusional divergence training.
500
Chapter17
PERIPHERAL FUSIN
RINGS (T13.7)
Purposes
Development of sensory fusin at far n true space
is the first goal of the peripheral fusin ring training
technique. The second goal is to train motor fusin
at far with Bl prism demands. The third goal s to
train perception of stereopsis atfar and, eventually,
to maintam the depth effect with increasing prism
demands.
Equipment
Large ringlike targets are used n the peripheral
fusin ring training. An example is the Root
Rings target (see Figure 13-9). Various modifications can be custom-made using red and green
rings on either a black or a white background.
Chapter17
501
502
Chapter 17
Apex
Base
Purposes
The use of televisin trainers and Bl prisms is
designed to monitor suppression during motor
fusin training, to train fusiona! vergence at far,
and to train vergence facility at far.
Equipment
The televisin trainer is a ciear actate sheet with
rubber suction cups that allow t to be placed on the
screen of a televisin set. On the actate sheet are
two large sections of either red-green (anaglyphic)
or crossed polarizing filters that produce mutual
exclusin of the images seen by the right and left
Chapter17
503
FIGURE 17-12Examples of televisin trainers, left view being polarized and right view being anaglyphic
(red-green). (Courtesy of Bernell
Corp.)
506
Chapter18
VOLUNTARY
CONVERGENCE (T14.1)
Purposes
The main purpose of voluntary convergence s to
prepare the patient for subsequent convergence
training. Another purpose s to develop kinesthetic
and proprioceptive awareness of the eye muscles
turning the eyes in a disjunctive, nwardly movement. This feedback s helpful when doing more
precise exercises later in the course of visin training i n exo cases, particularly f there s exotropia.
Equipment
No equipment is required ultimately. In the initial
phase of voluntary convergence training, use of a
real object, such as the tip of a pencil, may be necessary for the patient to bifixate. Later, an imaginary target, such as an imagined bug flying near
the nose, may suffice. Eventual ly, absence of a target is the goal.
feedback so necessary n this technique and n techniques that will follow. Another feedback clue to
convergence s the awareness of diplopia, which is
homonymous (uncrossed) as to distant objects. The
diplopic images alert the patient that the eyes are, n
fact, crossing and that there s no suppression.
Recommended oral instructions follow:
1. "I want you to cross your eyes so that each
eye s pointing toward your nose."
2. "It is all rightfor you to look at something up
cise to get started. You can look at the tip of
your finger and move it up cise to you."
3. "Try to feel your eyes convergng. This may
be a pulling feeling as your eye muscles
strain to cross your eyes."
4. "When you have your eyes crossed, try to see
whether you can notice that objects far away
are double." (Figure 18-1 Ilstrales homony
mous, uncrossed, diplopia as visual feedback
when the eyes are voluntarily crossed.)
5. "When you think your eyes are crossed, let
me look at them and give you feedback. I
will tell you whether your eyes are actually
crossed."
6. "When I confirm for you that the eyes are
crossed, try to notice the double visin at
far. The double visin lets me know that
you are not suppressing an eye when I see
that your eyes are actually crossed."
7. "If you cannot cross your eyes voluntarily,
it is all right to use your fingertip or a pencil
tip or similar targets. Try to use an imaginary target next. This might be an imagined
bug flying cise to the bridge of your nose."
8. "It may be helpful if you cross your eyes n
a downward gaze, whether you have to use
a real object, an maginary target, or do it
completely voluntarily without the aid of a
target. Your goal is to accomplish this task
completely voluntarily."
9. "Eventually, you should be able to cross
your eyes voluntarily in down-gaze, then
straight ahead and, finally, in up-gaze."
ChapteMS
crossed and looking directly at a pencil.
Your helper can tell you how you are doing,
as your doctor did in the office.
3. Next have your helper observe your eyes
while you imagine seeing a bug flying
directly in front of you, just a few inches from
the bridge of your nose. You need the helper
to tell you how you are doing, because you
may think you are crossing your eyes when
you really are not. For example, you may
have your right eye on the target, but the left
eye might be drifting out and away from the
target. Your helper can inform you of this and
encourage you to concntrate and make both
eyes work together to point exartly on the tar
getyour fingertip, for example.
4. When you can easily achieve the crossing
by using an imaginary target, try to cross
your eyes by using as a cue the pulling sensation of your eye muscles to achieve the
crossing. That is, cross your eyes without
the help of a target, either real or imagined.
5. When you can cross your eyes voluntarily
after proceeding through the steps 1-4, try
to perceive the doubleness of things across
the room as you hold your eyes n the con
verged posture.
6. The doubleness will actually help you to
cross your eyes and confirm that they are
crossed and that one eye is not suppressing
its image. This visual feedback lets you know
that you are performing the voluntary con
vergence technique properly. Besides visual
feedback, you have the puUing sensation
(which is kinesthetic and proprioceptive
feedback) to tell you what s happening.
And, of course, you can have auditory feed
back from your helper at home to tell you,
by observing your eyes, whether or not you
are performing the technique properly.
7. You should practice this technique as often
and for as long each day as your doctor
prescribes. This may be, for example, 5
minutes four times daily.
507
Perceived by Patient
FIGURE 18-1Illustration of
voluntary convergence n which
the patient s bifixating a
drinking cup at a far distance (a)
and voluntarily converging the
eyes (b) while being aware of
the diplopic image of the distant
target. Note that the patient has
uncrossed,
homonymous,
diplopia in this overconverged
state n which the right image s
seen by the right eye and the left
mage by the left eye.
vergence
and
divergence can also be trained, depend'mg on the
patient's heterophoria at ar and near. As examples,
fusional convergence is being trained with push-ups
in cases of convergence insuf-ficiency, but fusional
divergence s being trained with push-aways in cases
of divergence excess.
Equipment
An ordinary pencil, pen, pointer, sticker on a stick,
or fingertip can be used for push-up and pushaway training. A letter on an alphabet pencil s an
especially good target because t is large enough to
be seen easily and yet has sufficient detail to allow
for detection of blur. (See Figure 2-1, depicting
alphabet pencils.) The patient holds the pencil;
other equipment s unnecessary, unless lose
prisms are desired later n the training of this technique for increased demands on fusional vergence.
An solated object n the background, such as a
clock on the wall, is also useful as a physiologic
diplopia clue to monitor suppression.
508
Chapter18
Chapter18
of target) are al I effective ways of breaking suppression. If the patient contines to have difficulty breaking suppression, the pencil push-up technique
should be temporarily abandoned and other antisuppression techniques (e.g., stereoscopes, Brock string
and beads, red-green filters with penlight, and Vectograms [vectos]) should be introduced.
509
Equipment
The Brock string consists of a long white cord on
which are three differently colored beads (see Figure 12-7). One end of the string is held against the
tip of the patient's nose, and the other end can be
held by the doctor or therapist.
510
Chapter18
Intersection of string
image behind the beads
Chapter18
Equipment
The three-dot card (Allbee or similarly made cards) is
a 2.5 x 5.5-in. cardboard target on which appear
three red dots on one side and three blue dots on the
other side. The dots are arranged n gradually increasing size on each side of the card. The edge of the
card, nearest the smallest red dot and smallest blue
dot, is held vertically against the tip of the patient's
nose. The card acts as a septum (see Figure 14-1).
511
512
Chapter18
APERTURE-RULE TRAINER,
SINGLE APERTURE (T14.12)
Purposes
The main purpose of using the Aperture-Rule Trainer
is to improve fusional convergence, particularly n
cases of convergence insufficiency. Other purposes
include improving the range and speed of fusional
convergence, which is BO training, as well as monitoring suppression with ncreasing fusional demands.
Suppression and fixation disparity can also be monitored during fusional vergence demands.
Equipment
The parts of the nstrument are a "ruler" base, a
single-window aperture, a double-window aperture, and a spiral-bound set of picture cards (see
Figures 13-14, 14-3, and 17-3). To assemble the
Aperture-Rule Trainer for convergence training,
unfold the "arms" of the ruler base so that they are
straight. For initial suppression checking and alignment of the patient in the instrument, use the double aperture and the first two targets. (Refer to the
section on use of this nstrument for eso deviations
n Chapter 17.) Slide the single-window aperture
onto the base at the proper position indicated by
Chapter18
513
FIGURE 18-4Examples of targets used with the Aperture-Rule Trainer. Note that the suppression clues in the bear target, for example, are the
facial features, the dot below the circles for one eye, and the letter b and the plus sign above the circles for the other eye. When training patients
with exo deviations using a single aperture, the right eye will see the target on the left (e.g., the circle with the dot below it), and the left eye will see
the target on the right side (e.g., the plus sign above the circle). This is chiastopic fusin, and the inner circles are displaced temporally on Panum's
fusional reas; therefore, the fused smaller circle should appear to float closer in relation to the fused larger circle. Besides monit oring of suppression and stereopsis, fixation disparity can be monitored by whether the plus sign and the dot are exactly aligned. (Courtesy of Bernell Corp.)
the place aperture here setting. Slide the set of picture cards onto the base n the O position.
Place the AP1 Card at O on the rule with the
single aperture mask at setting / and 2. Training
can now begin for fusional convergence (BO
demands) n cases of exo deviation.
514
Chapter18
VECTOGRAMS AND
TRANAGLYPHS: CONVERGENCE
TRAINING AT NEAR (T14.9)
Purposes
The Dual Polachrome IlluminatedTrainer is applicable for either vectos or Tranaglyphs. It is used to
Equipment
The patient views the targets (either vectos or
Tranaglyphs) that are mounted on the Dual Polachrome Illuminated Trainer while wearing crossed
polarizing viewers. Selected vectos are Usted here
n appropriate order of difficulty (and are shown in
Figure 13-10):
1. Quoits (two-piece) (see Figure 13-11 a)
2. Clown (two-piece) (see Figure 13-11 c)
3. Mother Goose (two-piece) (see Figure
13-1 le)
4. Spirangle (two-piece) (see Figure 13-11 b)
5. Figure 8 (one-piece) (see Figure 13-11f)
6. Chicago Skyline (two-piece) (see Figure
13-11d)
If Tranaglyphs are used n the Dual Polachrome
Illuminated Trainer (see Figure 13-11), the patient
should wear the appropriate red-green filters.
BO training is emphasized in cases of exo deviation. Vectograms and Tranaglyphs are viewed at
near, but they can be projected onto a distant
screen for training at far. Note that a special
screen is necessary for vectographic projection.
Small targets (Minivectograms and Minitranaglyphs) are also available for office visin training
and are particularly applicable for home visin
training (Figure 18-5; see also Figure 16-6). These
small training devices are, however, for near
viewing only.
The immediate discussion here focuses on
T14.9, convergence training at near.
Chapter18
515
516
Chapter18
Chapter18
517
Left eye
Quoits
Vectograms
12 convergence
demand
6 convergence
demand
Right eye
VECTOGRAMS AND
TRANAGLYPHS: CONVERGENCE
WALK-AWAYS (T14.10)
Purposes
The main purpose of convergence walk-aways is to
promote fusional vergence at increasing fixation distances. If the patient fuses well at near but has difficulty at far, this technique helps build confidence for
the patient when trying to meet vergence demands at
far. The farther distance makes the image smaller and
more effort s required to keep from suppressing these
smaller images. Also, stereopsis is more difficult as
the fixation distance increases; this technique sharpens stereopsis.
Equipment
Convergence walk-aways are performed with the
same equipment as was described for Recommended Office Vision Training Instructions (Vectograms and Tranaglyphs [T14.9]). The difference n
the therapeutic training technique s that the
fusional vergence demand becomes mathematically
less as fixation distance increases. For example,
suppose there s a 12A BO demand at the conventional 40-cm distance. When the patient moves
away from the instrument to 80 cm, the BO demand
s reduced to 6A. This mathematic advantage may
help the patient who has an exo deviation at far. For
example, 12 A demand at 40 cm is only 6 A demand
at 80 cm (see Figure 18-6 for clarification).
Recommended oral instructions follow:
FIGURE 18-6Example of convergence walk-aways with vectographic targets. If, for example, the convergence demand at 40 cm is
12A base-out, at 80 cm the convergence demand s only 6A base-out.
Chapter18
Home Vision
Training Instructions
Note to patients: This technique may not be applicable if you do not have access to an overhead
projector. If one s available and if your doctor has
lent you the special screen, you can practice the
projected BO technique as you were trained to do
in the office. The following routine is suggested,
but this may have to be conducted in the office as
equipment may not be available at home.
1. Put on the magic glasses and look at the
illuminated screen across the room.
2. Use a familiar pair of vectographic slides
that your doctor has prescribed. Place them
on the overhead projector. You will notice
that the same pictures are now projected
onto the special screen on the wall.
3. Try to fuse the pair of targets, just as you
learned to do at near when you were looking directly at these pictures.
4. Put them together at the zero position; this
is an ortho demand and you don't need to
converge your eyes when the targets are in
ortho position. When you can fuse the pair
of slides, put in some BO demand to make
you cross your eyes to maintain fusin.
Start with 2A. The number 2 should show
through the small window of the masked
ruler. Now you will have to converge your
eyes to see singly.
5. When you can see singly with this convergence demand, try to see the fused image
clearly.
6. As your performance with this exercise
mproves, place greater and greater demands
on yourself to converge your eyes more and
more. Do this by separating the pictures in the
BO direction, so that larger numbers show
through the opening in the masked ruler.
7. As you make the convergence demand
greater, look to see whether the fused image
starts to blur or breaks into two images.
8. Look also for any suppression. You will
know that suppression of an eye is occurring f something s missing that should be
seen by that eye. For example, the vertical
519
CHIASTOPIC FUSIN
COLOREO CIRCLES (T14.14)
Purposes
The main purpose of the chiastopic fusin technique
is to increase fusional convergence. This technique s
also good for monitoring suppression during motor
fusin demands. Because this technique can enhance
open-space fusin skills, there is strong transfer from
the visin training to ordinary viewing n life.
Equipment
Any two similar objects or pictures may be used.
For example, two identical coins can be positioned
on a tabletop with a slight horizontal separation
(e.g., 2-3 cm). Two real objects may be a good way
to start a patient learning to perform chiastopic
fusin. The same principie of cross fusing applies
to representations of objects on a printed page,
such as the Keystone Colored Greles, known clinically as Lifesavers. (Refer to Figures 14-6 and 14-7.
Also see examples of targets of Bernell for chiastopic form n Figure 18-7.) The first discussion that
follows pertains to the Lifesavers.
520
Chapter18
fovea
Cyclopean eye
FIGURE 18-8Principie of chiastopic perception, illustrating cyclopean projection. This diagram explains why the patient perceives
three images, the middle image being the fused composite and the lateral images being seen homonymously.
FIGURE 18-7Examples of eccentric circles for the purpose of chiastopic fusin. In the upper right crner are barrel convergence cards
similar to the three-dot card. (Courtesy of Bernell Corp.)
Chapter18
521
CHIASTOPIC FUSIN
ECCENTRIC CIRCLES (T14.14)
Purposes
The main purpose of chiastopic fusin with eccentric circles is to ncrease fusional convergence and
monitor suppression during motor fusin stress.
This technique is excellent for enhancement of
open-space fusin skills while developing secondand third-degree sensory fusin skills. Training to
ncrease gross (absolute) convergence can also be
done by having the patient either trombone the targets or do near-far jump vergences while maintaining the chiastopically fused mage.
Equipment
The opaque stock Keystone Eccentric Circles are
preferred for chiastopic convergence (BO) training.
(See Figure 13-18.)
522
Chapter18
VERGENCE ROCKTELEVISIN
TRAINER AND PRISMS (T14.16)
Purposes
The main purpose of vergence rock using a televisin trainer and prisms s to monitor suppression
during fusional convergence training. Other important purposes are to develop a good fusional convergence range and facility at far.
Equipment
The televisin trainer (see Figure 12-9) is an actate sheet fitted with rubber suction cups that
allow the sheet to be attached to the screen of a
televisin set. On the actate sheet are two large
sections of either red-green (anaglyphic) or
crossed-polarizing filters that produce mutual
exclusin of the images seen by each eye when
corresponding filters are worn. BO prisms come
in various forms, such as Fresnel Press-Ons, lose
prisms, and flipper prisms. (See Figure 12-9.)
Chapter18
1. "Please put on the crossed-polarizing spectacles and look at theTV screen from a distance of approximately 40 in. (1 m)."
2. "\ will place this special sheet in front of
the screen, and I want you to watch the TV
picture through the sheet while you are
wearing the special glasses."
3. "Purposely cise one eye and notice that
par of the TV picture disappears."
4. "Open that eye and cise the other eye and
notice that another portion of theTV screen
disappears."
5. "With both eyes open, try to see al I portions of the TV screen at one time."
6. "I want you to back away to about double
the distance and try to see al I of the picture
al I of the time."
7. "Now try to back farther away and try to see
all of the picture all of the time, as before."
8. "I will place some prisms before your eyes
so that your eyes will be forced to converge
n order to see the picture singly."
9. "When you can see the TV picture clearly
and singly, I will add more prism power to
make you converge your eyes to an even
greater extent, while you try to see clearly
and singly."
10. "I want you to be able to see the picture
clearly and singly for a training period of
15 minutes with hardly any suppression
that s, without a portion of the TV picture
fading or disappearing."
11. "I want you to regain fusin of the picture
each time I flip a different prism power before
your eyes. Regaining fusin should be easy
and quick, taking approximately 3 seconds
with each flip; the picture that s fused on
each flip should be clear and single."
12. "I will give you the mximum prism powers
with which you can cope as you progress
successfully n therapy."
523
VERGENCE ROCKBAR
READER AND PRISMS (T14.17)
Purposes
Home Vision Training
Instructions
1. Put on the crossed-polarizing spectacles
and look at the televisin screen from a dis
tance of approximately 40 n. (1 m).
2. Place the special sheet in front of the
screen and watch the TV show through the
sheet while you are wearing the special
524
Chapter18
Equipment
Reading bars are available n several forms. A septum (e.g., a pend) or several of them can be
placed vertically between the reading material and
the patient's eyes. A more convenient technique,
however, s the use of either polarized or red-green
filter materials that are made n strips and placed
directly on the reading material (Figure 18-9).
Chapter 18
3.
4.
5.
6.
525
Purposes
The main purpose of vergence rock while framing is to
break suppression when viewing s at far. Framing at
far is analogous to bar reading at near. In addition to
developing a good BO fusin range at far, good vergence faciiity can be attained by flipper-prism rock.
Equipment
The patient holds a pencil while viewing a distant
target, such as a lightbulb. Prisms, such as lose
prisms, are used in the BO orientation. Flipper
prisms, as shown in Figure 13-12, are also used in
this training technique.
Recommended Office
Vision Training Instructions
The pencil or a suitable pointer stick is held by the
patient in midline straight ahead at a distance of
approximately 40 cm. The patient fixates on a distant object, such as a lightbulb or a penlight. Recommended oral nstructions follow:
1. "Please look at the penlight target across
the room and be sure you see t clearly and
singly."
2. "Hold the pencil in frontof you approximately
16 in. away, which is nearly 40 cm."
See Chapter 16 for further discussions of the techniques listed n this chapter and for other techniques and therapies for dysfunctions of saccades,
pursuits, and accommodation.
ELECTRONIC FIXATION
INSTRUMENTS FOR
SACCADES (T16.12)
The Wall Saccadic Fixator (and other similar instruments) are applied n this technique.
Purposes
The ntent of use of the Wall Saccadic Fixator s
to improve saccadic speed using an eye-hand
task. It also aids n eliminating head movement
during a saccadic task and in improving peripheral awareness.
Equipment
Equipment ncludes the Wayne Saccadic Fixator
(see Figure 16-2), for example, and an eye patch (f
training monocularly).
528
Chapter19
9
10
CONTINUOUS MOTION
FORSACCADES(T16.6)
Purposes
The purposes of continuous motion for saccades
ar to improve saccades, either gross or moderately fine, while developing peripheral awareness
skills and to develop quick and accurate saccades
with good eye-hand coordination.
Equipment
FIGURE 19-1Continuous motion worksheet. a. An example of a
custom-made worksheet for beginning patients using only 10 numbers. b. The same worksheet showing performance of a patient.
Chapter19
529
ANN ARBOR
(MICHIGAN) TRACKING (T10.7)
Purposes
Ann Arbor Tracking is used to improve fine saccadic accuracy and to train fine saccadic speed:
Equipment
The Ann Arbor (Michigan) Tracking technique uses
a page of this system's workbook (see a modified
sample n Figure 19-3a and performance of a
patient in Figure 19-3b) and an eye patch for initial
monocular training.
Chapter19
530
loid zarimp.
Min
^Sec.
_Js_Min__2o_Sec.
Actlvlty #10
Grele every "at," "be," and "from" n the section below. You will find at least
one oflhese words on every line.
3, T =
Equipment
An eye patch s used for nitial monocular training
with the sequential fixator. The sequential fixator
includes a clear actate sheet with targets that may or
may not be connected by horizontal lines. Note that
this type of target can be used in both testing and
training of fine saccades. For training purposes, custom-made sheets can be created for office and home
training (see Figures 2-7 and 2-8 for examples).
Chapter19
532
Chapter19
Equipment
Two flashlights with spot focus are needed to perform the flashlight chase, as is an eye patch for initial monocular training. A red filter s needed for
one flashlight and a green filter for the other.
533
white flashlights can be used. The patient, however, can wear red-green filters to work on motor
fusin control while mproving pursuit skills.
Purposes
The Hart Chart near-far rock technique (created by
Dr. Walter Hart, Tacoma, WA) s designed to help
the patient to learn to shift focus of the eyes quickly
and accurately so as to build good accommodative
facility. The technique also will demnstrate to the
patient the ocular sensation of response of accommodation to stimuli and the response of relaxation
of accommodation.
Equipment
Equipment includes Hart Charts, one for near (10
rows of reduced letters) to approximate the equivalent of 20/30 reduced Snellen and one for far (10
rows of larger letters) to approximate the equivalent of 20/30 at 10 ft. (Figure 19-5 shows far and
near Hart Charts.) Also required is an eye patch for
initial monocular training.
534
Chapter19
10
FIGURE 19-5Hart Chart. a. Letters for farpoint in which the letters can be recognized (e.g., 6 ft) and smaller letters to be placed at the patient's
nearpoint of accommodation. b. A larger farpoint Hart Chart used with the letter-word jump technique, which trains accommodative facility and
amplitude, jump vergence, saccadic tracking skills, and basic sight-word knowledge. The Hart Chart is placed at a distance of at Ieast 6 ft from the
patient. This distance can be increased as the patient improves tese visual skills.
Chapter19
20/20
Z
A O F N
4 ^7
Y B
C E T
b B X
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r MP
&
u
C R
F X
T T M
T H O
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10
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535
536
Chapter19
now
new
may
many
ate
upon
about
us
10
wish
again
want
any
could
where
does
tell
put
B
C
D
E
F
G
H
I
J
always would
ask
found
take
first
say
how
out
once
long
or
bring
been
only
done
open
every
never
goes
mus
much
pul
where
sit
their
show
work
small
very
these
think
which
those
buy
own
draw
keep
drink
kind
find
just
fll
grow
not
hold
off
why
pretty
well
please use
pick
light
beat
hurt
both
laugh
warm
right
sing
before read
read
shall
six
today
try
better
&r
clean
five
cut
four
eight
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sleep
write
seven
wash
start
fill
thank
10
T-wish
Z-could
B-once
K-long A-or
R-where A-sit
C-grow R-not
T-fr
H-white O-sleep S-write N-seven C-wash T-start K-thank U-sing Z-before L-read
G-hold D-off
S-today M-try
A-better R-light
P-bring
d
FIGURE 19-5(continued) c. Dolch sight words used with the letter-word jump technique. This chart s held by the patient just beyond the nearpoint of accommodation. The patient altrnales fixation from the Hart Chart that shows letters to the Dolch words and calis out corresponding letter-word combinations horizontally across the row. This performance should be timed and recorded. If the patient gets lost, the coach can cali out
the appropriate coordinates to re-establish accuracy. The clinician assigns a specific number of rows or the time period to be practiced each training
day at home. d. Answer sheet for the letter-word jump technique. The coach uses this sheet to check the accuracy of performance.
Chapter19
537
PLUS- AND
MINUS-LENS ROCK (T16.23)
Purposes
The plus- and minus-lens rock technique is intended
to mprove accommodative facility, first monocularly, then binocularly. It also will help the patient to
develop speed and accuracy.
FIGURE 19-6Sample of various powers of flippers for accommodative rock. (Courtesy of Dr. Jonathan Spilkin, Optego Vision, Inc.,
Toronto, Ontario, Canad.)
Equipment
Equipment required for the plus- and minus-lens
rock technique includes a set of plus-minus flippers (1.00 D, 1.50 D, 2.00 D, 2.50 D). (Figure
19-6 shows a close-up view of sample plus-minus
flippers; see also Figure 2-17.) Also needed are an
eye patch, a polarized bar reader, polarized filters,
a red-green bar reader, red-green filters, and aVectogram 9 target (see Figure 13-11 h).
538
Chapter19
540
Chapter 20
SUGGESTED SEQUENCING OF
TRAINING TECHNIQUES FOR
AMBLYOPIA
Develop central and steady fixation in cases of eccentric
fixation
T10.13
Basic central fixation training
T10.14
Steadiness of fixation training
T10.15
Saccadic movements with foveal tag
T10.16
Foveal localization with fast pointing
TO.17
Pursuits with foveal tag
TO.18
Resolution practice with foveal tag
Improve ocular motility
Tracing and drawing Throwing
and hitting games Video game
tracking Swinging ball training
Tracking with auditory feedback
Visual tracing Ann Arbor
Tracking
T10.1
T10.2
T10.3
T10.4
T10.5
T10.6
T10.7
Improve resolution
T10.8
HartCharts
T10.9
Counting small objects
T10.10
Reading for resolution
T10.11
Tachistoscopic training
T10.12
Monocular telescope
Break suppression
T10.21
Red filter and red print
T10.22
Visual tracking with a Brewster stereoscope
T10.23
Bar reading and tracking
SUGGESTED SEQUENCING OF
TRAINING TECHNIQUES FOR
ESO DEVIATIONS
Chapter 20
541
Basic Esophoria
Establish physiologic diplopia
T13.6
Brock string and beads, Bl training
Increase fusional divergence at near
Vergence rock techniques (flipper prisms)
Aperture-Rule Trainer (double aperture)
Vectograms and Tranaglyphs, divergence
training at near
Remy Separator
Orthopic fusin
Computerized divergence procedures
T13.12
T13.13
T13.8
T13.14
T13.15
T13.16
Increase fusional divergence at far
T13.4
Brewster stereoscope, tromboning
T13.3
Brewster stereoscope, isometric and step
vergences
T13.9
Vectograms and Tranaglyphs, divergence
walk-aways
T13.10
Vectograms and Tranaglyphs, projected Bl
sudes
T13.7
Peripheral fusin rings, Bl training at far
SUGGESTED SEQUENCING OF
TRAINING TECHNIQUES FOR
EXO DEVIATIONS
T14.4
T14.7
T14.8
T14.10
T14.11
T14.16
T14.20
542
Chapter 20
Convergence Insufficiency
Exotropia (Assuming Some
Sensory Fusin at Far)
Increase fusional convergence at far
T14.5
Brock string and beads
T14.7
Brewster stereoscope, sometric and step
vergences
T14.8
Brewster stereoscope, tromboning pushaways
T14.10
Vectograms and Tranaglyphs, convergence
walk-aways
T14.11
Vectograms and Tranaglyphs, projected BO
sudes
T14.16
Televisin trainer and prisms
Increase fusional convergence at near
T14.13
Pencil push-ups
T14.6
Three-dot card
T14.19
Pola-Mirror vergence techniques
T14.4
Bernell Mirror Stereoscope
T14.14
Chiastopic fusin
T14.9
Vectograms and Tranaglyphs, convergence
training at near
T14.12
Aperture-Rule Trainer (single aperture)
T14.17
Bar reader with prisms
Convergence
Insufficiency Exophoria
Increase fusional convergence at near
T14.13
Pencil push-ups
T14.5
Brock string and beads
T14.6
Three-dot card
T14.19
Pola-Mirror vergence techniques
T14.4
Bernell Mirror Stereoscope
T14.9
Vectograms and Tranaglyphs, convergence
training at near
T14.12
Aperture-Rule Trainer (single aperture)
T14.14
Chiastopic fusin
T14.17
Bar reader with prisms
T14.20
Computerized convergence training
Chapter 20
VISION TRAININGFOR
VISUAL SKILLS EFFICIENCY
Saccadic Dysfunction
Improve eye-hand accuracy and speed
T16.1
Picking up objects
T16.2
Toothpick in straw
T16.3
Peg-board games
T16.8
Dot-to-dot games
T16.9
Fillingos
T16.6
Continuous motion tasks
Improve saccadic accuracy and speed
T16.4
Wall fixations
T16.5
Fixations with an afterimage
T16.7
Lose prism steps
T16.10
Sequential fixation sheets
T16.11
Sequential fixation sheets with cognitive
demands
T16.12
Computerized programs
543
T13.13
T13.8
T13.15
T13.16
Increase fusional convergence
T14.13
Pencil push-ups
T14.6
Three-dot card
T14.9
Vectograms and Tranaglyphs, convergence
training at near
T14.12
Aperture-Rule Trainer (single aperture)
T14.14
Chiastopic fusin
T14.17
Bar reader with prisms
T14.20
Computerized convergence training
Intgrate accommodation and vergence
T14.5
Brock string and beads
T16.22
Jump focus rock T14.19
Pola-Mirror vergence techniques
Pursuit Dysfunction
Improve eye-hand accuracy and speed
T16.13
Automatic rotating disks (e.g., Peg-board
rotator)
T16.14
Swinging (Marsden) ball
T16.15
Penlight pursuits (or hand-held toys)
T16.17
Flashlight spot chasing
Improve pursuit accuracy and speed
T16.16
Pie-pan pursuits
T16.18
Minivectograms and Minitranaglyphs
T16.19
Computerized pursuits
Hyperphoria
Increase vertical vergence ranges and facility
T16.24
Vertical step vergence
T16.25
Variations on vertical vergence training
Stereopsis Deficiency
Improve stereoacuity
T16.26
Vectogram stereo enhancement
T16.27
Computer stereo enhancement
Accommodative Dysfunction
Improve accommodative amplitude
T16.21
Accommodative tromboning
Improve accommodative facility
T16.22
Jump focus rock
T16.23
Lensrock
PRACTICE MANAGEMENT
IN VISION THERAPY
Six practice modes of VT are presented. There may
be more VT settings n optometry than are covered
here, but the majority of modes of clinical practice
are included in these basic types: (1) prvate practice dedicated solely to VT; (2) prvate general
practice that ncludes VT; (3) prvate general practce wth a part-time VT specialist as an indepen-
544
Chapter 20
Prvate Practice
Dedicated to Vision Therapy
Fewer than 1 % of optometrists have practices dedicated solely toVT. Approximately half of these practices are operated by individual doctors, whereas
the others generally involve one or two partners
who also specialize n VT. The optometrist conducts
the diagnostic workup and prescribes lenses, occlusion, and other passive forms of therapy, and therapists do most of the visin training. Often, there are
two therapists per doctor. Only about half of the
patient visits are for treatment of binocular anomalies, the other half being for vision-related learning
problems (e.g., reading dysfunction) and other special therapies (e.g., sports visin).
The emphasis of treatment s on visin training.
Such practices, and those closely emulating them,
interchange the terms visin therapy and visin
training as if they are one and the same. Intervention with extraocular muscle surgery tends to be
minimized. Prisms and lenses, however, frequently
are prescribed for constant wear as part of the therapeutic rgimen. These practices appeal to people in
the upper socioeconomic strata who can afford the
sometimes lengthy therapeutic programs (ranging
from months to more than a year). Third-party coverage (e.g., by insurance companies and even some
school districts) may be accepted by these practices,
which assists the less wealthy patients n receiving
care. Intense office visin training is conducted
along with a modicum of home training, made possible by ampie equipment and materials given on
loan for that purpose. There is tight control of the
patients by the doctor, the therapist, and the dedicated patients (or parents, if patients are minors).
which a VT practice is in a distant city. In such settings, the optometrist treats only the anomalies with
the best prognosis for cure (e.g., convergence insufficiency with BO training, or convergence excess, with
relieving plus-addition lenses along with some Bl
training techniques). Most of the visin training, however, is prescribed for home visin training. Otherwise, referrals are made to other optometrists for
more complicated cases (e.g., strabismus and amblyopia) or to ophthalmologists for surgical considerations in large-angle constant strabismus. The general
practitioner may treat amblyopia, particularly of the
anisometropic type, with lens corrections and patching. When there is strabismic amblyopia with eccentric fixation, referral should be made.
Chapter 20
545
Optometrists in an
Ophthalmologic Office
Ophthalmologists specializing in pediatric and
strabismic care sometimes employ a certifed
orthoptist to treat strabsmus and, possibly, heterophoria. Large ophthalmologc group practices
sometimes include one or more optometrists with
various specialties (e.g., contact lenses, low visin,
and VT). The VT optometrist usually performs the
training alone, without an assistant. The patients
are mostly strabismic; few, if any, are seen for
vision-related learning problems. The emphasis
tends to be on pre- and postoperative VT (usually
called orthoptics n these settings). Training, if any,
is home-based. Nearly all the VT patients n this
setting have binocular anomalies, with most hav-
546
Chapter 20
549
Appendix A
Special Commentary: Vision, Learning, and DyslexiaA
Joint Organizational Policy Statement of the American
Academy of Optometry and the American Optometric
Association*
VISION AND LEARNING
Many children and adults continu to struggle with
learning in the classroom and the workplace.
Advances in information technology, its expanding
necessity, and ts accessibility are placing greater
demands on people for efficient learning and information processing.
Learning is accomplished through complex and
interrelated processes, one of which is visin.
Determining the relationships between visin and
learning involves more than evaluating eye health
and visual acuity (clarity of sight). Problems in
identifying and treating people with learningrelated visin problems arise when such a limited
definition of visin is employed.
This policy statement addresses these issues,
which are important to individuis who have
learning-related visin problems, their families,
their teachers, the educational system, and society.
POLICY STATEMENT
People at risk for learning-related visin problems
should receive a comprehensive optometric evaluation. This evaluation should be conducted as part of
a multidisciplinary approach in which all appropriate reas of function are evaluated and managed.
The role of the optometrist when evaluating people for learning-related visin problems s to conduct a thorough assessment of eye health and visual
functions and communicate the results and recommendations. The management plan may include
treatment, guidance, and appropriate referral.
The expected outcome of optometric intervention s an improvement n visual function with the
alleviation of associated signs and symptoms.
Optometric intervention for people with learningrelated visin problems consists of lenses, prisms,
and visin therapy. Vision therapy does not directly
treat learning disabilities or dyslexia. Vision therapy s a treatment to improve visual efficiency and
visual processing, thereby allowing the person to
be more responsive to educational instruction. It
does not preclude any other form of treatment and
should be a part of a multidisciplinary approach to
learning disabilities.
PERTINENT ISSUES
Vision s a fundamental factor in the learning process. The three nterrelated reas of visual function
are
1. Visual pathway integrity, including eye
health, visual acuity, and refractive status
2. Visual efficiency, including accommodation (focusing), binocular visin (eye teaming), and eye movements
3. Visual information processing, including
identification and discrimination, spatial
awareness, and ntegration with other
senses
To identify learning-related visin problems, each
of these interrelated reas must be fully evaluated.
Educational, neuropsychological, and medical
research has suggested distinct subtypes of learning difficulties. Current research ndicates that
some people with reading difficulties have coexisting visual and language processing dficits. For
this reason, no single treatment, profession, or dis-
550
Appendix A
visual defects that influence learning, affecting different people to different degrees. Vision is a multifaceted process and its relationships to reading and
learning are complex. Each rea of visual function
must be considered n the evaluation of people
who are experiencing reading or other learning
problems. Likewise, treatment programs for learning-related visin problems must be designed individually to meet each person's unique needs.
SUMMARY
Vision problems can and often do interfere with leaming. People at risk for learning-related visin problems
should be evaluated by an optometrist who provides
diagnostic and management services in the rea. The
goal of optometric intervention s to improve visual
function and alleviate associated signs and symptoms.
Prompt remediation of learning-related visin problems enhances the ability of children and adults to
perform to their full potential. People with learning
problems require help from many disciplines to meet
the learning challenges they face. Optometric
involvement constitutes one aspect of the multidisplinary management approach required to prepare
the individual for lifelong learning. Note: Citations
from the original report are not ncluded here.
Appendix B
Appendix B
Developmental History
Child's ame _____________________
Grade ____ School's ame and address
Teacher's ame ___________________
Mother's ame ____________________
Father's ame _____________________
Mailing address ____________
Who referred you to this clinic?
Birthday.
-Age.
Nurse's ame
Occupation _
Occupation _
Phone
Phone
Please state the main reason you would like your child examined:
II . Vision
Yes
No
Unknown
1. Headaches
2. Blurred distant visin
3. Blurred readinq visin
4. Holds books closer than normal
5. Eyes hurt
6. Eyes tire
7. Double visin
8. Eye turn (crossed or "wall-eyed")
9. Blinks excessively
10. Covers one eye while doing homework
III. School
Yes
No
Unknown
551
552
Appendix B
IV. Behaviors: Please rate the child on the following tems. Place a number in the blank to the left
of the item that describes the child's school or home behavior.
1Always 2Frequently
3Occasionally 4Rarely
5Never
6Unknown
Hyperactive
Easily distracted
Indistinct speech
Awkward or clumsy
Easily frustrated
Impulsiva
Behavior problems
Easily fatiqued
Emotional problems
day)
V.
Physical Development: At what age n years and months did the child:
2Grade level
Reading
Spelling
Writing
Art
Physical Education
Other?
Arithmetic
Have other family members had difficulties learning any of the above subjects?
No ____ Yes ____ If yes, state relationship to child and subjects: ___________
Does your child have memory difficulties? No _____ Yes ____ If so, what type of nformation?
Appendix B
Vil.
General History
Yes Date
previously
diagnosed?
No ____ Yes ____ If yes, please explain: _________________
Date
Has the child received a complete eye examination? No_____ Yes .
Has a visual problem been diagnosed?
No ____ Yes ____ If yes, please explain: ____________________
Does the child have any allergies?
No ____ Yes ____ If yes, please explain: _____________________
Is the child taking any medications or pills? No _____ Yes_____
If yes, please list the medications, their purposes, and duration: ___
Has the child previously taken medication for attention dficit or hyperactivity? No _____ Yes .
VIII. Therapy
Has there been any previous therapy for learning difficulties or visual or speech problems?
No ____ Yes ____ If yes, please state the type of therapy, duration, and results: _________
If you would like a copy of our examination results sent to any individual or agency, please list
ame and address below:
1. _______________________________________________
2. _______________________________________________
3. _______________________________________________
Date
Signature _________
Relationship to child
Comments:
553
Thank you.
554
Appendix C
Appendix C
Strabismus Examination Record
ame
Examiner
Date
Address
Recorder
Birth
Referred by
Report Rec'd
City
Phone
\
!
HISTORY
Is there now?
How often and under what conditions does the eye turn?
Patching?
Glasses?
Ages?
Exercises?
Surgery?
Type?
Results?
Other pertinent history?
RE
LE
Date
By
RE
LE
Date
By
RE
LE
Date
By
RE
LE
Date
By
ACUITY
Rx a b c d (circle one)
RE
LE
Method
Rx a b c d (circle one)
RE
LE
Method
CONFRONTATION
Angle kappa and steadiness
RE
LE
Suggests
RE
LE
Suggests
IPD:
Appendix C
Rx
. /1.00 D)
Other results
DIAGNOSIS
LE
m:
At
Magnitude
Direction Freq. of
Latera I ity
Strabismus
m: Magnitude
Direction Freq. of
Laterality
Comitance
ASSOCIATED CONDITIONS
Monocular fixation
Amblyopia
Retinal correspondence
Suppression
Fusin
Ametropia
Recommendations
Instructor's Signature
Source: Modified from form used at the School of Optometry, University of California, Berkeley.
Strabismus
555
556
Appendix D
Appendix D Stereoacuity
Calculations
OS &OD
Eta =
(206,000)
I.P.D. (x) d2
Assume, for instance, that the eyes are bifixating a
circle by means of polarizaron. Another target
(such as the disparate circles n the Wirt rings test)
is designed so that each element of the target can
be seen by only one eye. Assume that the lateral
displacement s 1 mm for this particular stereoscopic test, the IPD s 60 mm, and the testing distance is 40 cm (400 mm). Find xfrom the formula:
x
dsplacement
x+d
I.P.D.
x x + 400
T 60
59x = 400 x
= 6.78 mm
Now, substituting the valu for x into the linear formula for stereoacuity:
Eta =
60(6.78)
(206,000)
(400)2
Appendixes E and F
557
Appendix E
Conversin of Prism Diopters and Degrees
Prism Diopters
Degrees
Degrees
Prism Diopters
034'
1.75
09'
3.49
143'
5.24
2 17'
6.99
2 51'
8.75
3 26'
10.51
40'
12.29
4 34'
14.05
5 9'
15.84
10
5 43'
10
17.63
15
8 32'
15
26.80
20
11 19'
20
36.40
Appendix F
Visual Acuity and Visual Efficiency
Snellen Acuity
Angle of Resolution
1.0'
100.0
20/25 (6/7.5)
1.25'
95.6
4.4
20/30 (6/9)
1.50'
91.4
8.6
20/40(6/12)
2'
83.6
16.4
20/50(6/15)
2.5'
76.5
23.5
20/60(6/18)
3'
69.9
30.1
20/70 (6/21)
3.5'
63.8
36.2
20/80 (6/24)
4'
58.5
41.5
20/100(6/30)
5'
48.9
51.1
20/200 (6/60)
10"
20.0
80.0
20/300 (6/90)
15'
8.2
91.8
20/20 (6/6)
558
Appendix G
Appendix G
Visual Skills Efficiency Evaluation (Testing Outline)
Visual Skills Efficiency Evaluation (Testing Outline) Date: _______________________________
Patient _____________________ Age _____ Reason for Examination _____________________
1.VISUALACUITY
Lenses worn OD
OS
VA
At Nearpoint
SC V OD OS
C C V O D OS
At Farpoint
SCVOD
OS
Refractive data
OD OS
Comments
Appendix H
Appendix H
Visual Skills Efficiency Pass-Fail Gritera (Summary from
Previous Chapters)
OCULOMOTOR SYSTEMS OF POSITION MAINTENANCE,
PURSUITS, AND SACCADES
Fixations
Pursuits
Saccades
4+ accurate
3+ accurate
2+ gross undershooting or overshooting or increased latency (fail)
1+ nability to perform task or greatly ncreased latency or any head movements (fail)
Developmental Eye
Movement (DEM) Test
or Visagraph Test
ACCOMMODATIVE SYSTEM
AMP= 15- 0.25 (age)
MAF
Fail if <10 cycles per minute or if difference in eyes >2 cycles per minute (2.00 D)
NRA
PRA
Bin. x cyl.
MEM
AMP = amplitude; BAF = binocular accommodative facility; Bin. = binocularity; NRA = negative relative accommoda tion; PRA = positive relative accommodation; MAF = monocular accommodative facility; MEM = monocular estmate
method; x cyl. = crossed cylinders.
559
560
Appendix H
VERGENCE SYSTEM
Nearpoint of convergence
(NPC)
Break>8cm, fail; recovery >11, fail; approx. same vales for stamina (afterfive triis). If, however, target is very slowly moved at 1 cm/sec with 20/30 letter target, NPC break would be 6
cm and recovery would be 10 cm for sixth-gradechildren or 13 cm forthird-gradechildren.*
Ideal phorias
Facility
8 BO/8 Bl at near, <5 cycles per minute, fail (with suppression check) 8
Fixation disparity
Any fixation disparity; consider possibility of failure; consider shape of forced vergence
curve
NFC PFC
BO/4 Bl at far, <5 cycles per minute, fail (with suppression check)
SENSORY SYSTEM
Second-degree fusin (W4D/RL)
Stereopsis
Suppression
Pola-Mirror: at near, fail if one eye dark with mirror at 25 cm; at far (Vectographic Slide 20/30), fail if OD or OS letters suppressed
Appendix I
561
Appendix I
Visual Symptoms Survey
ame ______________________________________________ Age.
Date
Rarely (1)
Frequently (3)
Always (4)
Unknown (U)
Headaches*
(0)
(1)
(2)
(3)
(4)
(U)
(0)
(D
(2)
(3)
(4)
(U)
(0)
(1)
(2)
(3)
(4)
(U)
(0)
(1)
(2)
(3)
(4)
(U)
Eyestrain (discomfort)
(0)
(1)
(2)
(3)
(4)
(U)
Ti red eyes
(0)
(1)
(2)
(3)
(4)
(U)
Sensitivity to light
(0)
(1)
(2)
(3)
(4)
(U)
Eye redness
(0)
(D
(2)
(3)
(4)
(U)
(0)
(1)
(2)
(3)
(4)
(U)
(0)
(D
(2)
(3)
(4)
(U)
(0)
(D
(2)
(3)
(4)
(U)
Distracted, restless, or
inattentive
(0)
(D
(2)
(3)
(4)
(U)
Avoids or dislikes
reading
(0)
(D
(2)
(3)
(4)
(U)
562
Appendix J
Appendix J
Suppliers and Equipment
AcademicTherapy Publications
20 Commercial Boulevard
Novato, CA 94949 Tel: 800422-7249 Fax:415-883-3720
Ann Arbor (Michigan) Tracking and various visin
therapy and educational material
American Optometric Association
243 Lindbergh Boulevard St. Louis,
MO63141 Tel: 800-262-2210
Fax:314-991-4101 Vision education
material
Ann Arbor Publications PO Box
7249 Naples, FL 33940 Ann Arbor
(Michigan) Tracking
Ann Arbor Publishers Limited
PO Box 1
Belford, Northumberland, NE 70 7JX
United Kingdom
Ann Arbor (Michigan) Tracking
Bernell Corporation
U.S. Optical Divisin, Vision Training Products, Inc.
4016 N. Home Street
Mishawaka, IN 46545
Tel: 800-348-2225
Fax:219-259-2102
Accommodative Rock Cards (Terranova)
Aperture-Rule Trainer
Bernell Computer Software for Vision Skills, Computerized Aided Vision Therapy (program by Dr.
Gary Vogel)
Broken Wheel Test (visual acuity)
Developmental Eye MovementTest (DEM)
Dual Polachrome IlluminatedTrainer, Vectograms
and Tranaglyphs
Dyslexia screening and testing
Flippertrial lens/prism holder
Flippers, prisms, and lenses
Hart Charts
Interferometer
King-DevickTest
Macular IntegrityTester (MIT)
Mirror Stereoscope (Wheatstone)
Optokinetic Nystagmus Prism
Other equipment for binocular testing and training
Prisms
Rotation Trainer
Single Oblique Stereoscope
Striated (Bagolini) lenses
Televisin Trainer
Test Lantern for Fixation Disparity
Translid Binocular Interaction Trainer (TBI)
Christenson Vision Care
2215 Vine Street, Su te C
Hudson, Wl 54016 Tel:
715-381-1234 Fax: 715381-5357
Dyslexia screening, testing, and practice management material
Clement Clarke International
Ophthalmic Divisin Haag
Streit UK
Clement Clarke International Limited
Edinburgh Way, Harlow Essex, CM 20
2TT United Kingdom Tel: 44-0-1279414969 Fax:44-0-1279-456305
info@haag-streit-uk.com
http://www.haag-streit-uk.com
Synoptophore and SI des
Creative Publications
5623 W. 115th Street
Worth, IL 60453 Tel:
708-385-0110 Pegboards
Designs for Vision 760
Koehler Avenue
Ronkonkoma, NY 11 779
Tel: 800-345-4009
Yoke Prism Diagnostic Unit
Efficient Seeing 7551 Soquel Drive
Aptos, CA 95003 Tel: 408-688-2020
Fax: 408-688-2036 Various visin
therapy material
Appendix J
563
Keystone View
Divisin of Mast/Keystone, Inc./Nevada Capital
Group, Inc.
2200 Dickerson Road
Reno, NV 89503
Tel: 800-806-6569
Fax: 775-324-5375
Email: sales@keystoneview.com
Lifesaver Colored Circles (opaque and
transparent)
BrockTechnique (red-green peripheral
fusin rings)
Correct-Eye Scope and light boxes
Eccentric circles (opaque and transparent)
Sherman TVTrainer for Amblyopia and Strabismus
Stereograms (testing and training)
Telebinocular and other Brewster stereoscopes
Van Orden Trainer
VT Playing Cards
Lafayette Instrument 3700
Sagamore Parkway North PO
Box 5729 Lafayette, IN 47093
Tel: 800-428-7545
Tachistoscopes
Lakeshore Curriculum Materials
2695 E. Domingues Street PO
Box 6261 Carson, CA 90749
Tel: 800-421-5354
Various developmental materials applicable to
visin therapy
Light House Low Vision Services
New York Association for the Blind
111 East 59th Street New York, NY
10022
Light House Charts (Lea Symbols)
Lombart Instrument 8676
Commerce Avenue San
Diego, CA92121 Tel: 800573-2020 Fax: 619-537578-8369
Vision therapy testing material
Manico/Bloomington 418 East
17th Street, Suite 2 PO Box
5504 Bloomington, IN 47408
564
Appendix J
Tel: 812-336-2567
Rotating Peg-BoardTrainer
Translid Binocular InteractiveTrainer (TBI)
Meto n e
2801 Thornton Avenue
Burbank, CA91504 Tel:
818-845-4874 Metronomes
Midwest Vision Therapy Equipment Company, Inc.
PO Box 103 7
Cicero, IN 46034
Tel: 800-346-4925
Fax:317-984-9661
Accommodative Flippers
Anti-Suppression Bar Reader
Home Therapy System (HTS) (program by Dr.
Jeffrey Cooper and Rodney Bortel)
Near-Far Accommodation Charts
Polarized Glasses
Variable and NonvariableVectograms
RC Instruments
PO Box 109
1558 East Port Court
Cicero, IN 46034
Tel: 714-250-8070
Fax: 714-250-8157
Accommodative rock charts
Ann Arbor (Michigan) Tracking (symbols, letters,
words, sentences)
Dyslexia screening and testing
Hendrickson Lifesaver Cards
Maples OculomotorTest
Psychometric Acuity Cards (Wesson)
Rotation Peg-Board Machine
Super Stereoacuity Timed Tester
Test of Auditory Analysis Ski lis (TAAS)
TheTalking Pen
Various visin therapy testing, training, and information material
Visual-Motor Integration (VMI)Test
Wayne Afterimage Strobe Flasher
Wayne Computerized Saccadic Fixator
Wesson Fixation Disparity Card
Fax:317-984-9661
Computer Orthoptics, Home Therapy
System (HTS)
Appendix J
Tel: 800-344-9500
Fax:312-777-4985
Randot Preschool Stereoacuity Test
Stereograms for Brewster stereoscopes
Various stereopsis tests, Vectograms
Taylor Associates 2002 E. 2nd Street
Huntington Station
565
Self-Assessment Test
QUESTIONS
Chapter 1
1.1. A valu of having normal binocular visin s
having
a.
b.
c.
d.
Chapter 2
2.1. Saccadic eye movements can be tested
objectively with, for example, the 4+ system, in
which two targets are separated by _________ cm
at a viewing distance of 40 cm and failing would
be defined as the presence of__________ .
a.
b.
c.
d.
e.
a. 65.
b. 73.
c. 75.
d. 80.
e. 83.
2.3. Objective testing of pursuit eye movements
is done, for example, with the 4+ system. In performing this test, a target viewed at a distance of
cm s moved for one cycle in the hori
zontal direction, the vertical direction, and two
_________ orientations, and passing (3+ or better)
would be ndicated by _________ .
a.
b.
c.
d.
e.
568
Self-Assessment Test
a. 40, 5, 5
b.
c.
d.
e.
20, 5, 5
40,5,10
20, 10, 10
40,10,10
b.
c.
d.
e.
a.
b.
c.
d.
e.
a.
b.
c.
d.
e.
2.10.
1,
2,
3,
1,
2,
strong
weak
adequate
weak
strong
2.6. Monocular estmate method (MEM) retinoscopy is done at a viewing dstance of _________ ,
and the patient initially wears his _________
lenses; a lag of +0.75 is _________ .
2, adequate, 32
3, weak, 42
4, strong, 52
3, adequate, 62
2, weak, 72
Relative convergence is tested at the rate of
a. +0.50
b. +0.25
c. plano d. 0.25 e. 0.50
2.8. Infacility of accommodation when tested
monocularly with +2.00-D flippers would be ade
quate with__________ cycles per minute, and this
rate would normally be _________ when tested
binocularly because of the effect of _________ .
a. 6, higher, saccades
a.
b.
c.
d.
e.
Self-Assessment Test
Chapter 3
569
3.1. The relation between accommodative-convergence and accommodation (AC/A) is a ratio that
can be calculated from far and near phorias. For
example, a patient has 15 A of exophoria at 6 m
and s orthophoric at 40 cm. The calculated AC/A
ratio, assuming a 60-mm nterpupillary distance, is
_________ . If the gradient AC/A method were to
be used, the ratio would Nkely be _________ .
a.
b.
c.
d.
e.
Chapter 4
6/1, higher
8/1, lower
10/1, higher
12/1, lower
6/1, lower
a.
b.
c.
d.
e.
e.
4.2. Your patient has a left hypertropia that
increases on dextroversion and further ncreases
on right head tilt. The suspected isolated paretic
extraocular muscle is the _________ .
570
a.
b.
c.
d.
e.
Self-Assessment Test
Chapter 5
5.1. You test your strabismic patient for suppression. Based on the naturalness of conditions, the
test most likely to detect suppression would be the
a.
b.
c.
d.
e.
Pola-Mirror.
Brewster stereoscope and stereograms.
Wheatstone stereoscope and stereograms.
penlight with red-green filters.
Maddox rod test.
Snellen chart.
Bailey-Lovie chart.
psychometric chart designed by Flom.
Tumbling E.
picture cards.
ter of the fovea, the magnitude of the angle of eccentric fixation (angle ) most exactly is classified as
a.
b.
c.
d.
e.
central.
fovea I.
parafoveal.
macular.
peripheral.
eccentric fixation.
unsteady fixation.
anomalous correspondence.
suppression.
ocular disease.
Self-Assessment Test
10,1.00
15,2.00
20, 3.00
25,4.00
30, 5.00
Chapter 6
6.1. Functional cure of strabismus, according to
Flom, means that the patient has bifoveal fixation
_________ percent of the time, clear visin that is
_________ comfortable, and bifixation n all fields
of gaze and distances as cise as__________cen
timeters from the eyes and that corrective lenses
can be worn with the amount of relieving prism
being _________ prism diopters.
a.
b.
c.
d.
e.
95, always, 8, 5
99, generally, to the nose, 5
100, always, 8, 5
95, always, to the nose, 8
99, generally, a few, a reasonable amount of
571
a. poor.
b. poor to fair.
c. fair.
d. fair to good.
e. good.
Chapter 7
7.1. Some characteristics of primary comitant
esotropa are age of onset _
_____ and refracIn additon,
tive error ndicating ___
anomalous retinal
correspondence ________________________ .
a. at birth or shortly after, hyperopa, is almost
always present
b. after 6 months, no ametropia, may or may not
be present
c. at birth, hyperopia, is almost always present
d. after 6 months, hyperopia, may or may not be
present
e. at brth, little or no ametropa, s almost always
present
7.2. Sensory strabismus refers to loss of sensory
fusin, particularly if visual acuity of one eye s
severely reduced. The direction of the eye turn is
related to the age of onset, such that onset after the
age of __________ year(s) usual ly results in
a.
b.
c.
d.
e.
1, exotropia
2, esotropa
3, exotropia
4, esotropa
5, exotropa
Chapter 8
8.1. Paretic strabismus, as opposed to developmental strabismus, s suspected in the presence of the
following six factors: mode of onset, _______
age of onset, _________ ; diplopia, _______
head posture, _________ ; amblyopa, _______
and retnal correspondence, _________ .
a. sudden, any age, common, abnormal, rare,
normal
572
Self-Assessment Test
8.5. Your patient is a man who has constant nystagmus and reduced acuity of both eyes and
dampens with convergence and with left gaze. This
is probably a case of _________ nystagmus.
a.
b.
c.
d.
e.
congenital
physiologic
voluntary
latent
periodic alternating
Chapter 9
9.1.
Self-Assessment Test
techniques such as
573
and
Chapter 10
10.1.
In
amblyopia therapy,
any significant
10.5.
example of
larly good n cases of
a.
b.
c.
d.
e.
a.
b.
c.
d.
e.
10.3. Penalizaron becomes the preferred treatment option n cases of amblyopia n which there
s
and _ .
a. latent nystagmus, intermittent unilateral strabismus
b. congenital nystagmus, constant unilateral strabismus
c. latent nystagmus, constant alternating strabismus
d. constant unilateral strabismus, allergy to the
bandage
e. constant alternating strabismus, allergy to the
bandage
10.4. Examples of monocular fixation and motility activities for the amblyopic eye include training
10.7. Binocular training can usually be considered for ambiyopic patients when there is
a.
b.
c.
d.
e.
574
Self-Assessment Test
a. deep suppression.
b. harmomous anomalous correspondence.
c. unharmomous anomalous correspondence.
d. deep suppression and harmonious anomalous
correspondence.
e. limited motor fusin ranges and harmonious
anomalous correspondence.
Chapter 11
11.1. Your patient s 3 years od and has recently
developed comitant, constant, alternating esotro
pa. There is no amblyopia, but the patient has
anomalous retinal correspondence (ARC). You
would initially consider
a. constant unilateral occiusion between office
treatments for ARC.
b. ntermittent unilateral occiusion.
c. ntermittent alternating occiusion.
d. binasal occiusion.
e. no occiusion but beginning active functional
training.
11.2. You have a patient with constant esotropa
of 15A and ARC. The prism power that would be
used to break the ARC would be at least
base- _____________.
a.
b.
c.
d.
e.
15, in
15, out
25, out
30, n
30, out
a.
b.
c.
d.
Chapter 12
12.1. Your anisometropic patient has unilateral,
shallow, central suppression even when optically
corrected with either spectacle or contact lenses.
You give occiusion antisuppression therapy and
consider starting with an occluder that s
a.
b.
c.
d.
e.
Self-Assessment Test
Chapter 13
13.1. Your patient has esotropa of 15A at far and
an nterpupillary distance of 60 mm. There s normal retinal correspondence but deep suppression.
Training is done at the centration point using the
Brock string at a viewing distance of _________
cm, and the patient should wear addition lenses of
________ D.
a. 20,
1.50
b. 20,
2.50
c. 40,
2.50
d. 40,
4.00
e. 100, 1.00
13.2. Your patient has esotropa of 20A at far and
30A at near. Extraocular muscle surgery you would
consider efficacious would be _________ , which
could
also
575
13.4.
13.5. Assume the homologous points of a stereogram for a Brewster stereoscope are separated by a
distance of 67 mm. You wish to give your eso
patient vergence demands at near (at the 2.50-D
accommodative demand). The demand at far
would be _________ and at near _________ .
a.
b.
c.
d.
e.
13.7. Your patient with basic esophoria s working with the Brock string and beads. Jump ver-
576
Self-Assessment Test
b.
c.
d.
e.
a.
b.
c.
d.
e.
double, usually, 50
single, not usually, 40
double, not usually, 40
single, usually, 25
2,5,5
5,5,10
5, 7, 1 7
7, 7, 20
10,10,20
Self-Assessment Test
Chapter 14
14.1. Comparing exo deviations with eso deviations, the ratio regarding strabismus is
________________________________________
,
with _________ deviations being more prevalent.
Increasing fusional vergence with training is relatively easy when the strabismus is
________________________________________
,
which is more common in _________ deviations.
a.
b.
c.
d.
e.
577
15,20
20, 15
20,20
25,20
20,25
14.4. Your exophoric patient with convergence
insufficiency is prescribed the three-dot card for
visin training. This is__________ difficult for the
patient to converge than with the Brock string and
beads, because of the _________ . The best way to
help the patient learn to fuse a red and blue dot on
the three-dot card being held at the tip of the nose
is to _________ .
a. less, remoteness of the dots, move the end of
the card up
b. more, remoteness of the dots, move the end of
the card down
578
Self-Assessment Test
c. less, nearness of the dots, cut off the top portion of the card
d. more, septum, cut off the top portion of the
card
e. less, septum, cut off the top portion of the card
14.5. Your patient with basic exophoria is performing the technique of convergence walk-aways.
At the usual distance of 40 cm, the patient can fuse
and hold the separated Spirangle Vectogram with
the number 72 showing through the masked bar.
This indicates a prism demand of _________ . The
patient walks away to 160 cm, and the prism
demand s _________ .
a.
b.
c.
d.
e.
14.6. Your patient with convergence insufficiency is using the Aperture-RuleTrainer at home.
The patient's goal is ultimately to be able to fuse
card 12 looking through the _________ aperture,
which presents a _________ demand of
a.
b.
c.
d.
e.
14.7. Binocular accommodative rock can be useful n cases of exo deviations, particularly for
patients with _________ and __________ but, by
comparison, s not very effective n cases of
________ because of the _________ accommodative-convergence/accommodation ratio.
a. convergence insufficiency, basic exo, diver
gence excess, high
b. convergence insufficiency, divergence excess,
basic exo, high
c. basic exo, divergence excess, convergence
insufficiency, low
d. basic exo, divergence excess, convergence
insufficiency, high
e. pseudo-divergence excess, basic exo, conver
gence insufficiency, high
14.8. The Pola-Mirror convergence technique is
useful for patients with convergence insufficiency,
for whom the mirror is moved _________ the
14.9.
Presbyopic
exophoria
similar
to
Chapter15
15.1. Duane retraction syndrome and Brown
syndrome are examples of _________ deviations
and, f anomalous retinal correspondence exists,
visin therapy usually should _________ to establish normal retinal correspondence, because of the
possibility of effecting _________ .
a.
b.
c.
d.
e.
Self-Assessment Test
579
Chapter 16
a.
b.
c.
d.
e.
1, 3
1,5
3,5
5, 7
e. 5, 9
16.2. A general training sequence for improving
saccadic eye movements would be to
a. go from large to small saccades, slow to fast,
and monocular to binocular and then to elim
nate any head movement.
b. go from small to large saccades and slow to
fast, elimnate any head movement, and go
from monocular to binocular^
c. go from large to small saccades, fast to slow,
and monocular to binocular and then to elim
nate any head movement.
d. go from small to large saccades, monocular to
binocular, and slow to fast and then to elim
nate any head movement.
ANSWERS
Chapter 1
1.1.e. All are true. Also note that contrast sensitivity is better binocularly than monocularly.
1.2.>. Refer to discussion on heteronymous
(crossed) diplopia of an object that s nearer than
the fixation target.
1.3.a. The smaller, inner fused circle should
appear to be closer than the larger fused circle,
580
Self-Assessment Test
Chapter 2
2.1.c. The separation should not exceed 20 cm
at the near distance of 40 cm, as head movements
may be necessary for eye movements of such
magnitudes. Some undershooting is common, but
overshooting is not normally expected. Saccades
as small as 15 degrees or more can often genrate
some head movement. Clinicians in the past have
used a 25-cm separation at 40 cm, but that
tended to result in head movements or undershooting and s not considered valid testing of
gross saccades.
2.2.e. Refer to the formula for calculation. Note
that only the omission (O) and addition (A) errors
are taken into account n the formula. Significant
omission errors (in the denominator) are considered unfavorable n that the score time is raised,
thus making more likely its failure as to the horizontal time. Conversely, addition errors (n the
denominator) lower the score time. Substitution
and transposition errors are not quantified n these
calculations.
(
80 Adj.
time = test time x r^=^r
\LU U +
= 7580
'
72
= approximately 83 seconds
2.3.a. The recommended stimuli for pursuits is n
the pattern of the British flag, which ncludes diagonal lines. One fixation loss is allowed n this testing procedure that takes approximately 10 seconds
to complete.
2.4.c. Refer toTable 2-8. A ranking of at least 3 s
necessary for passing for either the 4+ on the 5point system of ranking.
2.5.b. Refer to the mnimum formula of Hofstetter, in which a 10-year-old should have an amplitude of 12.5 D. An insufficiency of 2 D would
Self-Assessment Test
Chapter 3
3.1.d. The calculated ratio would be 12/1 and
the gradient AC/A would most likely be lower
owing to the effect of proximal convergence
from far to near and possibly because of depth
of focus with lens changes during the gradient
procedure.
3.2.a. Relative vergence s measured from the
ortho demand (i.e., a point on the demand line) at
a fixed distance. The blurpoint s traditionally designated by a circle, and convergence (base-out
demand) is plotted to the right of the demand line
and divergence (base-in demand) to the left. 3.3.b.
An esophoric deviation would be relieved with
base-out prism. According to the formula of
Percival, the calculated valu would be 2A. Percival's criterion generally works well for esophoric
patients, whereas Sheard's criterion generally works
well for exophoric patients.
3.4.d. Refer to Figure 3-11b. In this case, the
patient has an associated exophoria of 6A. The fixation disparity forced vergence curve determines
the angle of fixation disparity by the magnitude (in
minutes of are) of the Y ntercept; the associated
phoria s determined by the magnitude of the X
intercept (in prism diopters). Note that the associated phoria and the dissociated phoria are not correlated as to magnitude, but the direction (eso or
exo) of each often, but not always, is n agreement
with that of the other.
3.5.c. A convenient mnemonic is that anomalies bearing the label excess have a high AC/A
ratio, anomalies bearing the label basic have a
normal ratio, and those labeled insufficiency
have a low ratio.
581
Chapter 4
4.1.c/. Acute diseases (e.g., hemorrhage, viral
disease, or brain tumor) may cause the deviation
to be noncomitant. Because these conditions can
often be life-threatening, evaluation of comitancy
s most mportant. Frequency of the manifest
deviation is next in importance, because the
prognosis for functional cure is highly related to
the percentage of time the deviation is manifest.
The prognosis of successful cure s better when
the strabismus is less frequent and worse when it
s more frequent.
4.2.b. Refer to discussion on the three-step
method. Paresis of the right superior rectus muscle
would cause the right eye to be hypotropic (i.e.,
relative hypertropia of the left eye). On right gaze,
the hypotropia of the right eye would be worse, as
the superior rectus becomes a pur elevator on
abduction. A right head tilt would cause the other
ntorting muscle of the right eye, which is the superior oblique, to come into play and further worsen
the hypotropic deviation. Furthermore, the yoke
muscle of the right superior rectus is the left inferior oblique, and the head tilt would cause an
overaction of the left inferior oblique muscle (an
elevator) due to Hering's law of equal innervation,
thus producing even greater hyper deviation of the
left eye on right head tilt.
4.3.e. Frequency of strabismus is either constant
(.e., 100% of the time) or intermittent (Le., 1-99%
of the time). Some authorities use the word occasional synonymously with intermittent. Laterality s
designated as either unilateral (right or left) or as
alternating.
4.4.a. A positive angle kappa (actually, angle
lambda) in esotropa gives the individual less of an
eso appearance, because an eye with a positive
angle kappa s anatomically positioned outward
(templeward) even though the eye may be centrally fixating in the primary position of gaze. Likewise, a narrow bridge of the nose gives a less eso
appearance than would a wide bridge.
Chapter 5
5.1 .a. The Pola-Mirror test s vectographic and is
considered natural relative to the more laboratorylike tests employing septa or colored filters. Suppression s not apt to be detected when testing
conditions are unnatural, such as in a dark room
with a bright fixation light and with the patient
looking through red and green filters.
582
Self-Assessment Test
Chapter 6
6.1.e. This s the recommendation of Flom as to
functional cure of strabismus. 6.2.d. Favorable
cosmetic factors for an exotro-pic individual are a
negative angle kappa, epican-thal folds, small
interpupillary distance, and a wide face.
6.3.e. Refer to Case 10. Factors such as intermittency and normal retinal correspondence are powerful indicators for a favorable prognosis. The high
accommodative-convergence/accommodation ratio
in this case of convergence excess can also be helpful if plus-addition lenses are used to relieve the
larger eso deviation at near.
Chapter 7
7.1 .d. Primary comitant esotropa should be distinguished from infantile esotropa. The main distinction
is the age of onset. In nfantile esotropa, the age of
onset is before 6 months, whereas primary comitant
esotropa is after 6 months but before age 6 years.
Prognosis is better in cases of primary comtant
esotropa than in cases of nfantile esotropa. Some
patients wth primary comitant esotropa have signifcant hyperopa, and optical correction wth lenses
can mprove the prognosis for a functonal curve.
7.2.e. Older individuis with loss of sensory
fusin tend to acqure exotropia rather than esotropa. This is fairly common n the elderly with unilateral cataract.
Chapter 8
8.1.a. Assumng the onset of noncomitancy s
after early childhood and the patient did have normal binocular visin, amblyopia and ARC are
highly unlkely after extraocular muscle paresis;
however, the symptom of diplopia and the sign of
abnormal head posture are likely.
Self-Assessment Test
8.2.b. The diagnostic action field of the left superior oblique muscle s down, right, and ntorted to
the right. The patient would compnsate by chin
depression, moving the face toward the right, and
tilting the head toward the right. The compensatory
head movements are in the direction of the diagnostic action field of the affected muscle. 8.3.c.
The description is probably of a Duane type 1
case, which s the most common and classic type
of Duane retraction syndrome. 8.4.d. Brown
syndrome is also known as tendn sheath
syndrome. The limitation of the eye to move to upgaze with adduction is similar to the action of a
paretic inferior oblique muscle. Differential diagnosis
can be made by noting an incyclophoria (or incyclotropia) with a paretic inferior oblique muscle but not
with Brown syndrome. Diagnostic differentiation
would be duction testing, observing the speed of
movement on up-gaze and inward gaze. In Brown
syndrome, the speed would be fast but limited, but
the speed would be slow with a paretic inferior
oblique. The forced duction test would also tell the
story. The range of motion would be full with inferior
oblique paresis but would be restricted by the tendn
sheath in Brown syndrome.
8.5.a. The most common type of nystagmus is
congenital, affecting males more than females. The
high prevalence and the characteristics of this
patient's nystagmus make the congenital type likely.
A history of nystagmus in early infancy would also
confirm the diagnosis.
Chapter 9
9.1 .b. Refer to the text discussions for this histrica! perspective.
9.2.d. Refer to the text discussions for this histrica! perspective.
9.3.b. Assuming a strabismic patient has both
amblyopia and ARC, the amblyopia should be
treated first, at least to 20/60 (6/18) acuity. Then,
treatment of ARC should be undertaken, providing
the prognosis is favorable for this course of action.
Antisuppression therapy s not feasible when there
is ARC, at least in patients with constant esotropa;
there are exceptions, however, in cases of exotropia with ARC. When there s normal retinal correspondence and little or no suppression, training
for sensorimotor fusin enhancement is then in
order.
9.4.a. Note that some clinicians say "jump vergence" when they mean "step vergence," as well
583
Chapter 10
10.1 .c. Constant unilateral strabismus is certainly
a major cause of amblyopia of an eye. Probably
more cases of amblyopia result, however, from
anisometropia than from strabismus. The first consideration in therapy is to correct any significant
refractive error, particularly anisometropia. In
young children, bilateral astigmatism will cause
meridional amblyopia in each eye, but a greater
astigmatic error in one eye will be amblyogenic for
that eye, as n spherical anisometropia. 10.2.b.
Altrnate occlusion is necessary because the left
eye s legally blind and the individual would
otherwise be unable to function well in daily
Ufe. Full-time occlusion s more effective for quick
results than is intermittent patching. When the
patient's right eye is patched, the direct occlusion
forces the ambiyopic eye to fixate and be used.
When the left eye is patched, the indirect
occlusion allows for good visual acuity while passively eliminating suppression. The exception to
full-time patching would be if the patient needs to
drive a vehicle. The patch should be removed then
to allow for a full visual field. 10.3.a. Latent
nystagmus occurs on unilateral occlusion, and
creating nystagmus in the ambiyopic eye during
treatment is not desirable. Occluding an eye in cases
of ntermittent strabismus may be unwise, because
fusin is disrupted and the frequency of the
strabismus may be increased or constant strabismus
might develop if there is prolonged occlusion. Penalization can allow for peripheral fusin and at least
some binocularity in the treatment program. 10.4.6.
Monocular training s involved n these
techniques. Binocular visin s required in techniques such as peripheral fusin rings, anaglyphic
fusin games, and reading bars. 10.5.a. The fovea
can be tagged with a Haidinger brush, just as with
an afterimage, for training for central and steady
fixation in the treatment of amblyopia. This is
usually done with monocular training as opposed
to binocular training, as in antisuppression
training.
584
Self-Assessment Test
Chapter 11
11.1.a. Constant occlusion between visin therapy visits s an mportant first step because it prevents continuance of the ARC, as it does not exist
(supposedly) under monocular viewing conditions.
Intermittent occlusion would probably not be
enough to break the ARC, and ARC would return
whenever there is binocular viewing. Binasal
occlusion is also a good option to keep the patient
alternating and prevent amblyopia. 11.2.e.
Overcorrection of at east 15A is recom-mended,
but sometimes a greater amount is needed to
disrupt the ARC. In this case of esotropa, base-out
of 30A would probably provide suffi-cient
Overcorrection.
Self-Assessment Test
Chapter 12
12.1.a. The suppression in this case is shallow,
and the treatment environment can be relatively
natural for this patient. The concept of graded
occlusion is consistent with the naturalness concept of testing the intensity of suppression; deeper
suppressions require more unnatural occluding
techniques, as with dark red lenses or total occlusion with an opaque lens or patch. The dominant
nonsuppressing eye is most often the one to be
patched.
12.2.b. Large, flashing, moving targets with high
contrast help break suppression. These variables
are applicable to the suppressing eye. Other
important variables are attention, brightness, color,
tactile and kinesthetic senses, and the auditory
sense.
12.3.e. Normally, the patient should see two
images of the string crossing on a bifixated bead.
The image of a portion of string farther from the
bead and viewed on the left s seen by the left eye;
the string that should be viewed by the right eye is
not seen, indicating suppression of the right eye.
Seeing only one string or a portion of string missing indicates pathologic suppression. Having the
patient blink the right eye may act as an intermittent stimulus (flashing) to break suppression. Using
red and green filters makes the environment less
natural and also helps to break suppression. Room
illumination should be ncreased, however,
because of the darkening effect of the filters. Only
one colored filter can be tried, but the complementary red and green colors applied to each eye
are less natural than application of a colored filter
to only one eye. Closing the left eye forces perception with the right eye; this can help the patient to
be aware of the right-eye suppression. 12.4.d. The
Pola-Mirror monitors foveal suppression and is
used in testing such suppression when the mirror
is held at a viewing distance of 25 cm (total
distance of 50 cm because of doubling of
distance). A good clinical goal that is realistic and
will ensure good bifoveal fusin with no suppression s a viewing distance of 75 cm.
585
Chapter 13
13.1.C. The centration point is calculated by first
determining the dioptric distance, which is calculated by dividing the farpoint deviation by the
patient's interpupillary distance. In this case, the
2.50 D represents a 40-cm distance (100/2.50). This
optical maneuver puts the patient's visual axes n
the ortho posture, which allows for out-of-instrument training with various techniques (e.g., Brock
string and beads, Pola-Mirror, and reading bars).
13.2.e. This patient has convergence excess esotropa. Bilateral medial recession would reduce the
magnitude of the eso deviation and possibly lower
the accommodative-convergence/accommodation
(AC/A) ratio. It s ideal to lessen the near deviation to
a greater extent than the far deviation n patients with
convergence excess. The other surgical options usually either have no effect on the ratio or increase it;
thus, those would not be recommended. 13.3.C. This
patient has divergence insufficiency in which the eso
deviation is greater at far than at near. Push-away
and walk-away training techniques allow for
relatively easy fusin of a penlight and anag-lyphic
filters, to monitor diplopia or suppression at near;
increasing the viewing distance creates greater
demands on fusional divergence at far. Although
base-in training is the essence of treating patients
with eso deviations, this patient has eso at far, and
that problem must be addressed. It is true that the
Bernell Mirror Stereoscope with base-in training can
be effective, but this is training at near and therefore
does not provide the ultmate goal of good fusional
divergence at far, as with fusin walk-aways. Nevertheless, optical infinity can be simulated with plusaddition lenses as with +3.00-D lenses using the
Bernell Mirror Stereoscope. The plus lenses can be
used to build a patient's confidence by increasing
the base-in range on this instrument. 13.4.c.
Widening the W creates base-in demands, an
outcome that s good for eso deviations at near, as
in convergence excess. The addition of plus
lenses can crate optical nfinity to simlate training
at far; the power for this instrument would be +3.00
D, which would be appropriate for eso at far, as in
basic eso or divergence insufficiency. 13.5.e. The
demand at far (0.00-D accommodat tive demand)
would be 10A base-out, calculatediqpr
subtracting 67 from 87 to give a 20-mm
dis| ment inward of the homologous points
and convergence (base-out) demand.
Dividing by 2 (2-dm viewing distance
[i.e., the decii
Self-Assessment Test
10 . Similarly, 67 mm at near is a 4C a t i n t h a n t h e
^
1 3.6.b. The patient with convergence excess naturally has more difficulty at near than at far
because of the greater eso magnitude at near. The
tromboning closer ncreases the base-in demand,
assuming the homologous point separation on the
stereogram is the same at far and near. If, for example, an orthophoric patient views a stereogram at
far with homologous points separated by 87 mm,
there is zero demand on vergence. When the same
stereogram is tromboned to the near position,
there s a base-in demand of approximately 18A
([87-631/1.33 = 11).
13. 7. o. Jump vergence implies the viewing distance is changing from near to far to near, and so
forth. Step vergence implies a constant viewing
distance but a change in the demand on relative
vergence with prisms (e.g., flippers). In cases of eso
deviation, the goal of training is to increase base-in
vergence ranges.
13.8.e. The variable Vectograms can move in the
slots of the Dual Polachrome Illuminated Trainer.
At the fixation distance of 40 cm, each letter represents a prism diopter; letters represent base-in
demands; numbers, base-out demands. If the fixation distance were 80 cm, however, the vergence
demand would be 2A base-in. The scale applies
only to the 40-cm viewing distance. 13.9.>.
Monocular rock should be adequate before
binocular rock is given. The patient with
convergence excess has a high AC/A ratio and is
likely to have difficulty with minus lenses,
because the eso deviation increases significantly
with responding accommodation to the lenses.
The patient with divergence insufficiency has a
low AC/A ratio, and the accommodative vergence
effect s, therefore, lessened with stimuli of plus
and minus lenses.
13.10.C/. The double aperture is used in eso
cases to crate an orthopic (base-in) effect.
Because of the dissociative effect that disrupts
fusin, the technique s difficult and must be
learned gradually as the patient learns how to
increase fusional divergence ranges. The viewing
distance of the targets (numbered 1 through 12)
remains at 40 cm.
deviation.
,
13.12.3. Assuming the ametropia is correctea
with the most pus /enses, the bifoca/ enses (p/usaddition lenses) for near can reduce the eso deviation
significantly because of the high AC/A ratio. If the
patient has good fusin at far, the chances of
amblyopia and anomalous retinal correspondence
(ARC) are small, therefore improving the prognosis
for cure. Also, near deviations are generally easier to
treat successfully than are far deviations for sev-eral
reasons, among which are more stereopsis as
"fusional glue" at near, larger retinal images for
peripheral fusin "glue" at near, and more tactilekinesthetic feedback owing to hands-on activity by
the patient as a motivator and patient's maintenance of attention to the task. 13.13.a. Such sensory
adaptations as ARC and amblyopia must be addressed
initially. Then, fairly good sensory fusin should be
established, which is most easily accomplished at
near. After that, motor fusin ranges can be
increased, more easily at near than at far.
Eventually, the sensorimotor fusin skills can be
transferred to far viewing so that good motor
fusin ranges can also be achieved for distant
viewing. 13.14.b. The majority of patients with
micro-esotropia have sensory adaptations such as
amblyopia, ARC, and poor stereopsis. Even in
those cases, there may be rudimentary peripheral
fusin, and patients can develop fairly good motor
fusin ranges, if needed, using peripheral fusin
stimuli such as large targets in a stereoscope. The
strabis-mic deviation (manifest) remains, so that,
for example, the esotropa is only 3A, as observed
with the unilateral cover test (cover-uncover test),
whereas the total magnitude measured with prism
and the altrnate cover test may be 10A prism
diopters or more; the 7A n this example are latent and
brought out only by continued occlusion dur-ing the
altrnate cover test.
13.1 5.>. The first mportant treatment n esophoria
s to ensure that any significant ametropia is corrected with lenses. Fusional divergence training s
tried next as a conservative mode of visin therapy.
If lenses and training do not resolve symptoms
owing to the esophoric deviation, then base-out
Self-Assessment Test
Chapter 14
14.1.e. There are more exo than eso deviations,
and exo deviations are easier to treat because intermittency is more common in exo deviations as
opposed to eso deviations. Intermittent strabismus
means there is fusin at least some of the time; t is
easier to ncrease existing fusin than t s to establish it, as n patients with constant strabismus.
14.2.a. Monocular training is the general rule
and the nitial step for most visin therapy patients.
Gross convergence training can sometimes elimnate anomalous retinal correspondence, and t sets
the stage for the patient having a nearpoint in
wh'ch sensory and motor fusin can be trained.
Classic anomalous retinal correspondence therapy
may be necessary if anomalous retinal correspondence does not covary with normal retinal correspondence. Sensory alignment can be possible f
there s good gross convergence and retinal correspondence. Antisuppression therapy should next
be given. Central sensory and motor fusin can be
improved. Note that it sometimes may be necessary to include extraocular muscle surgery in the
treatment rgimen. This is also true for prescribed
prisms and other lenses that may be needed nitial ly. For example, there are some patients who
require sensory alignment initially with the help of
base-in prism or minus-lens overcorrection (or
both). Professional judgment s required for such
decisions. Finally, good visual efficiency skills
should be ensured and home training prescribed
for maintenance.
14.3.e. These numbers are merely general guidelines. Some patients can tolrate much larger exotropic angles and be asymptomatic after successful
visin therapy. Constant exotropia, however, more
likely requires surgery as compared with intermittent
exotropia, because visin training techniques often
cure ntermittent exotropia, whereas the prognosis
587
588
Self-Assessment Test
ChapteMS
15.1 .c. Duane retraction syndrome and Brown syndrome are examples of infantile noncomitant deviations. Anomalous retinal correspondence is an
antidiplopia mechanism, and the patient with a lifelong condition of noncomitant strabismus needs all
the antidiplopia help possible. Breaking the anomalous retinal correspondence with visin therapy could
cause the patient to have symptoms of diplopia or
might exacrbate any previously existing symptoms.
15.2.e. Altrnate occlusion not only prevents
diplopia but also helps to prevent contractures. In
this case example, if only the right eye s occluded,
contracture of the right medial rectus muscle is
likely. If only the left eye is occluded, contracture of
the left medial rectus muscle is likely. A permanent
esotropic condition is probable in either event.
15.3.C/. The base-out prism could provide fusin
by compensating for the eso deviation while making the left eye turn inward and the right eye turn
out, which would lessen the contracting of the
right medial rectus muscle. There s some possibility that the left medial rectus could develop contracture, so the prism might be limited to part-time
use to maintain fusin more of the time than otherwise without prism compensation. 15.4.d Yoked
prisms can be helpful in small to modrate
amounts of head turn. The doctor should try various
directions and powers of prisms to determine what
actually works best. Theoretically, the patient likely
turns the head to his or her left when the eyes are
looking straight ahead, assuming a quiet zone on
right gaze. Also theoretically, the patient n this
example wants to look in right gaze to reduce the
nystagmus. When looking straight ahead, turning the
head to the left accomplishes this effect; the head
turn allows the patient to make a dextroversion and
thus reduce the nystagmus. Base-left yoked prisms
would make the eyes dextrovert, and the head could
remain in the straight-ahead position.
Chapter 16
16.1.b. Significantly different image sizes can
often be tolerated for peripheral fusi n, but 5% or
greater s too much for central fusin. Suppression
would be a means of relief, but this is not always
possible and so the patient tries to adapt to the
superimposition of different-sized images that are
not fusible; severe symptoms result. 16.2.a. Gross
saccades are voluntary and relatively easy as
compared with fine saccades, which are less under
volitional control. Therefore, training should
progress from easy to difficult; this is the general rule
in visin therapy. Similarly, start slow and work on
faster saccadic demands (easy to difficult). When
fairly good saccadic ability is shown with each eye
monocularly, proceed to binocular training. Any
head movements should be under the control of the
patient; the patient should be made aware that the
finely tuned eye muscles are more efficient than the
large neck muscles that move the head. Note that
fine saccades are important in reading; however,
large saccades may also need to be as efficient as
possible in other endeavors such as for sports visin.
Vision therapy for gross saccades might be necessary
for certain patients.
16.3.C/. Random dot stereograms usually have a
target that can be seen in four random positions: up,
down, left, and right. With practice, perception of
stereopsis is enhanced over time, and particularly so
when the base-in and base-out vergence demands
are met as the targets are separated to crate vergence demands. This is on the same basis as ordinary chiastopic and orthopic fusin techniques,
except that the computer uses either colored filters
for mutual exclusin of each eye's target or liquid
crystal flickering for this effect, Two chief advantages
of computerized training are the random presentation of the targets and the fact that it is less laborintensive than are hands-on fusin techniques (e.g.,
eccentric circles for chiastopic and orthopic fusin).
16.4.6. The kinetic cover test is similar to the
static altrnate cover test but differs n that the
patient views a target moving closer (as in pencil
push-ups) and farther away (as in pencil pushaways). The momentary deviations, either eso or
exo due to the changing of fixation distance, can
be revealed on the kinetic cover test, whereas they
are not obvious on the static cover test. 16.5.e.
Refer to previous chapters that promote the goal
of clear, single, comfortable, efficient binocular
visin.
590
Glossary
This glossary is ntended to provide brief definitions of terms and to clarify some of the abbreviations used n this text.
ing the center of the fovea; may vary in magnitude or direction from moment to moment or day to day and may be
relatively steady or unsteady
ET Esotropa at far
ET Esotropa at near
First-degree fusin Term used nterchangeably with supermposition
Fixation disparity A slght error of vergence in cases of heterophoria; limit of the magnitude of the angle of fixation
disparty (angle F) considered to be less than 30 minutes
of are
Fat fusin Term used interchangeably wth second-degree
fusin, which is the true fusin but wthout target disparties to produce stereopss
Free space Viewing condtions n which the patient s looking directly at a fixation object that s not housed inside
an instrument, such as a stereoscope, or that s not
viewed through any optical system n which the apparent
position of the object is being altered (see True space);
also clinically known as open environment
Functional amblyopia Central visual acuity reduction that is
not attributable to pathologic causes but to functional
causes (e.g., anisometropic, strabismic, and hysterical)
Functional cure In strabismus, determined by meeting the
criteria of single, clear, comfortable binocular v isin at
all distances from the farpoint to a normal nearpoint of
convergence with normal stereoacuity and with no central suppression; criterion of efficiency possibly also
included
Graded occlusion See Attenuation
HB Haidinger brushes; entoptic phenomenon used to tag the
projected location of the center of the macula
Heterophoria A latent deviation of the visual axes from the
ortho position that requires vergence in order for bifixation to be maintained; possible directions of the deviation: horizontal, vertical, or torsional
IPD Interpupillary distance; clinically but inappropriately
called pupillary distance (PD)
KCT Kinetic cover test; a test for estimating angle H by
means of a moving fixation target and altrnate occlusion
Maddox cross A graduated vertical and horizontal ruler in the
form of a cross with a light source placed at the ntersection for the purpose of subjectively measuring vertical and
horizontal angles of directionalization; also called Maddox
sea I e
Mental effort An attempt by the patient to make vergence
movements by imagining fixation above or below the
horizon or the use of other willful means to produce voluntary vergence or control other visual functions
MITT Macula Integrity Tester-Trainer of Bernell, an instrument used to produce the entoptic phenomena of Haidinger brushes; also called MIT
MS Maxwell's spot; entoptic phenomena used to tag the projected location of the center of the macula
Negative fusiona! vergence The ability to diverge the visual
axes behind the object of regard without blurring; stimulated by base-in prism
Nonvariable eccentric fixation A condition n which point e
has a fixed site, although fixation may be unsteady as to
the point used for fixation
NPC Nearpoint of convergence; single visin with bifixation,
Glossary
591
Index
595
Note: Page numbers followed by f refer to figures; page numbers followed by f refer to tables.
A A and V
patterns, 227-229, 228f
management of, 229 Abducens
nerve lesions, 239 Absolute
accommodation, 41-42, 42t,
49
Absolute convergence, 49-52, 50f, 50t
developmental features of, 51-52
facilityof, 51 functions of, 50-51
norms for, 50-51 stamina of, 51
sufficiency of, 51 testing of, 49-50, 50f,
50t AC/A (accommodativeconvergence/ accommodation) ratio,
70-72, 711, 132 Accommodation, 6,
7f, 40-49. See a/so
Accommodation training
absolute, 41-42, 421, 49 in
amblyopia, 148 amplitude of, 4142, 42t bioengineering model of,
97-99, 98f excess of, 44-45, 45t
facility of, 45-46, 46f, 47t, 48t
developmental norms of, 48
monocular vs. binocular, 47 illsustained, 48-49, 49t infacility of,
49
insufficiency of, 40-44, 411, 42t, 49
lag of, 43-44, 43f, 44f, 44t
monocular estmate method retinoscopy measurement of, 43-44, 44f
Nott dynamic retinoscopy measurement of, 43, 43f relative, 42-43, 42t,
49 stamina of, 48-49, 49t
Accommodation training, 462-466,
463t. See a/so Accommodation
accommodative tromboning in, 465
case study of, 472-473, 473f Hart
Chart near-far rock technique
in, 533-537, 534f-536f jump
focus in, 465 lens rock technique
in, 465-466,
537-538, 537f sequence of,
543 Accommodative esotropa, 215220.
See a/so Strabismus high AC/A ratio,
217-220 miotics in, 219-220 optical
treatment of, 218-219, 218f surgery
in, 220 visin training in, 218-219
refractive, 216-217, 216t optical
treatment of, 216-217, 217f
92
Adaptation theory, of anomalous retinal correspondence, 174, 324
Adherence syndromes, 247 Adjustable
suture procedure, 203 Afterimage tag
techniques, 439-440 Afterimage
transfer training, 300-305 Afterimages
at centration point, 337,
338f Afterimages testing, 37,
176-179, 177f,
178f, 179f
Allbee Card, 409-410, 409f Altrnate
cover test, 108-109, 109f,
1091,230, 230f Altrnate
fixation, on amblyoscope,
331 Alternation theory, of
sensory fusin,
16, 16f
Amblyopia, 143-166. See a/so Amblyopia therapy accommodation in,
148 Amsler grid testing n, 164
anisometropic, 144-145, 313-320 of
arrest, 146 Bailey-Lovie chart
testing in, 151,
151f
case history in, 148-149, 149t
classification of, 144-145, 145t, 160,
160t
contrast sensitivity in, 146-147
cortical dysfunction in, 147
definition of, 143 developmental
aspects of, 145-148,
146t
electroretinography in, 165 of
extinction, 146 eye disease
evaluation in, 163-165 fixation
pattern in, 147, 159-163,
160f, 160t, 161f, 162f
Haidinger brush testing in, 161-163,
162f
image degradation, 145, 145t infant
visual acuity assessment for,
154, 156-158, 157f
interferometry in, 159, 160f
isoametropic, 145 meridional,
145
monocular color visin testing in,
165
596
Index
299f
small object counting for, 299
swinging ball training for, 295-296,
296f
tachistoscopic training for, 300
throwing and hitting games for,
294, 295f
tracing and drawing for, 294
tracking with auditory feedback for,
296, 297f
video game tracking for, 294-295
visual tracing for, 296, 298f
occlusion in, 281-287 amblyopia
prevention in, 283-284,
284t
compliance with, 285 direct, 281283, 282f, 282t, 283f duration of,
286 efficacy of, 286-287 inverse,
281, 283-284, 284t motivation in,
285 occluder types for, 284-285,
284t partial, 281
prism therapy and, 291-292, 292f
progress with, 285-286 red-filter
and, 291 short-term, 292-293
total, 281
visin training with, 287 penalizaron
in, 287-291 efficacy of, 290-291
farpoint, 288-289, 288f
management of, 289-290, 290t near,
288, 288f optical, 289, 289f total,
288, 288f without spectacles, 287
pleoptics in, 305-309 Bangerter's
method of, 306 Cppers' method of,
306-307,
307f, 308-309, 309f
efficacy of, 307-308 Vodnoy
afterimage method of, 308,
308f
progress in, 312-313, 313f red-filter
in, 291 refractive error management
in, 280281
sequence of, 280t, 540 suppression
and, 310-312, 311f Amblyoscopes,
141-143, 142f, 143f. See a/so Major
amblyoscope Amblyoscopic
convergence technique, 407
Index
kinesthetic senses and, 351 major
amblyoscope n, 355-356 chasing
for, 355-356 endpoint suppression
for, 356 flashing for, 355 illumination
gradicntfor, 355 management
considerations n, 363364
modified Remy Separator n, 359
occiusion, 348
penlight and filters in, 356-357, 356t
Pola-Mirror in, 362, 363f reading
bars in, 362-363 tactile senses and,
351, 352f target contrast and, 349
target movement and, 351 target size
and, 350, 350f televisin trainers in,
361-362, 362f translid binocular
interaction trainer
in, 354-355, 355f variables n,
349-352, 349t, 350f Aperture-Rule
Trainer
in esotropa, 387-388, 387f, 492493, 493f n exotropia, 412,
412f, 41 3f, 512514, 513f
Associated phoria criterion, 85, 87, 91
Asthenopia, 21 Atropine
in penalization, 287, 289, 290t side
effects of, 289, 290t Attention, in
antisuppression therapy,
349 Auditory biofeedback, in
congenital nystagmus, 441, 442f
Auditory sense, in antisuppression therapy, 351-352
597
pharmacologic, 204-205
philosophies of, 263-268 of Javal
and French school, 263265, 264f, 265t
optometric, 265f, 265t, 267-268
of Worth and English school, 265f,
2645t, 2765-267
principies of, 268-276
prisms n, 200
retainer home training in, 276
sequence of, 268-270, 269t sliding
vergence training in, 270t,
271
step vergence training in, 270t, 271
tromboning vergence training in,
270t, 271 vergence training
methods in, 270273, 270t
visin training in, 201 Bioengineering
model, of accommodation and
vergence, 97-99, 98f Biopter
stereogram, 377, 379f Blindness,
saccadic, 23 Blowin fracture, 248
Blowout fracture, 247-248 Blur,
intermittent, 21, 41 Botulinum toxin
injection,
205-206
Brainstem lesions, 250 Brewster
stereoscope in antisuppression therapy,
311 in esotropa, 375-379, 376f,
499500, 499f in exotropia, 410
sometric vergences with, 377 step
vergences with, 377, 378f tromboning
with, 377-379 Brightness, in
antisuppression therapy,
349, 350f
Brock string and beads in
antisuppression therapy, 359-361,
360f, 361 f
in esotropa, 380, 498-499, 498f
in exotropia, 409, 509-511, 51 Of
Brock-Givner afterimages transfer test,
179, 180f
Brown syndrome, 246-247
Brckner test, 110, 110f
C
Cantonnet, A., 264-265 Centrationpoint training, 369-370 Chasing, with
major amblyoscope,
355-356
Chavasse, F. B., 266-267, 268
Cheiroscopic games, 357-359, 359f
coloring, 358
counting, 358
drawing, 351,352f, 358
point-to-point chasng, 358
tracing, 358-359
598
Index
249
Cogwheel pursuits, 250 Color, in
antisuppression therapy, 349350
Color fusin, 13, 50, 185, 336-337
Color visin testing, 165 Comitancy,
110-126 causes of, 110-111, 1111
criteriafor, 111-112, 112f, 113f
deviations and, 112-113, 114f, 118121, 120f duction testing for,
113-115, 114t,
115t
forced duction test for, 115 HessLancaster test for, 123-126, 123f,
124f, 125f, 126f recording
protocol for, 118-121,
120f
saccadic velocities test for, 114
single-object method for, 122-123
spatial localizaron testing and, 121
subjective testing for, 122-126, 123f,
124f, 125f, 126f
terminology for, 111-112, 112f, 113f
three-step method for, 115-118, 116t,
11 7f, 118f, 119f two-object
method for, 123-126, 123f,
124f, 125f, 126f
versin testing for, 113f, 114t, 115
Comitant esotropa. See a/so Strabismus
centration-pointtraining in, 368-370
changing viewing distance in, 371372
follow-up care for, 372
plus-lens additions n, 368
primary, 224-225, 224t
prisms in, 368
refractive error correction n, 368
sensory and motor fusin training in,
370-371,3711 surgery in,
372 visin therapy n, 368-373,
368t.
See a/so Esotropa, visin
therapy for
Comitant exotropia. See a/so Strabismus
diagnosis of, 226-227 follow-up care
in, 405 gross convergence training
n, 401402
intermittent nature of, 226
lenses in, 402-403 onset of,
226 primary, 225-227, 226t
prisms in, 402-403
395-396
Doll's-head maneuver, 7, 221
Dominancy, eye, 16, 133
Index
Dorsal midbrain syndrome, 250-251,
251t
Double elevator palsy, 241-242
Double Maddox torsin training, in
acquired noncomitant devi-
ation, 434
Doubling, intermittent, 21 Downbeat
nystagmus, 257t-258t Dual
Polachrome Illuminated Trainer,
381, 381 f, 491^92, 492f
Duane cover test, 108-109, 109f, 109t
Duane retraction syndrome, 37, 245246, 246f, 444-446, 445f
Ductions, 113-115, 114t, 115t Dvorine
stereogram, 377, 378f Dyslexia. See
a/so Reading policy statement on, 549550
391-393
in divergence insufficiency esotropa, 395-396 flipper prisms in,
384, 384f, 386,
502-503, 502f lens additions
in, 369 n mcroesotropia, 396397 orthopc fusin n, 389-390,
389f,
390f, 494-496, 495f
peripheral fusin rings n, 380381, 381 f, 500-502, 501 f
refractivo error correction in, 368
Remy Separator in, 388-389, 388f,
389f, 496^97 sensory and
motor fusin training
n, 370-371,3711 sensory
anomaly elimination in,
368-369
sequence of, 540-541 surgery
and, 372-373, 372t televisin
trainer in, 502-503,
503f Tranaglyphs in, 381f,
383, 491492 Vectograms n, 381386, 382f,
385f, 491-492, 492f
vergence rock techniques n, 384f,
386
viewing distance in, 371-372
Euthyscope, 306-307, 307f
Exophoria
accommodation with, 45 basic, 9394, 94f convergence insufficiency,
93, 93f divergence excess, 94, 94f
presbyopic, 93 reading performance
and, 22 visin therapy n, 405406, 406t,
542
Exophthalmos, 243
599
prognosis for
Allbee Card in, 409-410, 409f
amblyopia treatment in, 401
amblyoscopic convergence technique in, 407 anomalous
retinal correspondence
treatment in, 401 ApertureRule Trainer in, 412,
412f, 413f, 512-514, 513f
bar reader with prisms in, 418,
523-525, 524f n basic
exotropia, 421-423 Bernell Mirror
Stereoscope in,
408-409 binocular
accommodative rock in,
416-417
Brewster Stereoscope in, 410
Brock string and beads technique
in, 409, 509-511, 51 Of case
studies of, 419-427 chiastopic
fusin n, 414-416,
414f, 41 5f, 41 6f, 41 7f, 519522, 520f
compensating prisms n,
402-403
computerized convergence training in, 418-419 n convergence
insufficiency exophoria, 423^27, 426f
convergence training at near n,
411, 514-517, 515f
convergence walk-aways n, 411,
517-518, 517f n
divergence excess exotropia,
419-421
follow-up care in, 405 framing
with prisms in, 55, 418 gross
convergence training in,
401-402
sometric vergence training in, 410
lens additions in, 402^03 pencil
push-aways n, 412-414,
507-509 pencil push-ups
in, 412^-14,
507-509, 508f
peripheral fusin rings in, 408
Pola-Mirror vergence techniques n,
418
600
Index
Exotropia (continuad)
projected base-out si des in, 411412,518-519
refractive error correction in, 401
sensory and motor fusin training
in, 403-404 sequence of,
400-405, 400t, 541542
step vergence training in, 410
stereoscope tromboning n, 410
televisin trainer in, 41 7-418,
522-523 three-dot card in,
409-410, 409f,
41 Of, 511-512
Tranaglyphs in, 410-412, 51 7-519
Vectograms in, 410-412, 517-519,
51 7f vergence rock
techniques in, 417418, 522-525, 524f voluntary
convergence technique
in, 407, 506-507, 507d
Extraocular muscles, 5-6, 6f, 7f
surgery on, 201-204. See a/so Surgery
Eye movements pursuit, 8, 9f, 35-38.
See a/so Pursuit
eye movements saccadic, 7,
8f, 9f, 22-35. See a/so
Saccadic eye movements vergence,
8-10, 10f. See a/so Vergence
vestbulo-ocular, 7-8, 39-40, 221 Eyehand coordinaron techniques, in
monocular fixation training, 294297, 295f, 296f, 297f, 298f
92, 90t
three-dimensional model of, 86f-87f
Fixation disparity curve, 84-85, 85f,
89-90
Fixation training, 293-300, 293t. See a/so
Amblyopia therapy, monocular fixation
training n for saccades, 527-528
Flashing, with major amblyoscope, 355
Flashing targets at objective angle,
329-331, 330f
Flashlightchase, 532-533 Fat fusin,
14 Flipper prisms, 384, 384f, 386,
502503, 502f Flom swing
technique, 333-336, 334f,
334t, 335f, 344-345 Fly
stereopsis test, 60f Forced duction test,
115 Four base-out prism test, 109110,
110f Fourth cranial nerve
palsy, 239-240,
240f
Falling eye sign, 240, 240f Farnsworth
test, 165 Farpoint penalizaron, 288289, 288f Fast pointing (foveal
localization),
303-304
Field of visin, 4, 4f Five-dot card test,
25-26, 27f Fixation, 38-40, 39f. See
a/so Fixation
disparity
bifoveal, loss of, 104 classification
of, 160, 160t eccentric, 159, 160 in
amblyopia, 147 Hering-Bielschowsky
test and, 178,
179f
strabismic amblyopia and, 144
evaluation of, 38-39, 40t, 159-163
Haidinger brush testing in, 161163, 162f
visuoscopy in, 160-161, 161f, 162f
Southern California College of Optometry 4+ test of, 38-39, 40t
unsteadiness of, 38, 159, 160, 160t
vestbulo-ocular reflexes and, 39^1-0
Index
529
with Aperture-RuleTrainer, 494, 514
with Bernell Mirror Stereoscope, 491
with Brewster Stereoscope, 500 with
Brock string and beads, 499,
510-511 with chiastopic
fusin technique,
521, 522
with convergence at near, 516-517
with convergence walk-aways, 517518
with flashlight chase, 533 with Hart
Chart, 533, 537 with lens rock, 538
with Marsden ball, 532 vs. office
training, 272-273 with orthopic
fusin, 496 with pencil push-aways
and pushups, 498, 509
with peripheral fusin rings, 501-502
for regression monitoring, 276, 276t
with Remy Separator, 497 with
sequential fixator, 531 with standing
rotator for pursuits, 531 with televisin
trainers, 503 with three-dot card, 512
with Tranaglyphs, 492, 517-518, 519
with Vectograms, 517-518, 519 with
vergence rock, 523, 524-525 with
voluntary convergence, 506507
Homonymous diplopia, 12, 12f, 122
Horopter, 11-12
in anomalous retinal correspondence,
1 70, 172, 1 73f
601
K
KeystoneTest 1, 58
Kinesthetic sense, n antisuppression
therapy, 351
in amb\yop\atY\etap y, 1^-lftA m
com\Xantexo\ro9\a, 401-403 in
esotropa, 369 in exotropia, 402^1-03
n high AC/A accommodative esotropa, 218, 218f
n nfantile esotropa, 222-223 n
microtropia, 232 prescription for,
76-78. See a/so
Prism prescription in
strabismus, 199 for visual skills
efficiency, 464^65 Levodopa, n
amblyopia therapy, 291 Linear
displacement test, for stereoacuity,
59-60, 62-63, 621, 63t Ludlam's
rockum sockum method, in
anomalous correspondence therapy,
328, 337
M Macular Integrity
Tester-Trainer, 300305, 301 f, 302f Macular
massage, 331 Maddox, E., 267 Maddox
rod test, 129, 130f Major
amblyoscope, 141-143, 142f,
143f, 182-183 anomalous
correspondence therapy
with, 328-336, 329t altrnate
fixation for, 331 entoptic tags for,
332-333, 333f flash ng targets at
objective anf^e
for, 329-331,330f Flom swing
technique for, 333336^
334f, 334t, 335f, 344-345
macular massage for, 331
open space training with, 333
vertical displacement of I
331 anomalous
retinal
testingwith, 182-1CI
antisuppression therapy wM^J
chasingfor, 355-356 endpoint
suppresson ( flashingfor, 355
illumination gradient i Mallet
fixation disparity test4
602
Index
Stereoscope
Misdirection syndrome, 240 Mbius
syndrome, 239 Monocular estmate
method retinoscopy, 43-44, 44f, 44t,
45, 45t Monocular fixaton tranng,
293-300, 293t. See a/so Amblyopia
therapy, monocular fixation train-ing in
Monocular telescope, 300 Monocular
visin, 11 Monovision, 455 Morgan,
Meredith W., 267, 267f Morgan's
expected criterion, 77 Morgan's
normative analysis, 76, 76t Motivation
in amblyopia therapy, 285
in binocular visin therapy, 273275, 274t, 275t Motor
fusin, 370-371, 371t Motor fusin
training. See Sensory and
motor fusin training Motor theory, of
anomalous retinal cor-respondence, 1
74-1 75, 324-325
Mltiple sclerosis abducens nerve
lesin n, 239 internuclear
ophthalmoplegia n,
249
Muscle paretic nystagmus, 257t-258t
Myasthenia gravis, 242-243, 242t
N
Near penalization, 288, 288f
Neurogenic palsy, 238-242 vs.
developmental strabismus, 238,
238t
etiology of, 238, 238t of fourth
cranial nerve, 239-240, 240f head
posture in, 238 of Mbius syndrome,
239 of sixth cranial nerve, 239 of
third cranial nerve, 240-242,
240t, 447-448
Neutral-density filter testing, 164-165
Night myopia, 45
Noncomitant deviation, 110, 111,
113f. See a/so Comitancy;
Strabismus
acquired, 430-435, 431f, 432f, 433f
diagnosis of, 430 double Maddox
torsin training in,
434
follow-up for, 435 fusin field
expansin in, 434 occlusion n,
430-431, 431 f ocular calisthenics
in, 433 prism compensation in,
432-433,
432f, 433f sensory and
motor fusin training
in, 433-434 surgery in, 434435
diplopia and, 121 head posture and,
121-122, 122t infantile, 429-430
diagnosis of, 429 management of,
429-430, 430t Noncomitant
intermittent hypertropia,
O
Obi que muscles, 5-6, 6f, 7f
Occipital lobe, lesions of, 250
Occluders, 282f, 284-285, 284t
Occlusion, 200-201
n acquired noncomitant deviation,
430-431, 431f
in amblyopia therapy, 281-287, 282f,
282t, 283f, 284t. See a/so
Amblyopia therapy, occlusion
in
in anomalous correspondence therapy, 325-326, 326f in antisuppression
therapy, 348 in intractable diplopia,
436-437 Occupation
binocularity and, 4-5, 5t intermittent
blur and, 41 Ocular calisthenics, 433
Ocular dominance, 16, 133 Ocular
myopathy of von Graefe, 244245
Oculogyric crisis, 251
Oculomotor nerve
in Duane retraction syndrome, 245
lesions of, 240-242, 240t, 447-448
Open environment techniques, 336340, 336t afterimages at
centration point in,
337, 338f Bagolini lens
technique in, 339-340,
339f
binocular luster training in, 336-337
Haidinger brush technique in, 338339 prism-rack afterimage
technique in,
338 Open space training, with
major amblyoscope, 333 Ophthalmography,
25-27, 26f, 27f, 28f,
29f
Ophthalmoscopy, 1 63-1 64 Optical
penalization, 289, 289f Optokinetic
nystagmus (OKN) testing,
156-158, 158f
Orbit, fracture of, 247-248
Orthophoria
basic, with restricted zone, 96, 96f
visin therapy n, 469
446-447, 446f
Nott dynamic retinoscopy, 43, 43f Nuil
regin, 254 Nystagmus, 252-259
acquired, 443-444 congenital, 253255, 254t, 438-443,
43 9f, 440f afterimage tag
techniques in, 439440
auditory biofeedback in, 441, 442f
case study of, 448-449, 449f
diagnosis of, 438 intermittent
photic stimulation in,
440-441, 440f
optical management in, 438^439,
439f
Index
Orthopic fusin, 389-390, 389f, 390f,
494_496, 495f Orthoptics,
263. 5ee a/so Binocular
visin therapy
Palsy, 238
myogenic, 242-245, 242t, 244t
neurogenic, 238-242, 238t, 240f,
240t,
447-448
Panum's
fusin
reas,
11
Paradoxical
anomalous retinal correspondence, 169, 170f, 171f
Paralysis, terminolgica! use of, 111
Paresis, 238. See a/so Strabismus
terminological use of, 111 Paretic
strabismus. See Neurogenic palsy
Parietal lobe, lesions of, 250 Parinaud
syndrome, 250-251, 251t Parkinson's
disease, 251-252, 251t Past pointing,
121
Patching. SeeOccIuders; Occlusion
Penalization, 287-291
efficacy of, 290-291
farpoint, 288-289, 288f
near, 288, 288f
optical, 289, 289f
total, 288, 288f
without spectacles, 287
Pencil push-aways
in esotropa, 497-498, 497f
in exotropia, 412-414, 507-509
Pencil push-ups, in exotropia, 412414 ; 507-509, 508f Penlight
and filters, 356-357, 356t Perception,
simultaneous, 58 Percival's criterion,
78, 90t, 91 Periodic alternating
nystagmus, 257t258t Periphral
fusin rings
in esotropa, 380-381, 381 f, 500502, 501 f
in exotropia, 408
Philosophy of binocular visin therapy,
263-268
of Javal and French school, 263-265,
264f, 265t
optometric, 265f, 265t, 267-268
of Worth and English school, 265f,
2645t, 2765-267 Phoria line,
72, 73f Photic stimulation, 440-441,
440f Photophobia, 226
Photorefraction, 165-166, 1 66f Picture
card testing, 153-154, 156f, 157f Pierce
saccade test, 28-30, 30t, 34t
Pilocarpine, for penalizaron, 287
Pleoptics, 305-309
Bangerter's method of, 306
Cppers' method of, 306-307, 307f,
308-309, 309f
308f
Pleoptophor, 306
Plus-lens
in esotropa, 369
in exotropia, 402-403
for visual skills efficiency, 464-465
Point zero, 137 Pola-Mirror
n antisuppression therapy, 362, 363f
in exotropia, 418 Pola-Mirror test,
139-140 Position maintenance. 5ee
Fixation Practice management, 543546
clinic, 545
group, 545
in ophthalmologic office, 545-546
prvate, 544 Preferential looking tests,
for visual acuity testing, 156, 157f Presbyopic
exophoria, 93 Primary microtropia, 230
Prism(s), 200, 200f. 5ee a/so Prism prescription
n amblyopia therapy, 291-292, 292f
diopter-degree conversin for, 557
in esotropa, 369
flipper, 384, 384f, 386
in occlusion therapy, 291-292, 292f
Risley, 53 Prism compensation,
402-403, 432433, 432f, 433f Prism
displacement, 437 Prism
overcorrection, 327-328, 327f,
343-344
Prism prescription
adaptation test for, 92
associated phoria criterion for, 85,
87, 91
clinical wisdom criterion for, 77, 9091,90t
confirmation procedure for, 91-92
criteria for, 76-78 validity
of, 87-90, 89t
Morgan's expected criterion for, 77
Percival's criterion for, 78, 90t, 91
Sheard's criterion for, 77-78, 90t, 91
Sheedy's criterion for, 85, 87, 90t, 91
Prism-rack afterimage technique, 338
Prognosis, n strabismus, 190-199, 190t.
5ee a/so Strabismus, prognosis for
Progressive supranuclear palsy, 251
Projected base-in sudes, 382f, 385-386
Projected base-out slides, 411-412,
518-519
Proptosis, 243
Pseudo-Argyll Robertson pupil, 240
Pseudo-Graefe's sign, 240
Pseudomyopia, 44-45, 45t
603
Psychogenic
amblyopia,
144
Psychogenic
strabismus,
103
Psychometric chart testing, 151-153,
151f, 152f-153f, 154f Pupil
defects, in amblyopia, 148 Pursuit eye
movements, 8, 9f, 35-38,
36f, 36t
afterimages and, 37 in amblyopia,
147-148 characteristics of, 35-36
defects in, 35-36, 37-39 direct
observation of, 36, 36f HeinsenSchrock scale for, 36-37,
36t
Southern California College of
Optometry 4+ test for, 36,
36f, 38
testing of, 36-37, 36f, 36t, 38
training of, 304, 305f, 460-462, 460t
flashlight chase in, 532-533
Marsdenball in, 531-532 sequence
of, 543 standing rotator n, 531, 532f
R
Random dot E stereopsis test, 60f
Randot stereopsis test, 60f, 61 f, 65
Rapport, n binocular visin therapy,
273-275, 274t
Reading, 473-474
dysfunction of, 21-22
in monocular fixation training, 299
policy statement on, 549-550
pursuit eye movements and, 37
Visagraph testing in, 474^76, 475f
interpretation of, 476-479
Rectus muscles, 5-6, 6f, 7f Red
filter
in amblyopia, 291
in antisuppression therapy, 310-311
in occlusion therapy, 291 Red lens
test, 140 Red print, n antisuppression
therapy,
310-311
Reflex fusin test, 54-57, 56t, 57t
Refraction
n amblyopia, 163, 280-281
in esotropa, 368, 369
in exotropia, 401
visual skills efficiency and, 20
Reindeer stereopsis test, 60f Relative
accommodation, 42-43, 42t,
49
Relative convergence, 52-54, 53t, 54t,
55t
at far (negative), 52-53, 53t, 54t
at near (positive), 53-54, 55t Relative
scotoma, 137 Relative vergence, 5254, 53t, 54t, 55t Remy Separator, 359,
388-389, 388f, 389f, 496-497
604
Index
94
Simultaneous perception, 58
Single-object method
in comitancy testing, 122-123 in
diplopia testing, 122-123 Sixth
cranial nerve palsy, 239
Index
110, 110f
605
434-435
in comitant vertical deviations, 233
n congenital nystagmus, 441-443 in
consecutive strabismus, 234 in
esotropa, 372, 372t
n Graves' disease, 244
n high AC/A accommodative esotropa, 220
u
108f
J08t
nilat
37
77
^' oQ onA
?nnf
263-
inAandVpatterns, 229
~^2M t s^-3
Spllt-tield eftect, 172, 174f 185
i n
-m\m\l^^A^
1 . . t
er
al
,
1
0
'
f/
Index
saccadic eye movement training for, 455-459, 456t, 457t,
458f, 459f
case study of, 470-472, 471 f, 472f
sports and, 481
stereopsis enhancement for, 469^170
ergence range improvement for,
466-469
visual acuity and, 557
Visual Symptoms Survey, 561
Visual tracing, 296, 298f
Visual tracking, 311
Visually evoked potentials, 158-159, 158f, 159f
607